· a month%y jo%rna% devoted to the chemistry, physics and therape%tics of radi%m and radio-active...
TRANSCRIPT
I w frm'
BY
CHAR%ES H. VIO%, Ph. D.
WI%%IAM H. CAMERON , M. D.
VO%. V A%G%ST, 1915
C O N T E N T S
Cancer Destruction by Radium, Joseph Bissell,M. D ., F. A. C. S .
Radium in the Treatment of %eloids , Frank
E. S impson , M. D .
Reviews and Abstracts
PHYSICS AND TH E RA P E % T IC S OF RA D I %M
A N D R A D I O - A C T ' V E S % B S T A N C E S
No.
A MONTH%Y JO%RNA% DEVOTED TO THE CHEMISTRY , PHYSICS AND
THERAPE%TICS OF RADI%M AND RADIO -ACTIVE S%BSTANCES.
Ed i ted and Pub l ished by Charles H. V iol , Ph'
. D., and W i l l iam H. Cameron, M. D .
w i th the assistance of col laborators work ing in the fie lds ofRad iochem istry , Rad ioact iv ity and Rad iumtherapy .
S ubscript ion per year, or 25 cents per copy in the %n ited S tates and Canada
in all other countries per year.
Address all commun icat ions to the Ed itors, Forbes and Meyran Avenu es ,Pi ttsburgh, Pa.
VO%. V. A%G%ST, 1915 No. 5
CANCER DESTR%CTION BY RADI%M:
BY JOSEPH B ISSE%%, M . D . NEW YOR% .
V i s i t ing S u rgeon ,B e l le v u e and S t . V incen t’s H os p i ta ls .
By the word destructi on i s meant loca l removal o f a neop lasm,in
con t rad i st i nc t ion to cure , the term cure mean ing complet e and permanentefi
’
a’
cement of the mal ignan t growth and its non - recur renc e in any otherpart of the pat i en t . The word cancer i n th i s paper i s u sed in i t s gener i csen se and cove rs a l l ma l ignan t growth s . The ration al e of the comp le teremova l o f a tumor by radi um appl icat ion can be sat i s facto ri ly demonstrated on ly by a thorough micro scop ical exam ination o f the invo lvedt i s sue s
,carr ied ou t f rom t ime to t ime du r ing the act ive t reatmen t and
a fte r i t s comp let ion . I n thi s way the h i stological changes in th e cel l s ,morb id a s we l l a s normal
,may be anatomical ly demonstrated and th e
actual effect s of rad iat i on u pon these new growth s , as wel l a s upon thesurround ing struc tu re s , may be accu rately a sce rtained beyond quest ionand in a defin i te manner .O f ten
,how eve r
,fo r good and suffi c i en t reason s apparent to al l o f
u s , i t i s impos s ibl e to make the se observat ion s . We then have to dependu pon th e find ings a s exh ib ited by th e cl i n i cal and obj ect ive symptoms .
A con s iderabl e amount o f ev i dence i s on record , from the wri t ingsof some of the rbes t modern pathologi st s , which shows the s truc tu real terat ion s tak ing place duri ng the appl i cat ion of rad ium . To quoteonly a few au thori t i e s :
Gau s s de scri be s the h i sto logical change s ob served i n ten p iece s o ft i s su e exci sed at variou s peri od s in a c ase whe re myom-ata were unde rt reatmen t by radiat ion
.S t r ik ing change s are shown : At the begin
n ing a micro scopi ca l sect ion show s adenocarcmoma ; two weeks later at th e
‘S u r e r y ,Gy n e co logy and Ob s te tr i cs ,
V ol . 21 , p p . 98 1 02, J u l y , 191 5. R ead agu nna l me e t in g o f th e M ed ica l Soc ie ty of th e S ta te of l\ ew Y ork , B u ffa lo,
A p r i l 27 , 1 91 5.
94 RA D I % M
sect ion in the same locat ion shows connect ive - t i s sue a nd cancer nes t s ;th re e weeks later st i l l , th e cancer ev i denc e s have di sappeared and th emi c roscope d i sc lo se s noth i ng except benign‘
tissu e with epithel i al debris .
D egrais and Bel lot pointed ou t,in a recen t pu.blication
, ,that when
epi thel iomatou s cel l s are exposed to rad ium there i s hypert rophy o f th enucleu s and degene rat ion o f the prOrt'Oplasm ,
together wi th a ce rtainamoun t of keratin iza t ion . Th i s p roce s s was cont inued
,and twenty
days or so a f te r rad iat i on these epithel i omatous masse s became t ransform-cd i nto kerat in i z ed diébr is . The formed element s b reak up andd i s in tegra te ; young fibroblast s and connec t ive - t i s sue c e l l s , lymphati ccel l s , and po lymorphonucl ea r c el l s infi l t rate the growth and carry on aphagocyt i c funct ion
,and meanwhi le c i catr i zat ion occu rs at the expen se
o f the hyperlastic and regenerated st roma o f the tumor .%I n a case r epo rted by A i k in s
,o f Toron t o
,a bone tumor involving
the righ t t ib i a was removed January 6,1914
,and examlined . The
path ological examinat ion showed that i t was a m-ye loid and round- cel ledsa rcoma . Three week s a ft er rad ium t reatment a port ion o f t i s sue wasremoved f rom the origi nal l ocat ion fo r lfu rthe-r e xaminat ion . T h epathologi cal repor t i s as f ol l ows :
“The t i s su e examined con s i st s o f a port ion of l a rge fungat inggrowth removed f rom the ante rio r port i on of the thigh .
“The ep idermal element s have completely d i sappeared an d th ei r
place s have been taken by a large fungat ing tumor wh ich cl in i cal ly i ssa rcomatou s . On micro scopica l examinat ion one s ee s that th i s is a
sa rcoma with very la rge ce l l s and a few Spind l e ce l ls . The sarcomatoust i s sue infi l t rate s al l th rough i t , th ere i s no t i s sue react i on , but a connective—t i s sue s t rom a i s pre sent wh ich i s oedematou s and fi l l ed with a
pigment w h i ch i s ev i den tly haemosiderin . The nucl ei are o f ten veryla rge . The s i z e vari e s
,but everywhere it shows mi tot i c figure s and com
forms to al l th e characte r i st i cs o f malignant suarcomata .
“On June 4 the tumo r w as exposed cont inuously to th e rad iumrays
,a dosage of 240 cent igram hour s be ing given , and on June 15 ah
oth er port ion was removed .
“Here we se e w onder fu l changes . I n place of th e sarcomatou sfungat ing tumor we find a s tructure much reduced in s ize . The largec el l s o f the growth under th e influ ence o f the rays have changed to
smal le r connect ive—t i s su e and sp indle ce l l s . The ce l l s sh ow necros i sand necrob io s i s . The connect ive - t i s sue cel l s h ave been mob i l i z ed andth e l eu‘
cocyt i c i nfi ltrat i on i s mo s t i nten se , du e doubtl e s s to th e t roph i cst imulu s . The connect ive t i s su e has been va scula ri zed , not by a mereinflammatory react ion
,bu t by a truly specifi c st imulus , wh ich has ex
pre s sed i t se l f i n th e d-efininte form o f conn ective - t i s su e el ements .%Another ev idence o f the h i sto logi cal changes p roduced by rad ium
rays upon canc er—ce l l s i s shown in the case reported by D rs . A ik ins andS imon
, of Toront o , i n the D ominion Medical Monthly , S eptember , 1914 .
This pati ent twelve year s prev iou sly had the r igh t breas t removed forcarcinoma . I n March , 1914 ,
a recurrence was not ed in the l e f t b reast .I t cons i sted of a hard mass o f indu ra t i on about one and a hal f i nche si n d iamet er . The n ippl e wa s ret racted and glands were pre sent in theax i l l a
,togethe r wi th oth er typi cal symptoms o f ca rcinoma . Rad ium
w as appl i ed several t ime s by a capabl e expert , and at the end of th emonth o f May the brea st was removed . The fol l ow ing i s th e pathologist
’
s report :
95
A spec imen of what p roved to be an adenoca rc inoma of the breas twas subm itted to u s a f te r being subj e ct ed to the influence of rad ium .
We fo und the upper port ion of th e skin wh ich previou s ly had been re
ported to be in fi l t rated w i th the growth to be tota l ly f ree f rom any re
ma ins of mal ignan t t i s sue . D eepe r in the t i s sue,howeve r
,th e re seemed
to have su rv ived a d iffu se growth , the ce l l s be ing smal ler a s we nearedth e su r face . These cel l s wou ld al so have been destroyed had rad iat ionbeen cont inued .
“
Some of the carc inomatou s cel l s were markedly hypert roph ied ,some w ere mon st rou s , some vegeta t ive , whi l e th e p rotop lasm showedmarked eos inoph i l i a , p roving beginning degenerat i on . The var ious ti s suee lement s had become broken up and eosinOphilic ; young fibrob la st s hadev iden tly rep laced th e growth in the part s neare r th e sur face .%
D omin ic i and Barcat exam i ned a spec imen from healed radiumbu rn s . The t i s sue s were composed o f fib robl asts and connect ive - t i s suebund les paral l e l to each othe r and paral l e l to the su r face o f the sk in .
The fixed cel l s became rarified,th e ch romopla sm o f th e parenchyma l
ce l l had d i sappeared and was changed into hyaloplasm . Th ey not edthat the connect ive- t i s sue bundle s separated and the fibrobl as t s becameth i cken ed . These obse rvers al so d i scovered that th ose port ion s o f thet i s sue wh ich had been subj ected t o radium became essent ial ly d ifferentiated f rom those not with in the rad ium field . A l l t i s sue - cel l s a re affected by the rays . The cel l s of th e neopl asm are e spec ial ly su sceptibl e .A s a genera l ru l e the more vic iou s th e ce l l th e greate r the effect uponi t o f the ray . Normal t i s su e- cel l s a re inj ured
,but whe re they a re in clos e
relat ion wi th cancer- ce l l s i t was dis cove red th at be fore they are hu rt beyond recovery the cel l s of mal ignan t growths are e i the r dest royed or sochanged that normal , healthy st ructu re i s sub st itut ed . Normal ce l l sappea r to have a greate r re si stanc e or a l e s se r su scept ib i l i ty and are notso eas i ly influenced by radia t ion . They recover more qu ickly a ft erin j u ry wh i l e th e cancer- cel l s so affect ed recove r thei r act ivi ty s lowly or
not a t al l,being o f ten replaced in st ead by normal connect ive t i s sue . Th i s
is th e so- cal led se l ect ive act i on .
The conclu s ion s d rawn by Teitschlaender *of V i enna . a f ter re
peated patho logi cal examinat i on s of m al ignant t i s su e exposed to radiumappl i cat i on s a re a s fo l l ows : “Th e ch i e f act i on seems to be the i nh ib it i ono f karyok in es i s and act ivat ion o f l eucocytes and destruct ive changes ,al low ing the abnormal t i s sue s t o degen e rat e .I n sa rcomata the ret rogre s s ion takes place acco rd ing to th e fol low ing
1. The s i ze o f th e body and the nucle i of the l a rge ce l l s dec rea se .2. A s they sh rink th e neoplast i c el ement s elongate
,but the shape
of th e nucleu s becomes regula r , an d they eventual ly a ssume th e form o f
l arge embryon i c conn ect ive—t i s su e cel l s , fo rm ing into a cel led’ mas ss imilar to that o f a t rue fibroma . Thu s w e may emphas i ze the fact thatsa rcomata a re tran s formed by rad i um into a t i s sue anal ogou s to that ofa fibroma wi th myxoma‘tou s changes .
As regard s epi th el iomata and carcinomata under th e influence o f th erad ium ray s ,
w e find thatl . The c el l s g radual ly d im in i sh i n s i ze and s tain ing propert ies .2. Th i s at rophy corre spond s . not to the metamo rphosis of th ose
defin ite,formed el ement s
,but t o the ir dest ru ct ion , a s shown by keratini
zation or ab so rpt ion .
0The epi th el i omatou s cel l s d i sappear e i ther by mean s o f progres s ive‘M ona ts ch r . f. Geb u r ts h . u . 1 91 3 , xxxv i i i , 296 .
96 RA D I % M
absorpt ion of protoplasm and nucl e i th rough the l eucocyt i c infi l t rat ionor by a so rt of granu lar degenerat ion .
The other p roce s se s a s soc iated with‘ th e development of eve ryep i the l i a l tumor are ar re st ed
,wh i l e va scu lar connect ive t i ss ue i s re
organ ized acco rd ing to th e method j u st de scr ibed .
A s proo f that the changes in i ti ated by radium are such as l ead toimmuni ty , great importance must be a ttached to th e ce llu la r infi l t ra t i onfir st leucocyt ic , then late r a round - ce l le d infi l t rat ion . I t has recentlybeen shown these act iv it i e s requ i re d ifferent r eact i on s o f the . t i s sue forthe i r func t ion ; hence rad ium must affect the b lood . These infiltrationshave a lways been noted in a l l cases of an imal exper imenta l transplantation o f mal ign ant cel l s and always accompany the case s i n wh ich thean imal become s immune and the tumor d i s int egrated .
The pathologi ca l ev i dence s o f chemical,h i sto logi cal
,and anatomical
a l te rat i on s in mo rb id and normal t i s sue s from the effect of rad iumappl i cat i on s seems
,there fore
,to be abundant , substant ia l . exact , and
in cont rovert ibl e . The cli n ica l p roo f s of th i s act ion o f rad ium are i l lu strated in the fol low ing cases . For the pu rpose of th i s paper tho se on lyhave been se lected in whi ch the tumors have been proved by pathological examinat ion to be mal ignan t and in wh ich , under t reatment , th egrowth has d i sappeared .
CASE 1. J . S . ; f armer ; age 61 ; March 21, 1914. Pat i en t has basal ‘ce l l ed ep i thel ioma of the neck , recurrent . Has an extens ive and deepu lcerat i on ext en ding f rom the root of the ear down the neck . Part ofthe lobe of the ear i s de stroyed . The u lce rated sur face is about th reeby two and a hal f inches in extent . The large ve s se l s of the neck areexpo sed . Bes ide s tw o p rev iou s operati on s the ulcer has been recentlytho rough ly cauteri zed . Forty m i l l igrams o f rad ium appl ied for 9 hou rs .Apri l 10
,40 mg . o f rad ium appl i ed for 9 hours . Apr i l 16, 40 mg . of
rad ium appl ied for 9 hour s . Apri l 23 , the lobe of th e ear i s ent i re lyhea l ed and covered over w i th new sk in , and the u lce r i s reduced toabout hal f an inch in diamete r , which i s h eal ing in rap id ly . Forty mi lligram s o f rad ium app li ed for 12 hours , and the pat i en t l e f t fo r h i shome the next day , writ i ng me at the end of two month s that the ulce rwas ent i re ly healed and that there was no further u se for dre s s ings .He rece ived in a l l mg . hou rs of rad ium in th e cou rse of h i s t reatment .CASE 2. J .
F. F . ; s torekeeper ; age 57 ; Octobe r 9,
1914 . Pat ien thas a l ump abou t th e si z e o f a smal l orange involv ing the uppe r pa rt o fth e ste rnum at its j unct i on w ith the clav i cle extend ing po s‘t er io rly intothe mediast inum and external ly in to the right ce rv i cal region . Threew eek s previou s ly a tumo r o f th i s s i ze had been removed by operat ionand the wound had heal ed k indly and rap id ly . Recu rrence began abouta week a f te rward
.Pathological repor t a s to tumor was that i t was a
carc inoma .
Today 101 mg . w as appl i ed , proper ly screened , ove r theregion and al l owed to remai n for 20 hours , pat ien t gomg to h i s homein th e coun t ry next day . Octobe r 16, h e retu rned compla in ing of
.
a
s l igh t bu rn ingo f hi s sk in
,bu t wi th th e tumor reduced to abou t ha l f i t s
s i ze.
Octobe r 29,sk in i s s t i l l v ery tende r , but the tumor has almos t
ent i re ly d i sappeared . November 12,ve ry sl ight ev idence of tum-
or re
main ing
,
but h e has two wel l - marked rad ium bu rn s ; one rathe r deepe schar about an inch in d iamete r and another about hal f an inch ind i ameter , both pa in fu l and dischargingflone t o‘ th e r ight and th e othe rto th e l e f t o f the upper border o f the ste rnum . D ecemben 10 ,
th e two
RA DIUM 9;
s ides of the s te rnum and each clavi c le in the s ternum region appear tobe
.
S im i lar and normal . No ev id ence whateve r of any tumor . Thesk in i s s t i l l tender ove r the burned r egion's . Pat ient d isoharged .
Onerad ium appl i cat ion of mg. hours .
CAsE 3 . Mrs . S . ; age 40 ; hous ewi fe ; seen S eptemebr 10, 1914 .
H i sto ry of carcmoma of the breas t of two yea rs ’ s tand ing .Breast t e
moved November 10, 1915 Smal l nodu l e s s catte red a rou nd the woundand in the surround ing sk in ; recu rred in May , 1914 . The patho l ogi s t’sreport avas adenocarcmoma o f the r ight b rea s t . A t th i s date lol '
in 0.
of rad ium appl ie d in d ivi ded tubes for 30 hour s over a ci rc le o f about sixinch es in d iamete r . October 1, wel l -marked rad ium burn s p re sent , butnea l ing ; some of
.
the.
nodu les have di sappeared,bu t as the indu rat i on
along the wound i s st i l l marked another app l icat ion of radium was adv ised but re fus ed on account of the burn s . Nov ember 2
,rad ium bu rn s
st i l l p resent bu t slowly irnlprov mg . A number of new - skin nodu le shave appeared ou t s ide the c i rcum fe rence of the othe rs . One hundredand one m i l l igrams of rad ium appl i ed for 15 hours . D ecembe r 6, radiumburn s s t i l l severe . One la i ge bu rn on he r s ide ove r a recen t nodule i sve ry deep and t rouble some and i s about an i nch and a hal f i n d iameter
,
excavated and qu i te pa in ful . One hundred and one mil l ig rams of
rad ium appl ied for 9 hou rs , changing the lo cat ion of the appl i cat ioneve ry hou r . D ecember 19,
cond it ion about the same excep t that someof th e burn s are heal ed . There are p re sent at least a hundred nodu le s ,some of them qu ite l arge . One hund red and one mil l igrams of rad iumappli ed for 22 hour s , changing th e site o f the appl i cat ion eve ry tw o
hou rs . The rad ium was s creened by 8 m i n . of fe l t as wel l a s by mm .
of l ead . D ecembe r 23 . nodules are s lowly d i sappear ing and on ly one of
the large one s remain . February 5, 1915, pat i ent i s improv ing. Mosto f the bu rns have healed . The large bu rn po st erio rly i s s t i l l pre sent ,bu t the i ndu rat ion unde rneath i t has gone , a s ha ve apparent ly most 0 1th e o ther nodul e s . Pastient
’
ts genera l condi t ion i s very much improved .
Sh e has i n creased in we ight , has bette r colo r and appeti te , s l eep s wel l ,and is qu i te contented w ith h er cond it i on . One hun dred and one mi li igrams appl i ed to var iou s pa rt s o f th e l e s ion for 20 hour s . Apri l 15.
pat i ent has had two appl i cat ion s of,ra
'
dium of 101 mg . fo r 20 hou rseach t ime s ince th e la st note . The nodules have al l d i sappea red excepttwo or three su sp ic i ou s spots i n place of th e hundred and more i ndurat ion s she had when th e treatment began . Two smal l rad ium burns st i l lpe rs i st
.Ninety mi l l igrams o f radium appl i ed fo r 20 hours to the su s
piciou s point s . In her t reatment th i s pat i en t rece ived i n al l mg .
hour sCASE 4 .
Madame % . D . ; age 69 ; occupat ion , gove rne s s . Pati entgave a h i s to ry of having had a laparotomy for removal of a tumor ofthe uteru s seven yea rs ago
.S i x month s previ ou s to my see ing he r she
had a tumor removed f rom her back . w h ich the patho logi st reported tobe a round - cel l sarcoma . One mon th late r recurrence took pla ce . Onadmi ssi on to the hosp i ta l
,at th e s i te o f a sca r ove r the border o f th e
l e f t scapula r sp in e,at i t s inner ext remity . was seen a smal l u l cerated
grow th w i th characteri st i c odor . Thi s , th e pat i ent stated . had beenpre sen t for about two weeks
.On February 26 ,
1914 . th i s grow th wasremoved toge ther w ith the remain ing sc a r—t i s sue . Th i s w as rep ortedby the p athologi s t to be sarcoma .
The operat i on w ou nd heal ed k indly .
bu t on Ma rch 10 . as the re seemed to he som e tendency to infi l t rat ion of
the sk in at th i s poin t . 40 mg . o f rad ium elemen t w e re appl ied fo r 2hou rs
.
A f te r the fi r st appl i cat ion th ere w as no furth er d i scharge ; the
98 RA DIUM
indurat i on and S l igh t tendency to u lcerat i on wh ich had been pre sen t,
di sappeared ; th ere w as no furth e r pa in or i rr i ta t ion of any k ind
, and theS i te of the Operationwvou nd was apparently normal excep t for a wh i teS
car lme . h xammation on May 10 showed no ev idence o f any returno f the growth , bu t 40 mg . of rad ium were aga in app l i ed for 2 hours .Apr i l 10 , 1913 , there was no retu rn o f the growth . Th i s pat i ent rece ivedin al l 160 mg . hours .
CASE 5. J . MCE ; age, 55 ; occupat ion , wai te r ; August 27, 1914.
Twelve.
day s ago th e pat ien t fi r s t not i ced a t iny abrasi on in s ide thelower l ip to the r ight of the middle . On S ep tember 30 th i s had ihc reased to the s i ze of a large pea . Octobe r 20
,the whol e le s ion was
exc i sed and the wound sutu red . The patho logi s t’s repo rt was sa rcoma .October 21
,20 mg . of radium in two tube s were app l i ed for 1 h our .
October 23 , th e wound appe ared enti re ly h ealed and st itche s were re
moved . October 29, l ip was apparent ly norma l . I nci s ion had healedby fi rs t i n tent ion . Thirty- s ix mi l l igrams app l i ed for 30 minute s .November 12, 20 mg . were appl i ed to the inner sur face o f the l ip and 26mg . to the oute r , over the l i ne of the inc is i on , for 40 minutes . D ecembe r10
,20 mg . i n two tubes app l ied for 40 minute s . The l ine of i n ci s ion has
p ract i ca l ly d i sappeared . There has been at no t ime any loca l react i on .
Ap r i l 5, up to d ate there has be en no retu rn of the tumor . Th i s pat i en thad 8 1 mg . hou rs .
CASE 6. Rev . C . McC. ; age , 70 ; occupat ion , eccl e s iast ic ; D ecembe r26
,1914. Thi s pat ien t ha s growth in f ron t of l e f t ear , ra i sed three
quarters of an inch a‘bove %s kin su rface and abou t one-hal f inch in itslongest d i rec t ion by th ree- e ights of an inch i n w idth , wi th supe rfi c i al u lce rat ion
.Th i s tumor has been grow ing for severa l month s . Without
removal 10 mg . o f rad ium was app l ie d for 20 m inute s . D ec ember 30 ,no apparent react ion of the sk in o r tumor . The growth was removedw i th cu rved sc i s sors under loca l anaesthe s ia and immediate ly a fte rwards50 mg . of radium was appl i ed to the excavated base . Examinati onp roved i t to be ep i thel i oma . January 27 : S i nce the removal of the
grow th he ha s made weekly v i s i t s and 10 mg . of rad ium have beenappl i ed each t ime for 10 minute s . Feb ruary 8 , growth seemed to bes l ightly fi l l ing in f rom the bottom, Twenty- five mil l igrams of rad iumwere appl i ed for 10 minute s . March 10 . up to date 10 mg . o f rad ium for
10 minute s each v i s i t have been appl ied for four v i s it s s ince the la streport
. The u lce r ha s been comp l ete ly dest royed and new skin i s runn ing in from the edge s . There is no evi dence of rad ium burn . Apr i l6 .pati ent cal l ed for ob se rvat ion . There i s no change in th e cond i t ion .
Pat ient wa s tol d to ret u rn i n a coupl e o f mon th s to see i f fu rther t reatment was n ece ss ary .
Apr i l 11 : He d ied th i s morn ing of a suddenatt ack o f pneumoni a . I n al l th i s pat i ent had mg . hou r s t reatment .
CASE 7. F . W . ; age , 16 ; school gi r l ; March 17, 1914 . Pat i en t ha ssuffe r ed fo r severa l month s f rom enla rgement o f the l e f t l ower j aw andadj oining lymphat ic glands . Pathol ogical examinat i on o f one o f theg l and s showed i t to he sa rcomat ou s t i ssue of sp indl e
- cel l ed var iety .
Forty m il l igram s o f rad ium appl i ed i n d iv ided dos e s for 4 hour s .March 20 , no l ocal react i on f rom the preced ing t reatment; the sw el l ingo f
gl and s and j aw w as markedly l e ss ened ; 40 mg . o f rad ium aga in ap
pl i ed fo r 4 hou r s . Two w eek s l ate r th e pat ient appe ared to have eh
t itely recove red
.
Th ere was n o i rr i tat ion or rednes s o f th e sk in overthe tumors . Ap r i l 17. 1915. th e p ati en t
’s moth e r report s that pat ien t i st
' re l Yel l. She had 320 mg . hours .C“ 1
C risis%8 . F . C . ; age , 42 ; occupat ion ,broker ; October 17, 1914.
Pat ient has ep ithel ioma o f th e floor of the mouth involving the lowerj aw at the med ian l ine . Th is
‘
tumor was removed and the patholog ica lreport confi rmed the d i agnos i s . October 22, 45 mg . of rad ium app l iedfor 10 hou rs in d iv ided d ose s to the in s ide and outs ide of the j aw
, one
tube.
of 25 mg .
Ibe ing appl ied 10 hour s under the tongue clo se to themed ian l ine . Octobe r 29
,under su r f ace of the tongue somewhat ih
fl amed and tende r. Ten m i l l igrams o f radium,we l l screened
,app l ied
to the unde r su r face of the tongue at affected po in t and 51 mg .t o the
u nde r sur face of the ch in for 4 hou rs . Novembe r 12,no return o f the
tumor not iced , bu t there is a s light tendernes s and superfic ia l swel l in ga t the root of the tongue beh ind the teeth , a t the s i te of theSkin on the under sur face of the ch in i s red
,tender
, and sca l ing . No
rad ium app l i ed on account of tendency to burn . February 9, 50 mg .
app l ied fo r 22 hou r s to the under su r face of the ch in . On account ofa wel l—marked burn on the under s ide of the tongue no radi um is appl iedon the ins ide of the mouth . Ap r i l 4
,1915, the rad ium burn s have al l
d i sappea red and there is no evidence of any return o f the growth . Heha s a s l ightly en larged and tende r lump in the middle l in e beh ind thep rominence of the ch in . S eventy- one mil l igrams of radium app l i ed tothi s po in t for 8 hour s . Thi s pat i en t had i n al l mg . h ours o ft reatment .
CA SE 9. J . W . ; 51 ; occupat ion . sh i p’s carpente r . Th i s pat i enthad ep i thel ioma of the eye l id . E leven years ago he was operated uponfor a s imi lar tumo r sai d to be mal ignant. The pre sen t tumor w as re
moved,and patho logi s t ’s repor t showed i t to b e epithe l ioma . A fte r ex
cision the wound was un i ted by th ree s t i tches , ‘
w hich pa rted on the thi rdday ,l eav ing a gaping wound . Thi s was resu-
tu red , and at the same t ime10 mg . o f rad ium were appl i ed fo r 20 minutes . No ev idence o f rad iumburn w as not i ced f rom e i the r of t he se app l icat ions . At the end of threeweeks f rom the fi rs t Operat ion 10 mg . o f rad ium were appl ied again for20 minutes and the pat i en t w as di s-charged . Thi s pat ien t had mg .
hou rs’ t reatment . No r ecu rrence when seen Apr i l 20 , 1915.
CASE 10. J . S . ; age , 58 ; occupat ion , fa rme r ; June 20 , 1914 . Hepre sen ts h imse l f with a large excavated u lce r o f the r igh t base o f th etongue extend ing forw a rd al ong the r ight s i de of. th e tongu e and acro s sthe back o f th e tongue to the l e f t s id e . The tongu e i s badly swol len ;s al i va i s exce s s ive ; great d iffi cu lty in mast icating , and i t i s a lmost imposs ibl e to swal low food or sal iva . The who le tongue i s exceed inglypain ful
.The submaxi l l ary and cerv ical gland s o f th e righ t si de are
swol l en and tende r.He has l o s t about 40 pounds in the past five we ek s ;
i s unab le to s le ep f rom the pain ; c annot tak e nouri shment except i n verysmal l quan t i t i e s
,and i s p ract i cal ly unab le to swallow or breathe w i th
com fort,lying down .
His whol e condi tion i s p i t iable . The t i s su e takenf rom the u lce rated edges
~ of th e sore by pathologi st s in h i s home townhas been reported as epi the l i oma . One hundred and on e mill igrams'
of rad ium in fou r separate tubes w i th tw o mm . of le ad screen appl i edwel l back on th e r igh t s i de of the tongue and cover ing part o f the u l
cerat i on,for 10 hou r s ; 5 mg . o f rad ium al so appl i ed ove r submaxi l lary
gland s and changed f rom time to t ime . At the end.
o f 24 . hou rs th epat i ent w as d i scharged to go home to the country W i th the request toreturn in S ep t ember . On Augu st 25. the pat i ent retu rned fo r 0 1)
servat ion.
Th e u lc erat i on at the back of the tongue had c i catr i zed ; th esw el l ing o f th e gland s had di sapp eared ; en larg ed g l and s cou l d no l onge rbe made out in neck ; th e pat i en t had i ncreased 20 pound s in we igh t andwas abl e to mast i cate and sw al l ow any k in d o f food ; ext ra secret ion of
100 RA DIUM
sal iva had ceased . Pat ien t con s idered himsel f cur-ed . Curious ly enoughhe had a rad ium burn on th e ti p of the righ t s ide of the tongue
, wh ichhe sa id w as very much better than a f ew week s ago and was ev identlyhea l ing . I n a l l h e had mg . hour s o f t reatment .
CA SE 11. Mis s A . ; age 32 ; occupati on , c lerk . Enti r e brea s t andax i l la ry con tent s removed on February 15
,1914 . Reported as adeno
carc inoma . Octobe r 20, smal l nodule s wh ich had appeared i n scar re
mo ved . November 21, several new ,smal l i ndurat ion s have appeared
in the sca r a round i t . The large st i s the s i ze o f an almond . Thi rtyfive mil l igrams of rad ium were appl ie d to the mos t p rominent lump s for12 hou rs . D ecember 22
,marked radium burn over s i t e o f larger tumor
,
w h i ch i s nea rly gone . The smal l e r one has di sappeared,bu t a numb e r
of new smal l n odules , the s i ze of r i ce seed-s , are p re sen t . One hundredand one mil l igrams of radium appl i ed for 22 hour s .These cases , al though few in number, represent a vari e ty o f mal ig
nant tumors,al l of wh i ch a re su sceptibl e of remova l by u se of rad ium .
They do not by any manner of means rep re sen t the l a rge number of
pat i ent s a ffl i cted w i th cance r of var iou s stage s and cond it i on s where thedegree of the d i s ease and compl icat ion s are su ch tha t ou r pre sen t knowledge and experi ence do not permit u s to encourage th em to hope for acu re by mean s o f operat ive procedu re s , the u se o f rad ium , se ra , vaccine s ,or any oth er known anti cancerous therapy . None o f th e above - reportedca se s a re cla imed to be cu re s . T ime enough has not e lapsed for such acla im
,bu t a s we learn more of the act ion of radi um i t i s b e l i eved that
more of the cance r case s wh ich a re looked upon as hopele s s at p re sen tmay be rel i eved by rad ium alone or by a proper col l abo rat ion o f rad iumwith th e vari ou s other remed ie s at ou r d i spos al . I n sp i te of the greatadvance r ecen tly in the method s and techn ique in u s ing radium , the re i ss t i l l much to be l ea r ned . The amount needed depends upon the differentpurpose s of appl i cat i on , th e d ifferen t depth s of t i s sue to be affected . thevari ety of t i s sue , the degree o f malignancy , its s tage , the l ength o f t imeo f a
ppl i cat ion
,and many othe r factors st i l l t o he set tl ed . A l l th ese in
d ication s can be defined only a f te r much exper imentat i on , l ong con
t inn ed , togethe r w i th a p roper app rec iat ion o f ou r rap idly accumulat ingpathologi cal knowl edge o f the act ion o f th i s power fu l remedy on l i vmgt i s sue s .Many phase s a re developed dur ing the cour se of rad ium t reatment .
Certain case s o f mal ignant growth s y iel d rap id ly to smal l quanti t i e s ofthe remedy ; on the other hand , other s are st imu lated apparent ly by smal ldo se s
.
Some skin s are ext remely sen s i t ive to very smal l quant it i e s o frad i um
.Othe r pat i en t s have sk in wh ich i s not affected at a l l by large
quant i t i e s conti nuou s ly app l ied and f requently repeated , W i thou t regardto the p rotect ion supposed to be given by screen ing .
Curiously,exact ly sim i lar ca se s of mal ignant growth s rayed exact ly
the same w ay ,wit-h the same amount o f sc reen ing , the same l ength o f
t ime o f appl i cat ion
,in person s o f as near a s pos s ib l e the same age and
per iod of t ime of tumo r , and where the p rev iou s operat ive t reatmentwas s im i l a r , may and do give exactly oppo s i t e re sul t s . For example ,Case s 3 and 11 were preci se ly s imi l ar to anoth er case not reported
.
here ,where th e recur rent nodule s pe rs i s ted and in creased in sp i te o f S im i l a rt reatment in every way . The pathological report was the
% same ; re
cur rence took place in the same manner , but a f te r one .
l a- hou r ap
pl i cat ion o f 100 mg .sh e w en t f rom bad to worse and died in a few
w eek s . My feel ing i s th at one appl icat ion was not suffic ien t and that
in sp i te of apparent fai lu re the treatmen t should have been pers is ted in .
To the lay mind a very seri ou s compl icat ion i s the burn wh ichsomet im e s fol lows the app l i cat i on . Th i s may be extens ive and deepand at t imes very pain fu l and d ifficul t of cure .
Some of my pat ients have not i ced the more rap id d i sappearanceofp ort ions of th e growth under the bu rned area than under that port i onunaffected in thi s manner . The se pat i ent s sometimes ask to have therad ium le ft on long enough to produce an escha r , bel i ev ing th i s to hast enthe cure .
The clo se r the rad ium to the Obj ect the greate r the effec t of therays . A s th e rays shoot ou t i n every di rect ion f rom the c ente r the i dealcourse of t reatment would be to have the rad ium as nearly as poss ibl e inthe m iddle of the tumor . There fo re a mal ignan t growth in one of thenormal tube s of the body and wi th i n reach o f rad ium app l i cat ion— as forinstanc e , i n the oesophagu s , or the rectum— i s theoret i cal ly much moresu scept ib le to t reatment
,espec ia l ly i f the mal ignant growth su rrounds
the canal than whe re the neop lasm can be rad iated f rom one su rfaceon ly. I f the re i s a s inu s runn ing to or throu gh the tumor
, or i f i t i s ina lo cat i on where i t can be p ierced to accomodate the in se rt ion of th erad ium , sat i s factory treatment can al so be carr ied on . When n e ithero f these methods i s poss ib le
,we have to re sort to what i s cal l ed cros s
ray ing or cro s s- fi r ing . In th i s mean s o f t reatment we d ivide the radiumi nto cap sule s and place i t on the oppos i t e s i de s of the growth , protect i ngthe sk in from the burning ray s a s much as po ssib l e by means o f screen so f d iffe rent th i cknes s . A ll the se detai l s are ma tte rs o f techn ique and
depend upon the ind iv idual pat i ent an d the d i s ease a s wel l a s upon theexper ience of the ope ra to r and upon hi s personal equati on .
So l itt l e i s yet know n of the ac t i on o f rad ium on l i ving t i s sue s an dso much i s s t i l l to be lea rned that , working as hard as one can anddesp i te the vast amount of materia l , even with an ample quanti ty of
rad ium . i t may st i l l be years be fore a p roper and suc ce s s fu l method of
treatment appl icab le to each indiv idual tumor can be sat i s facto r i ly and
effi c i ent ly worked ou t.
Here are twelve pat i ent s w i th new growth s,patho log ical ly an d
cl in i ca l ly mal ignant . Th e se neoplasm have di sappeared du ring rad iumappl icat ion s . Fol lowing the i r de stru ct i on o r removal th e t i s sue at th efo rmer s i te o f th e se tumor s i s now normal and remai n s so . , Certa inthe se re sult s meri t our furth e r care fu l cons ide rat ion .
RADI%M IN THE TREATMENT OF %E%OIDS
FRAN % E . S IMPSON ,M . D .
, CH ICAGO .
Th e i n t roduc t ion of rad ium furn i shes u s wi th a the rapeut i c agentof great value in the t reatment o f kelo ids . Un fortunate ly
,one is no t
always abl e cl in i cal ly to d iffe rentia te pure ke lo id s from those mixedw ith scar t i s su e .Pure kelo ids
,espec ia l ly tho se of recen t formati on and in young
chi l dren can o ft en be resolved with sel ect ive % doses o f rad ium ray s,
‘ J ou rna l of th e Ame r ican M ed ica l A s s oc iat ion ,V o l . 64, pp . 1 3 00- 1 , 191 5.
102 RA D I % M
that is , with an amount of ray ing that cause s l i t t l e or no inflammatoryreact ion .
% e lo ids mixed wi th sca r t i s sue are more res is tant to rad iu‘m,but
even the se can gene ral ly be' made to d i sappear by us ing doses that causemore or l e s s des t ruct ive act ion .
The exact do se neces sa ry in ' indiv idual cases is difficu l t to s tate , buta f te r some exper i enc e w ith d iffe ren t rad ium applicator s i s obta ined , an
F ig. 1. —% e lo id fo l low ing b u rn on r igh t grea t toe . From p ho tograp h take nMa y 27 , 1 91 4.
approx imate “ es t imate of the amount o f raying necessary can o ften be
given , espec ial ly i f the cl i n i ca l type of kelo id is c lear.Pain
,wh ich o ften radiate s from the keloid
, is us ual ly re l ieved at
the same t ime w it-h the re so lut i on of the tumo r . Th i s i s fo rtunate asi t i s o f t en pa in , whi ch may be ,
of an excruciat ing character, that b r ingsthe pat i ent for re l i e f . Somet imes rel i e f i s sought for cosmet ic reason sal one
,and sometimes becau se the ke lo id i s in an inconven ien t s ituat ion .
I n upwards of a dozen ke lo i ds of variou s type s w h ich I have treatedw i th rad ium
,the re su lts have been super io r to those obta ined by othe r
method s .The apparatu s and techn i c employed vary somewhat wi th the type
%
oi l es ion . W ith kelo id of cons ide rab le s i ze , the varn i sh appl i cator i s byfar the bes t in st rument to u se . -For l in ear ke lo id s , su ch as may fol lowan operat ion inc i s ion , th e rad ium tubes a re very conven i ent , althoughthe varnish appl i cato rs can be used by screen ing off th e heal thy t is sueon each s ide o f the kelo id .
F ig. 2.—A pp earan ce of toe s h ow n in F igu re 1 , af te r ab ove tw e l ve hou rs ’
rad iumt re atmen t . From p h otograp h taken J an . 3 0 ,
1 91 5.
In p ract ic e th e theoret i c u se o f purely select iv e doses,wh ich may
cau se the kelo id to d i sappear , must o f ten give way to the more rap idm ethod o f des t ruct ive dose s . The genera-l prmcrple of u s ing a sufli crent
RA DIUM 103
d ose to produce a s l ight b u t not an excess ive react ion i s th e one I u sual lyfol l ow . Repeat ed and st rong react ions are u sual ly unneces sary and arel i ab le to be fol l owed by te langiecta se s
,which det ract ve ry much from
the co smet i c appearance o f the t i s sue s o f repai r .In favo rab le cases the s i te o f the ke lo i d may become almos t l i ke the
normal sk in both in colo r and textu re . In othe r ca ses i t may be smoothand wh ite and sometimes i t may be redde r than normal . In no casehas the re been an absolute re s i s tanc e to the act ion of the radium .
F ig. 3 .—% e lo id on b ack s i tu ated b e tw e e n th e s p in e and low e r an g l e of r igh t
s cap u la. From pho tograph taken Ap r i l 4, 1 914 .
A brie f h i s tory of the fol low ing il lu st rat ive cases w i l l show them ethod of treatment and the re su l t s ob tained .
CASE I . (Re fe rred by D r. J . R . Buchlb inder .) I n a gi r l , aged 15.
a kelo i d developed a fter a carbo l i c- ac‘i d burn near the metatarsophalang ea l j unct i on of th e r ight great toe . The kelo id , which was of blu ishred co lo r, covered an area o f about 4 square centimete rs and wasel evated abou t 2 cm . above the l evel of the surrounding sk in . I tc au sed great inconven ience from it s s i tuat ion so that a th i ck p iece of
felt fenest rated to admi t the kelo i d w as worn to p revent pre ssure of thes hoe . A quarte r- st rength rad ium app li cator s creen ed with 1- 10 mm .
o f lead was used . Between May 27 and June 4 ,1914 ,
th i s was appl iedfor s i x hou rs in f ract ional do ses o f an hou r each . Th i s series o f t reatm ent s was repeated in about s ix w eek s . The kelo i d completely fl attened out at the end o f fou r week s more a fte r having undergone ve ry
104 RA DIUM
s l ight inflammatory reacti on . At p resent on ly a s l ight wrinkl ing of the
sk in marks the s i te , complete invo lut ion h aving pers i st ed .
CASE 2 . (From the Ch icago Pol i c l i n i c .) A l a rge ke lo i d on the
back between the spine and the l ower angle o f the l e f t sc apula O f a
woman 45 years of age had fol lowed a bu rn wi th a flat i ron . The
tumor was deep red in colo r and i t s su r face was traversed by several
F ig. 4.—App earan ce of ke lo id sh ow n in Figu re 3 , af te r ab ou t s ix hou rs ’
rad ium
grea t
gn en t. N ote remo va l of low e r ha l f of ke loid . From ph otograp h taken Se p t.
0 , 1 1 4 .
la rge venu les . I t was about 15 cm . long and 4 cm . w ide and was
e levated abou t 2 cm . above the genera l l evel of th e sk in . Excruc iatingburn ing pa in of paroxysmal character w as compla ined of and th is hadb rough t th e pat ien t for re l ie f . Between Apr i l 6 and 22, 1914, e ightt reatments of twen ty minutes each were given to the lower hal f of thekelo id w i th a quar ter—s t rength rad ium apparatu s un screened . Moderatereact i on fol lowed whi ch su bs ided in abou t four weeks . Between May27 and Ju ly 3 certai n areas that had not involuted complete ly were given.
th ree hours exposure in f ract ional do se s with quarte r—s t rength and hal fst rength appl icato rs screen ed with 1- 10 mm . of lead . Thi s resu l ted incomplete involu t ion . The pain rad iat ing from the kelo id was completelyrel ieved .
59 EAST MADISON STREET .
REVIEWS AND ABSTRACTS
.J o seph B . Bi s sel l , Radium Therapeuti c s Othe rwi se Than ForMal ignancy — Med ica l Reco rd
,Vol . 87
,pp . 1023 -4
,1915.
Case report s are given O f pat i ent s who have been t reated and curedby the u se of rad ium .
“These are not case s o f mal ignant di sease,and
i t i s inte re st ing to real i ze that rad ium i s avai lable to re l i eve other thancancerous cond it ion s . %
CASE I.
—Mr . J . McC ., 43 years .oi age
,has always been a heal thy
,
robus t man , workng hard as a labo rer . A few days be fore coming intothe hosp i ta l h e in fec ted his thumb wh i l e Open ing oysters . He state sthat a p iece o f oys te r she l l penet ra ted under his thumb na i l
,making a
very pain fu l wou n d . Th i s soon became red and swol len,and the pa in
and tende rne ss extended up h i s arm . On ente r ing my serv ice at Bellevu e h e p resented a typica l p ic tu re of i n fect ion O f the thumb and forearm , with an involvement O f the metacarpophalangea l j o i n t and ost i t i sof the bone s entering into th i s j o int of the r ight thumb . There wasa seve re cel lu l it i s o f the sur rounding so f t part s with absces ses extend ingup th e arm . The d i seas e was t reat ed in the usual way by inc i s ion s
,i r
rigation s , and wet dre ss ings . A t the end of th ree weeks there wereseve ra l p ro fu se ly d i scharging s inu se s about the thenar eminence
,and
bare bone was fe l t th rough these s i nu ses . An x- ray p i c ture taken atth is t ime , d i sc lo se-d a badly d i sorgan ized j o in t , and a nec rosi s o f bothbones . I t was dec ided by the pat i en t and mysel f that the be s t th ing todo to ge t h im wel l qu ickly was to remove th e thumb . Be fore do ing so ,
however,I dec ided to t ry the effect O f short t ime rad ium appl i cat ion s
in t o the s inu se s . Th i rty mi l l igrams o f rad ium in three d ifferent tube swere inse rted in to the s inu ses l ead ing to the j o int . These in sert ion swere made on four d ifferen t occa s ion s , and th e rad ium was al l owedto remai n in the s i nu se s t en m inute s each t ime . The appl icat ion s weremade four or five day s apart . Immediately fol l owing the fi rst appl icat ion th e d i scha rge decrea sed
,th e s inu se s cont rac ted , the swell ing began
to l e s sen in amoun t,and at th e end o f th e th i rd appl icat ion only one
s inu s remained large enough t o in se rt a tube in to . The o the r two tubeswere there fo re placed on the out s ide o f the affected part and for thefi f th and l ast appl i cat ion al l th ree tube s were so appl i ed . A t the end o ftw o week s f rom the beginn ing o f th i s t reatmen t the in fect i on had en
tirely d i sappea red . the thumb w as again a sol i d par t o f the hand andth e pati ent was abl e to u se i t as you see now . Here 15 a remarkablechange f rom a so ft
,j e l ly - l ike mass o f b roken down t i s sue s W i th a
. fou lOdor
,d i scharging s inu se s , and a pain fu l and u sel e s s hand to w hat 15 as
you see a per fec t ly com fortab l e and avai lab l e organ , al though somewhatscarred and st iffened .
He u ses th e thumb now for every pu rpo se forw h ich i t w as des igned .
At no t ime was any dead bone removed or d i d
anycome away
,al though th e x- ray pi ctu re shows i ts pre sence .%
CASE I I.— Another pat i ent a woman . 35 years old . who suffered
f rom an in fect ion of the foot , due to a compound fracture of the secondphalanx o f th e second toe o f he r r igh t foot . The in iu ry was so severeand th e in fect ion so d eep that the toe was ampu tated at th e metatar sophalangeal j o in t ; th e in fect ion cont inued how eve r , .
and involved themetata rsa l bone
.A t the end o f several weeks a s inus rema ined , ex
tend ing f rom the up per su rface o f the foot to th e.
d i seased bone W i thno tendency to h eal ing .
In to th i s s inu s , and al ongs ide the ‘bone .%
a tubeconta in ing ten mi l l igrams o f rad ium was inserted and al l owed to re
106 RA DIUM
ma infor twenty m inu tes . Pain,swel l ing and d ischarge at once began
to d isappear , and the s inu s to grow sma l le r , so much so that the nextinse rt ion of the tube five day s later was qu i t e d ifficu lt and almost umnece s sary . A week a f te r the o riginal appl i cat i on th e pat ien t had en
ti re ly recove red and walks w i thou t a l imp or any evid ence O f havingso recent ly convale sced f rom a seve re in fect ion .
“CASE I I I .— Mr. % . M.,28 years O ld
,cl erk
,has been suffer ing for
thet
past th ree years f rom d iabete s . Early in D ecembe r, 1914 , he fi r st
not iced pain and swel l i ng O f the under su r face O f th e ba s e O f the secondtoe . Thi s gradual ly “became loca l i z ed in to an absce ss at th i s pointfo l lowed by an os t i t i s and necro sis o f the head o f th e second metatarsa lbone and the adj oi n ing phalanx . February l 0th a s inu s remain ing
,
and no improvement hav ing taken place in th e foot wh ich wa s nowqu i te decidedly i nvo lved in a secondary ce l lu l i t i s and lymphangi t i s
,the
S iri u s was wash ed ou t with a weak so lu t ion o f rad ium and 10 m i l l igram s
of rad i um protected by a s i lve r cap su le and rubber screen appl i ed forhal f an hou r . Three day s l ate r the d i scharge was much les s p ro fu se
,
nd 35 mil l igrams of radium were appl i ed to th is region, 10 mi l l igrams
of radium be ing appl ied as be fo re in to the s inu s . Five days later thes inu s was so n ear ly h eal ed that i t w as impos s ib le to in se rt the rad iumcap su le . The same quant i ty o f rad ium was appl i ed in d iv i ded do seson both sur face s o f the toe and foot nea r th e s inus . Ten days a f ter th efi r st appl i cat i on of rad ium there were no further ev idences of inflammat i on of the foot o r bone , and the pati ent was ou t of bed and walkingwi th on ly a s l igh t l imp . H is d iabete s had been t reated d ietet i cal lyduring th i s su rgi cal a tten t ion
,and his gene ral imp rovement was al so
marked . He was d i scharged March 10 f ree fr om sugar and apparent lymed ical ly and su rgi cal ly wel l .
“CAS E IV .—Anotli er ca se
,Mary H .
,49 years old , had been t rea ted
by me seven years be fo re the pre sent t roub l e . A t that t ime I had re
moved a cart i laginous and badly lacerated fibrou s ce rv ix ute r i . Thepat i ent had had no symptoms of any t roubl e in th i s respect u nti l s i xmonth s ago , when she p resented h erse l f t o my fr i end ,
D r. Baldwin ,o f th i s c i ty , becau se of con stant u ter in e h emorrhage . He t reated th i sw i th va ry ing degree o f su cce s s for several month s . About s ix month sago I saw her and put her under an anes th et i c for an examinat i on andremoval o f a p iece of the bl eed ing t i s sue fo r microscopi cal examinat ion .
On examinat i on unde r e the r blood could be seen ooz ing f rom the stumpof the ute ru s . Curet tage w as per formed rath er un sat i s facto ri ly ,
‘
75
mi l l igram s o f radium w as then appl ied again s t the cu rett e'
d po int andkept in place by packing fo r e igh teen hou rs . The pack ing
.
was re
moved.i r r igat ion s advi sed
,and no fu rthe r t reatment app l i ed . The
radium was appl i ed June 25, 1914 . There ha s been no retu rn Of bleeding up to dat e . Fol low ing th e rad ium insert ion th e pat ien t had a veryseveral rectal an d ves i cal tenesm-
u s l a s t ing several weeks , and aecompan ied
by rath er pro fuse and p ain fu l vaginal d i scharge . Th is I a ssumewas due to a rad ium burn . The rad ium in th i s i n stance was screenedoff by a “hal f mi l l imete r o f l ead and s i lve r , rein forced by another hal fmi l l imeter o f ru bber and adhes ive p last e r covering .
%
“CASE V .
— Thi s lady,25 year s ol d , unmarr i ed , had been Operated
u pon some s ix weeks b e fore Feb ruary 1 , 1915, for galls tone . 0
Follo
owmg
the i r removal th e gal l -%bl adder was dra ined and the b i l iary sinu s i s st i l lopen
.Sh e i s suffe ring now f rom smal l ab sces se s in e i the r ax i l l a . These
ab sce sse s are not l arge,abou t th e s i z e o f a smal l g rape , and superfiCial
in depth.They were slow in h eal ing af-te r Open ing and in that way
108 RA DIUM
t a lu e i n the t reatment O f cancer of a l l k ind s,whether operable or-
,in
operabl e . Two of the th ree ray s emi tted by rad ium ,the beta and the
gamma ray s , affect the t i s sues o f the body most p ro found ly , fortunate l y ,
however , act ing much more potent ly on the weake r cance r cel l s thanupon the normal ce l l s of the body . N O one cla ims and one ever hasc laimed that rad ium would cure all cases o f cance r— that e rroneous sta tement i s due to th e da i ly new spapers
,hunting for someth ing dramati c for
the i r co lumn s .%
Rad ium has , h oweve r , won for i t sel f a defin i te place in cancer therapy,
and w i th t ime and experi ence , and above al l , wit h increased amounts O frad ium and newer methods o f app lying i t
,i t s domain ove r th i s d read
realm wi l l undoubted ly extend f rom vear to year . %'
Radiuni therapy is analogou s to x- ray therapy,with the st r ik ing d i f
ferences tha t rad ium i s far more potent and i s l e s s l ikely to cause anyi rr itat i on or in j ury to the sound t i s sue s . Radium act s more speed i ly thanx- ray ; for example , i t i s the rul e to fin i sh the t reatment o f a fibro idtumor wi th one or two appl i cat ion s of rad ium
,whi l e many x—ray t reat
ment s a re cal l ed for extend ing over weeks or even month s . I includehere under the b road term cance r , s arcomata as wel l a s ep i the l ia lgrowths .
'
At fi rs t the ques tion w as : does rad ium real ly cure % Bu t now thatquery can be an swered pos i t ively and in the affi rmat ive a f te r the lap s eof years . Th i s fun damental matte r has a l so been set at rest by autopsymade yea rs a f te r t reatment of inoperabl e cancer .%Cancer s o f the sk i n are most amenabl e to radiat ion . The on ly obstin
ate and re f ractory group of ca ses here is the case s wh i ch have ex i stedfor years and wh ich have been t reated by caute ry , cau st i c s , e tc . Thos ecase s a re ob st inate wh ich h ave invaded the deepe r t i s sue s or which havecrept ove r on to th e mucou s su r faces . The most Obv iou s advantage s ofrad i um are seen in cancers around the eye . the ear , th e l i p s , the nose ,where the heal ing takes place w i thout mut i l at i on , i n marked cont rast w ithexsective su rgery . Even where there has been exten s ive u l cerat i onth ere i s o f ten a su rp ri s i ngl y good re storat ion of form .
%
“The ent i re surgical world has been start l ed by the re su l t s s ecured so
rapi d ly in t reat ing w i th rad ium that h i the rto hopele s s group the l ym
phosarcomata .Here great tumors inte rpenetrat ing al l th e anatom i c
st ructu re s even to th e b a se o f the skul l , the neck or in to th e chest , l i te rally mel t aw ay in a few days ’ t ime . The rays act l ike myr iad s o f microscop i c kn ive s . attack ing every ind i v idual i nvading ce l l , whi l e s par ing normal t i s sue s .
“Many othe r sa rcomata a re a lso h elp ed in a remarkabl e manne r . bu tnot in such a large pe rcentage of th e case s . Ep i thel iomata O f the mouth ,ton s i l s and l ary nx , e speci al ly the basal cel l ed . even in tota l ly inope rab l econdi t i on s , can
. be cu red in a fai r percent age o f in stan ces .%“A favorable form of cance r i s that o f th e thyro i d g l and . Thymu s
g row ths O f th e smal l round—cel l type a re very amenable to t reatment .% ip cancer s y iel d more and more a s our experi ence grows , but th e b lockdi s sect ion i s a lw ays cal l ed .
“N earlv al l breast tumor s re spond in some measu re , the la rger mednl
l a ry formbeing th e most su sceptib l e . The be st rul e h ere i s operat ionfi rs t
,w hen feas ibl e . and rad iat ion a f terw ard . Cance r o f the vag ina u su
al ly d i sappears rap i d ly under rad iat i on .
%
I am glad to report that cancer s o f the cerv ix are among th e mos tamenab l e to rad ium therapy , and th i s remarkable stat ement hold s good
RA DIUM 109
not on ly for the early , b u t even fo r the late r ca se s whe re the d i sea se,tho
mass ive , s t i l l remain s loca l i zed .
“ I n nearly 30 pe r cen t of the inope rable cases even the d i sease has d isappeared unde r effi ci en t rad iat ion wi th large amoun ts o f rad ium e lement .Th i s was t rue in a group o f over two hundred ca se s t reated by D r.
C.
F .Bu rnam and myse l f . I t i s a common s igh t to witnes s,too
,the disap
pearan ce o f a growth recu rring in the vaginal vaul t a f te r operat ion.I t
is a quest ion for the nex t th ree year s to sett l e,whethe r we w il l continue
to operate on any of th e group o f case s wh ich mel t down unde r ou r
rad ium the rapy .
Up to the pre sen t radium has been used repeatedly to sh rink an inope rab l e growth down and then to ope rate rad ica l ly .
“Final ly , in conc lud ing th i s b rie f resume le t me say that wh i l e rad iumman i fe st ly ough t to replace s u rgery in many in stances
,and wh i l e i t does
s ome o f i t s bes t work in cu ring cases wh i ch surgery has not th e remotesthope of tou ch ing , yet , on th e whol e
,there remain s a large p lace for
rad ium combined wi th su rgery,e i the r by fol lowing the su rgi ca l opera
t ion w i th rad iat ion s to reach nes t s o f cel l s whi ch th e su rgeon has not
been ab l e to e rad icate , or to immun ize the t is sue s , or t o remove a growthwh ich sh r inks , bu t doe s not di sappea r o r to t rea t recurrence s . With sucha b ri l l i an t p re sen t who can decl are what th e fu tu re for th i s n ew andmost poten t agen t may be % May we not l egi t imately look fo rw ard to adevelopment a s great a s that we have witnes sed in so short a term of
yea rs in th e fi el d o f x- ray th erapy and emanat ion s %%
T . Casper Gi l ch r i s t , M .D . . Cance r of th e Skin . Maryland Med icalJ ou rnal
, j uly , 1915, pp . 157- 60.
“The keynote to the whol e ques t ion o f cance r is ear ly d iagnos i s . I fth i s d i sea se were accompan ied by severe pa in s in its earl i e s t s tages
,the
large maj or i ty of pati en t s would undoubtedly be cured by modern method s of t reatment . I t has been sa id that there are th ree stages of the d isease : ( I) when the pat i ent does not know what i s go ing on , (2) whenthe fami ly doc to r is not su re of hi s d i agnosi s and in many cases doe s no tsu spec t cancer
,and (3) wait ing to decide what to d o a fte r the d iagnosi s
i s made by th e surgeon o r speci a l i s t . To cor rect th e fi r s t the publ i c ough tto be t rained to seek the doc to r earl y . To correct the second the doctorsdur ing the i r s tuden t cou rse should be bette r t ra ined i n dermatology .
“The defin i te d iagno s i s in so far as skin cancers are concerned ough tto be made by the dermatologi s t , and n ot by the su rgeon , becau se th efo rme r is fami l ia r w ith other affect ion s and th e su rgeon i s not . The
maj or i ty of pract i t ioners who have come for post- graduate courses inde rmatology have genera l ly made th e remark that they know l e s s aboutsk in d i sease s than about any other b ranch o f medi cin e . The teach ing cannot be en t i re ly at faul t , becau se i t cons i s t s most ly o f demonst rat i on s ofca ses ; bu t a good deal of the weakness o f the doctor’s knowledge i s du eto th e fact that
,in stead of attempt ing to fi rst di agnose the ca se h imsel f ,
a s,
he ought to be tra ined to do,the case s are de scribed and d iagnosed by
th e lectu re r , a f te r wh i ch the student s do not examine the pat ien tsthorough ly enough to remembe r them . Again , enough emphas i s i s h otl a i d on the f requen t demonstrat ions o f the common eru pt ion s , includ ingal l the var i et i e s of the early stage s o f cance r o f th e sk in .
“ I n my experi ence,I find that the pract it i one r more fre quently th inksfi rs t o f lupu s vu lgar is ( tubercu lo si s) a s a po s s ibl e d iagnos i s o f a ch ron ic
110
ulce r, e speci a l ly o f the face , wherea s that d i sease i s very uncommon ascompared wi th th e frequency o f cance r or syph i l i s .
“ I n comment ing upon cance r o f the skin, one real ly cannot do bette r
than presen t the ch ie f d i agnost i c po int s of the var ious fo rms of sk in cancer and the othe r comm on u lc ers for which i t i s m i staken .
%
“ I . Ca ncer . D efini t i on . Cance r is a spec ial new epi thel ial ce l l grow thwhich overcomes normal re si stance
,has a de st ruct ive tendency and
may form metas ta ses .%Epithel ioma . Term usual ly appl i ed to sk in cancers
,o f which there are
tw o main type s : ( a) squamou s cel l , (b ) basa l ce l l or roden t . Epithelioma is f requen t in m idd le or o l d age ; usual ly s ingl e l e s i on ; begi n s in sca lySpot , excor iat ion , fis su re , nodu le , wart or mole ; f requently re su l t ofch roni c i rr i tat ion .
“
(a) S quamous ce l l type— more mal ignant vari ety . Often begin s a sa p ink i sh or wh ite skin nodu le
,growing upward and downward ; has an
el evated , i ndurated border ; has sl igh t v i sci d d i scharge st reaked w i thb lood (because b l eeds ea s i ly) su r face nearly a lway s c ru sted and underneath cru st , l ike coarse granu l ation t i s sue ; new growth more than u lce rat i on when nea r su r face ; s l ow growth and final ly o ften l ead s to enlargement of nearest glands ; s i tuated u sual ly abou t eyel i d s , nos e or l i p s ; i nearly stages no pain
,l a te r pa in fu l . %
“O n %ip. Any pers i s ten t l ocal i zed th ickening or abra si on or fi s sure o f
s everal month s’ durat ion is very su spi ci ou s o f ep i the l i oma . %ate r l e s ioncons i s t s of
'
raised,i rregula r
,indu rat ed growth wi th coarsely granular
and cru s ted sur face ; bleed s eas i ly ; neares t glands frequent ly enlarged ;mic roscop i ca l ly show s pear l n est s , w hi ch are ab sen t in roden t u lc e r . %
“
(b) Roden t Ulcer ( basa l cel l .) U sual ly s i tuated about temple,eye
l i d s and nose ; superfic ia l ; shows very l i t t l e n ew growth ; apparent ly healing
,then break ing down again ; sp read s very s lowly , w ith l i t t l e or no el e
y ated edge ; i n some stages narrow . p early- whi te , rol l - l ike border ; u lce rat ion may last year s ; no glandul a r enla rgement ; w‘hen invades eye so cket ,can dest roy whol e eye ; p ract i cal ly pa inle s s .%
“N on - u lcerative Form of Rodent. Has a fi rm
,s l ightly rai sed , rol l ed
edge wi th scarl ike at roph ic cente r ; very ch ron i c and very s l ow -growing ;sect i on f rom margin revea l s natu re o f growth .
%
“Treatmen t. Rad ium ,
X - rays . exc i s ion when feas ibl e .I I . S vfi/u
’
l itic Ulcers . ( a) Primary . \Vhen ext ragen i ta l is most freq uen t on l ip ; more o ften in early adul t l i fe ; rap i d growth ;% short durat ion( l i t tl e t endency to act i ve u l ce rat ion) markedly infil t rated ; neares t gland ssoon become very much enlarged ; later other symptoms of general i zedlue s become v is ib l e ; pre sence of sp i rochaeta pal l ida c l inche s d iagnos i s .
“
( b) %ate S econdary or Tertiary . I n mi ddl e or late l i fe ; frequentlyon face ; two types nodula r ; one or more pea—s i zed and largersuperfici al ul ce r s in group s ; sp reads w i th s erp iginou s outl in e ; punchedou t ; raw—ham colo r ; so ft scarr ing ; i ndurated . (2) Gummatou s ; deep ;s ing l e ; markedly punched out ; indu rated ; necroti c ba se ; d i scha rge s f reely ; bad odor ; bone may be involved ; pain fu l at nigh t ; o ft en su perfi c ial lypunched - ou t so f t scans el s ewh er e : h i story o f lues .
“ I I I. %upus Vu lgaris . Commonest form o f tubercu lo s i s o f sk in ; rare
i n Un i ted S tate s ; beg in s in early l i f e . ra rely a fte r 20 years ; pecu l i ar yellow i sh
,l a rge p inhead s i zed , red , i nfi l t rated m-acu les , point s on nodu
les o fso ft consi st ence ( probe eas i ly pu shed in) ; most f requ ent S i tuat ion onface ; very slow cour se ; very ch ron ic ; u lcer s sha l l ow ; s can ty d i s charge ;n o se rpiginou s ou tl ine ; bone rarely involved ; sca r p ften dense . thick andtough ; o ften tub ercu lou s hi s to ry ; pre s s ing on marg in W i th gl as s sl ide W i l l
RA DIUM 111
show presence of p inhead—si z ed brown i sh a reas ; m icrosc0 pic secti on sshow tubercule s in skin .
%
IV . B las tomycos‘is . Begin s a s pustu le or papu lo
- pu stu le ; l ate r becomes pap i l l omatou s wi th m i l ia ry absces s es a round the margin ; maysp read rap id ly ; ra i sed , rather so ft‘ wi th pu s exud ing on pre s su re frombetween pap i l lae ; auto inocu lab le ; o ft en see more than one le s ion pre sent ;o ft en heal ing w i th s o f t sca rs . Microscop i c examinati on o f pus soakedin l iquor potassae wi l l reveal p re sence of budd ing doubly- contou red bodi e s about th e s i ze , and la rger , o f a red blood cel l . %
“
V . Varicose Ulcers . U sua l ly on low e r th i rd of l eg ; supe rfic ia l ; i rregula r in shape according to age ; cal l ou s edge ; su rrounded by eczematou s , deeply - reddened sk in ; les s pain s a t n igh t ; marked var ico se ve ins .%
“VI. S taphylococci Ulcers . Infected . Those not due to above can s
es ; fol l ow bad or neglected t reatment o r secondary in fect ion of eczema ,exco ri at ions
,s l ight wound s
,vacc inat ion , pu stu le s , in fected granulat ion ,
etc .,usu al ly superfi c ia l ; i rregu lar ; pa in fu l .%
Epithel ioma of the Tongu e . U sual ly hypert roph i c ; no ulc e rati on inearly stage ; fol l ows leukoplakia , syph i l i s or dental u l ce r ; a s mami l latedtumor ; i rregula r ; l a rge r a t base than apex ; su r face more v i l l ous than normal ; later u l ce r on deep ly i l l - defin ed nodul e ; eve rted borde r ; bloody d i scharge ; most f requen t on anteri or ha l f and edge s of tongue ; aged 40 to60 years ; gland s enlarged ; pain fu l sal ivat ion .
%
“Treatment. Exc i s ion , rad ium ,
X - rays . %I f th e p ract i t ione r i s i n doubt about th e u lcer be ing syphi l i ti c or
mal ignan t,th e VV
assermann t e s t or i nternal ant i syphi l i t i c t reatment wi l lf requent ly help to cl ear up th e d iagnos i s . Whil e in doub t about thed iagnos i s
,l eave the ul ce r alone
,o r p re scr ibe bori c o in tment or other
mi l d ant i sept i c appl icat i on s . D o not on any accoun t u se silver nitrate or
other caus tics , becau se the se u su al ly st imu late th e d i sease an d l haves een many case s become very mal ignan t and grow rapi dly a f te r such un
sk i l l ful appl i cat ion s .%FRE%% EN CY OF CAN CER
In the la st 20 years ’ experi ence I have come to the conclus ion thatcancer of th e sk in has not not i ceably increased in fre q uency , bu t theeffici ency of diagnos i s has improved so much that the di sease on ly ap
pea rs t o be more f requent .“Treatment. Thi s var i e s according to th e stage and pos i t ion of th e
cance r. Du ring the l as t s ix yea rs I h ave ob tain ed very succe s s fu l re s ul t s
w i th the appl i cat ion o f rad ium ,especi al ly when the cance r has attacked
th e low e r eyel i d . i nn er or oute r canthu s o f th e eye , var iou s parts of th eno se o r other part s o f th e face . The re su l tant sca r i s h ard ly noti ceab l e ,the appl i cat i on pain l e s s
,and w i th proper screen ing o f the rad ium no
unneces sa ryreact i on i s p roduced . A l l forms o f roden t u lce r can nu
doubted ly be succes s fu l t reated w i th rad ium . I have had 16 years’ experience w i th the u se o f X - rays in the t reatment of sk in
.
cancer s . andhave seen very many cu re s
,the most appropr iate cases aga in be ing those
o f th e rodent u l ce r ty pe .%“The u se o f the Cool i dge tulbe has s impl ified the t reatment o f mal ig
nan t
grow th s by in crea sed do ses of s creened X - ra v s , w h i ch n eed only be
given a few t imes .%“Complete exci s ion of smal l grow th s in appropr iate place s i s al so good
t reatment. bu t su rgi ca l p rocedu re i s not th e proper t reatment inbeginnin g ep i th el iomata o f the eyel i d s and vari ous part s o f th e no se .
’
0
“ I t is now a m oot q u e st ion w heth e r exc i s ion . X - rav s o r rad ium i s th ebest t reatment for early cancer s o f the l ip . Speaking general ly , t reat
112 RA DIUM
ment by X - ray s in sk i l l ed hands has given as good resu l t s a s su rgica l procedu re
, which has the d i sadvantage of caus ing much d i sfigurement . Ra
dium, which i s now be ing given in more i ntense dose s and sc reened i s
now producing excel l ent resu l t s . I have treated number s of ve ry pers i s ten t le s ions of l ips and tongue
,whi ch one cou ld not defin i te ly decide
whether they were cancerou s or not , but may have been p recancerou sl e s ion s , with radium with marked succes s .%
I sotopes . The word i sotope aroused a good deal o f d i scu s s ionat a recent meet ing of the Roentgen Socie ty , when M r . A lexander Fleck ,B .S c .
,of Gla sgow Un ivers i ty
,read a pape r on the chemi st ry o f the
rad io- e l ement s . I sotope is a te rm appl i ed by Pro fes sor Soddy to denominate bod ie s wh i ch a re chemicall y i dent i ca l , a lthough they may diffe rs l ight ly in atomi c w e igh t . The p roce s s o f radi um di s in tegrat ion . s tart i ngf rom uran ium
,may proceed th rough a whol e ser i e s o f el ement s and
a rrive final ly at the end - product,w h ich i s i so top i c w ith l ead— that i s ,
which is l ead in re spect to a l l i t s chemica l and oth e r prope rt i e s , bu t d ifferss l igh t ly from lead i n atomi c weight . Acco rd ing to th e late s t determinat i on s
,pi tch-blende lead
,the final product of rad ium ,
has an atomi c weightsl igh tly d iffe rent f rom that of ordi nary l ead
,and th i s d ifferen ce i s not
acc iden tal . But the word “ i sotope% involve s th e whole th eo ry o f th econst ruc t i on of th e a tom . Ruther ford ’s concept ion o f the atom , sa idMr . Fleck , was the only one which recommended i t se l f to the m ind o fth e ch emi st . I t postu lated a pe r fect sys tem wi th in the atom ,
con s i s t ingof an inte rna l nucleu s su rrounded by a r i ng of e l ect ron s
,and i t w as the
pos i t i ve cha rge i n th i s atom,together with the st ru ctu re of the nucl eu s ,
which determ ined the p rop ert i e s of a given el ement , and i t s p lace in thepe ri od i c tabl e . In any tw o i so top ic e lements
,the re fore
,the re woul d be
the same nuclea r charge in s ide the atom o f each,and presumably a
system o f e lect ron s a rranged in the same manne r . I n the cour se of thed i scu s s i on Pro fe sso r N ichol son sa id that i f the chemi st s we re p reparedto accept the theo ry of i so tope s , no se ri ou s acriticism was l ike ly to beforthcom i ng from the phys i cis t s . The poi nt wh i ch puzz led h im
,howeve r ,
was wheth er , theoret i cal ly , the spectra of a pa i r of i sotope s ough t to beident i cal . The an swer depended upon th e point o f v iew taken as theo rigin o f spect ra . Some w r iter s contended that th ey were o f dynami co rigin ; oth ers , in c luding %o rd Ray le igh . th at thei r or igi n was kinemat ica l ;and , on the lat te r pre sumpt ion , a d ifference in atomic Weigh t , howeve rsmal l
,wou ld be expected to produce a d ifference in the spe ct rum .
Pro fes so r A . \V. Porte r , who con s idered that the arrangem ent of th erad io- el ement s in th i s / o rderly sequence w as the mos t important gene ralization made s ince Mende léeff. con fe ssed that he pre ferred the t erm“ i so tope % t o th e more rigid Engl i sh o f th e te rm “ chemical i denti ty
,
%
becau se th e forme r w as l e s s defin i te , and might be st retched a l i t t l e a st ime w ent on and the n eed for some rearrangement o f idea s becamemani fe s t . Mr . Fleck as su red th e meet ing , how ever , that when Pro fes so rS oddy appl i ed th e te rm “ i sotope % t o these product s o f rad io - d i s in tegrat i on he never thought of us ing i t merely in th e sense of st rong simi lar i ty .
Chemica l iden ti ty - as,for example , between th e end product o f rad ium
and l ead— d id not inc lude phys i cal i den t i ty . and the atomi c weigh t , beinga phys i cal rath er than a chemical determinat ion , might va ry w ith i n con ~
s ide rab le l imi t s . I t was th e pos i t ive charge and th e nucl eu s of th e atomwhich determined th e prope rt i e s of a bod y .
% Bri t i sh Med . JO l l l‘
n . , March27th , 1915, p . 563 .
TERNA%
RADI ERAPYIs Indicated In
ARTHRITIS and
HIGH B% D P %REDEFIN ITENESS and CON STANCY o f DOSAGE are the im
portant facto rs i n the succes sful app l i cat ion o f radiumtherarpy .Th i s i s
pos s ib le only w ith so lut ions contain ing rad ium elemen t in known quantity . I n the fo ll ow ing table are given the rad ium element content andmache un i t equ iva lent of rad ium emanat ion o f the “S tand ard% Rad iumPreparat i ons .
S tan dard
S tandard Uni t s)
40 to 50% of any quant i ty o f radium e l ement,intravenou s ly u sed ,
i s e l iminated in the fi rs t 10 days . The remainder i s e l iminated at a dai lyra te o f l es s than one per cent . of the rad ium present , and may be h eldcons tant in quant i ty by admin is ter ing one bott l e of S tandard RadiumSolu t ion for D r ink ing, % every two to four days , depend ing upon theamount of rad ium fi rs t u sed .
Send for Clinical and Descriptive %iterature
lCZt om an
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