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RADIUM THERAPY 



RADIUM THEBAPY 



BY 

FRANK EDWARD SIMPSON, A.B, M.D. 

PROFESSOR OF DERMATOLOGY, CHICAGO POLICLINIC; ADJUNCT CLINICAL PROFESSOR OF 
DERMATOLOGY, NORTHWESTERN UNIVERSITY MEDICAL SCHOOL; ATTENDING DER- 
MATOLOGIST TO MERCY HOSPITAL, ALKXIAN BKOTHEKS HOSPITAL, HENROTIN 
HOSPITAL, ETC.; FORMER PRESIDENT AMERICAN RADIUM SOCIETY; FORMER 
VICE CHAIRMAN, SECTION OF DERMATOLOGY AND SYPHILOLOGY, 
AMERICAN MEDICAL ASSOCIATION; DIRECTOR OF THE FRANK 
EDWARD SIMPSON RADIUM INSTITUTE. 



WITH 166 ORIGINAL ENGRAVINGS 



ST. LOUIS 

C. V. MOSBY COMPANY 

1922 




COPYRIOHT, 1922, BY C. V. MOSBY COMPANY 
(All rights reserved) 



Printed in U. S. A. 



Press of 

The C. y. Mosby C 
St. Louis 



TO 

M. B. L. S. 
MY WIFE 



PREFACE 



The completed manuscript of this book was {riven to the publishers 
on July 6, 1921. The delay in publication, due to unusual industrial con- 
ditions, has enabled me to make some minor corrections in the clinical 
part of the work and to bring the bibliography up to date. 

A survey of the literature referred to in the bibliography, which I have 
tried to make comprehensive rather than critical, indicates the wide- 
spread interest in radium therapy. Unfortunately, lack of space has made 
it possible to mention specifically in the text the Work of only a few of 
the authors listed in the bibliography. 

The immense task of verifying all of the references in the bibliography 
has been accomplished only through the assistance of Mr. Robert J. Usher, 
Mr. William L. Teal, Miss Beryl L. Kanagy and Miss Hazel B. Kraft and 
I desire to express my thanks for their invaluable help. 

I wish also to express at this time my appreciation of the great kind- 
ness of several of my colleagues and friends. Dr. Paul Degrais and Dr. 
Bellot of Paris have generously loaned me the drawings of microscopic 
sections, taken from their own immense material, which are reproduced 
in this book. Dr. George Winchester has prepared the framework of 
the chapter on the collection and purification of the emanation for thera- 
peutic purposes. Mr. L. W. Taylor has made the schematic drawing of 
the emanation apparatus and has constructed the emanation decay table 
inserted in Chapter IV. Dr. C. H. Viol has loaned me the photograph of 
the Debierne-Duane-Failla emanation apparatus which is reproduced in 
the book. He has also read over the sections on the physics of radium 
and made valuable suggestions. Mr. James Eglin has carried out the 
actual work involved in the experiments on the absorption of gamma 
radiations in water, and has made the mathematical calculations used 
in the contruction of the tables in the chapter on dosage. Miss A. B. 
Hepburn, formerly physicist in our laboratory and Mr. Melvin Mooney, 
the present physicist, have also made valuable suggestions relative to the 
physics of radium. I am also indebted to Mr. Mooney for the schematic 
drawing of the electroscope. I wish to take this occasion to thank the 
publishers for their kind and unfailing cooperation. 

It is hoped that the book may be of interest, not only to those actually 
engaged in radium therapy, but to all physicians, and that it may serve 
as a reflex of the current practice in this branch of medicine. 

F. E. S. 

Cnir.\(io. M;m-h, 1922. 



CONTENTS 



CHAPTER I 

PAGE 

THE RADIOACTIVE SUBSTANCES 17 

The Discovery of Radioactivity, 17 ; The Discovery of Polonium, Radium, 
Mesothorium, Radiothorium and Ionium, 17; Transformation of the Radio- 
active Substances, 18; The Radioactive Families, 19. 

CHAPTER II 

RADIUM ITS ORHHN AND CHEMICAL NATURE 21 

Origin, 21 ; Urauinito and Carnotite, 21 ; The Chemical Nature of Radium, 
22; The Occurrence of Radium in Nature, 22. 

CHAPTER III 

BADIUM EMANATION AND RADIOACTIVE DEPOSIT 24 

The Decay of Radium into Radium Emanation, 24; The Absorption of Ra- 
dium Emanation by Different Substances, 24; The Decay of Radium Emana- 
tion into Radioactive Deposit, 25; The Radioactive Deposit, 26. 

CHAPTER IV 

THE TECIINIC OF THE PREPARATION OF RADIUM EMANATION FOR THERAPEUTIC 

USE AND THE METHOD OF MEASURING ITS GAMMA RAY ACTIVITY ... 29 
The Preparation of the Emanation, 29; Measurement of the Gamma Ray 
Activity of Emanation Tubes, 35. 

CHAPTER V 

THE RADIATIONS FROM RADIUM AND ITS DECAY PRODUCTS 40 

Alpha Rays, 40; Beta Rays, 41; Gamma Rays, 41. 

CHAPTER VI 

ABSORPTION AND FILTRATION OF RAYS 43 

Absorption of Rays, 43; Filtration of Rays, 45. 

CHAPTER VII 

THE ABSORPTION OF GAMMA RAYS IN WATER 49 

First Observations of Intensities with First Type of lonization Chamber, 53; 
Second Series of Observations with First Type of loni/.ation Chamber, 54; 
First Observations of Intensities with the Second Type of lonization Cham- 
ber, HO ; Second Series of Observations with the Second Type of lonization 
Chamber, 04; Final Series of Observations with the Second Type of loniza- 
tion Chamber, 66. 

CHAPTER VIII 

PHYSICAL AND CHEMICAL EFFECTS OF RADIUM RAYS 69 

loni/.ation of Gases, 69; Penetration of Opaque Matter, 69; Production of 
Heat, 70; Kmission of Light, 71; Phosphorescence and Fluorescence, 71; 
Photographic Action, 71; Coloration of Various Substances, 71; Other 
Chemical Kll'ects, 72. 

9 



10 CONTEXTS 

OHAPTKR IX 

PAGE 

BIOLOGIC EFFECTS OF RADIUM RAYS 7.'! 

Effects (if Radium Rays on Living Oils, "."> ; Effects of the Rays on the 
Skin, 7(i; Kfl'ccts on the Spleen, Lymphatic Glands, :md Hone Marrow, Ml; 
Kll'ects <ui (lie Blood, 80; Effects of the R:iys on Connective Tissue, Muscle, 
mid Cartilage, S2 ; Kffccts i.f the R:iys on tile Tliyioid and Thynins (iliinds, 
83; Effects of the Hays on the Stomach, Liver, Salivary Glands, 1'ancrease 
and Kidneys, 83; Effects of the Rays on the Testis and Ovary, HI; KflVcis 
of the Rays on the Xervons System, SI; Effects of the Rays on the Eye, 
85; Effect on Blood-Making Organs, s<; : The Method of Action of Radium 
Bays on Normal Cells, 86; Effects of the Different 'lypes of Rays, 88. 

CHAPTEB X 

BIOLOGIC EFFECTS OF RADIUM BAYS (Continued) 00 

Effects of Radium Rays on Malignant Cells, 90; Effect of Rays on Human 
Carcinoma, 92; The Method of Action of Radium Rays on Malignant Cell-. 
97; 'The Question of Stimulation of Tumor Growth by Insufficient Radiation, 
98. ' 

CHAPTEB XI 

T&E RADIUM REACTION .103 

Surface Radiations, 103 ; Intratuinoral Radiation, 107 

CHAPTER XII 

THERAPEUTIC APPARATUS . 1M 

Apparatus Containing Radium Salts, 109; Apparatus Containing Radium 
Emanation, 111; Apparatus for Using the Radioactive Deposit, 114. 

CHAPTER XIII 

DOSAGE . . . 109 

Surface Radiations, 116; Intratuinoral Radiations, 141. 

CHAPTER XIV 

THE TECHNIC OF RADIATION 

Surface Radiations, 14ti; Intratuinoral Radiation. 1 .">.">. 

CHAPTER XV 

RADIUM IN GENERAL SUKGEKY 158 

Malignant Tumors, 158; The Treatment of Carcinomata, 160; Sarcomata, 
228; Benign Tumors, 240; Chronic Infections, 240. 

CHAPTER XVI 

RADIUM IN GYNECOLOGY 

Malignant Tumors, 241; Benign Tumors, 241; Metritis and Endometritis, 
244; Metrorrhagia and Menorrhajfia not Due to Cancer or Fibroid, 244; 
Myopathic Hemorrhage, 244. 

CHAPTER XVII 

RADIUM IN DERMATOLOGY 245 

Malignant Tumors, 24fi; Benign Tumors, 246; Chronic Infections, 284; In- 
flammatory and Granulomatous Infiltrations of Uncertain Nature, 2S6; 
Hypertrophies, 294; Neuroses of the Hkin, 294; Disorders of the Appendages 
of the Skin, 295. 



CONTENTS 11 

CHAPTER XVIII 

PAGE 

K.MHI'M IX OlMlTII.U/MOLOfiY, OTOLOGY, RlIIXOIXXiY AND LARYNGOLOGY .... 297 
Ophthalmology, 297; Otology, 298; Rhinology, 298; Laryngology, 2!)S. 

CHAPTER XIX 

RADIUM ix DISKASES or THE DUCTLESS <~!LAMS 30.1 

Leukemia, .'id. 1 ',; Hodgkin's Disease (LynipliiKlcnonia). :!OS; Ooiter, :!OX ; Kn- 
l.-n-c'.l Tliyimis Ol.-ui.l, ::n!i. 

CHAPTER XX 

KADIUM IN INTERNAL MEDICINE 310 

The Administration nncl Elimination of Radium, .'ilO; Physiologic Effects of 
Radium, 313; Morphologic Changes in the Tissue Caused by Radium, 31(i; 
Therapeutic Indications, 318. 

CHAPTER XXI 

PROFESSIONAL INJURIES DUE TO RADIUM 322 

l.w.-il Kllrrts, .",22; Constitutional Effects, :i22. 

RIBLIOORAI'IIV 
BIBLIOGRAPHY . .... 325 



ILLUSTRATIONS 



FIG. PAGE 

1. Debierne-Duane-Failla apparatus 30 

2. Diagrammatic plan of apparatus in Fig. 1 31 

3. Diagram of electroscope 33 

4. Diagram showing electrical connections for null method of using ionization 

chamber 50 

5. Diagram of first type of ionization chamber 51 

6. Diagram of apparatus used for measuring absorption of gamma rays in water 52 

7. Diagram of second type of ionization chamber . . . 53 

8. Graph showing intensity in water. Base of applicator 3 cm. above surface 54 

9. Graph showing intensity below surface of water. Base of applicator 6 cm. 

above water 55 

10. Graph showing field 5 cm. below surface of water. Base of applicator 1 cm. 

above water 56 

11. Graph showing field 10 cm. below surface of water. Base of applicator 1 

cm. from water 57 

12. Graph showing field 15 cm. below surface of water. Base of applicator 1 

cm. from water I 58 

13. Graph showing intensity on surface of water. Base of applicator 1 cm. 

from water 50 

14. Graph showing intensity on surface of water. Base of applicator 1 cm. 

from water fiO 

15. Graph showing field in air 61 

16. Graph showing field in air, perpendicular to plane of tubes 62 

17. Graph showing field in water, perpendicular to plane of tubes 64 

18. Diagram showing change in intensity due to distance as compared with 

change in intensity due to absorption in water 67 

19. Apparatus for the application of radium 109 

20. Appartus for the application of radium emanation 113 

21. Diagram showing two radium tubes affecting three different points on skin 122 

22. Graph illustrating Table XXVII 134 

23. Diagram illustrating multiple portals of entry 136 

24. Photograph showing the method of handling radium 146 

25. Forceps 30 cm. long for handling radium tubes 147 

26. Three pronged forceps 30 cm. long for handling radium tubes 147 

27. Author's forceps for wrapping radium tubes in rubber dam 148 

28. Screen holders . 149 

29. Same apparatus as in Fig. 28 but of smaller size 149 

30. Flat silver screens with caps, devised for holding from 2 to 6 enamel emana- 

tion tubes 150 

31. Tandem gold screens for holding one or more enamel emanation tubes . . . 151 

32. Platinum screen for containing a glass emanation tube 151 

33. Screen for inserting radium tubes into the esophagus 151 

34. Radium pad composed of "squares" of soft wood 152 

35. Needle holder devised by Dr. O. T. Freer 153 

36. Author's instrument, constructed on the plan of an ordinary syringe, for 

burying emanation ampoules 153 

37. Heavy cast-iron movable shield for the protection of the operator .... 154 

38. Epithelioma of right cheek 162 

39. Patient in Fig. 38 after radium treatment 163 

40. Epitheliomia of right side of nose , 164 

41. Patient in Fig. 40 after radium treatment 165 

42. Epithelioma of tip of nose 166 

43. Patient in Fig. 42 after radium treatment 167 

44. Epithelioma of left lower eyelid 168 

45. Patient in Fig. 44 after radium treatment 169 

Hi. Epithelioma of right inner canthus, eyelids and nose 170 

47. Patient in Fig. 46 after radium treatment 171 

48. Epithelioma of left inner canthus, eyelids, nose, cheek, and upper lip . . . 172 

49. Patient in Fig. 48 after radium treatment 173 

50. Epithelioma of the right temple 174 

51. Patient in Fig. 50, after radium treatment 175 

13 



14 ILI.rfsTKATIOXS 

FIG. PACE 

.",2. Kpithclioma of the left temple 176 

53. Patient in Fit;. .">_ after radium treatment 177 

54. Epithelioma of left malar region 173 

55. Patient in Fig 54 after radium treatment 179 

50. Epithelioma of forehead 180 

57. Patient in Fig. 56 after radium treatment 181 

58. Epithelioma of right ear 182 

50. Patient in Fig. 58 after radium treatment 183 

60. Epithelioma situated below right ear and involving ear lolie 1S4 

(il. Patient in Fig. 60 after radium treatment 185 

62. Kpithelioma of nose, left eyelid, cheek, and upper li| 186 

63. Patient in Fig. 62 after indium treatment 187 

64. Epithelioma of lower lip ]!)() 

65. Patient in Fig. 64 after radium treatment . . : 191 

66. Epithelioma of upper lip . . 192 

67. Patient in Fig. 66 after ladium treatment 19!! 

68. Epithelioma supervening on leukoplakia of right cheek . 194 

6!l. Patient in Fig. (18 afler radium treatment 195 

70. Carcinoma of the tongue in patient aged 6.1 years . 196 

71. Patient in previous figure after insertion of 19 milHeuries of radium emana- 

tion continued in 1~> bare glass ampoules 197 

72. Carcinoma of right superior maxilla involving antrum 200 

73. Patient in Fig. 72 after radium treatment 201 

74. Adenoepithelioma of the prostate 209 

75. Same lesion as in Fig. 74 after radium treatment . . 210 

76. Carcinoma of the breast after powerful radiation 21.". 

77. Portion of Fig. 76 at higher magnification 214 

78. Portion of Fig. 76 at higher magnification 214 

79. Atypic cubical epithelioma of the breast, before radiation 21 "> 

SO. A part of Fi"'. 79 highly magnified 216 

81. Same epithelioma as in Fig. 79, after radiation 217 

82. A part of Fig. 81 highly magnified 21 * 

83. Carcinoma of left breast 219 

84. Patient in Fig. 83 showing improvement under radium treatment .... 220 

85. Metatypic pavement cell opithelioma of the neck of the uterus. I'.efore 

treatment 222 

56. Same epithelioma as in Fig. 85. Fragment removed 10 days after the first 

application of radium I'L'L' 

87. Same epithelioma as in Fig. 85. Section removed on the 29th day after tTie 

first radiation . . . 22.'! 

88. Same epithelioma as in Fig. 85. Fragment removed from the surface of the 

cicatrix of the neck of the uterus three months after first radiation . . 224 

89. Polymorphous sarcoma with predominance of fusiform cells. Before radia- 

tion 228 

90. Same sarcoma as in Fig. 89. Section of large nodule removed 15 days 

after powerful irradiations 229 

91. Same sarcoma as in Fig. 89. After radiation 230 

92. Sarcoma of right ear. Recurrence after excision 231 

93. 1'atient in Fig. 92 after radium treatment 231 

94. Sarcoma of left cheek in girl aged nineteen 232 

95. Patient in Fig. 94 after radium treatment ...... 233 

96. Tumors of eyelids 234 

97. Patient in Fig. 96 after radium treatment 235 

98. Sarcoma of bone. Recurrence after operation 236 

99. Patient in Fig. 9S after indium treatment 237 

100. Lymphosarcoma of neck 23S 

101. Patient in Fig. 100 after radium treatment ... 239 

102. Cicatricial keloid, following a burn of the face. Before radiation .... 246 

103. Same keloid as in Fig. 102 after radiation 247 

304. Keloid of right great toe 248 

105. Patient in Fig. 104 after radium treatment 248 

106. Keloid of back due to burn from a flat-iron 250 

107. Patient in Fig. 106 after radium treatment 251 

108. Keloid of back of neck. Recurrence after surgical removal 252 



ILLUSTRATIONS 15 

no. PAGE 

109. Patient in Fig. 10$ after radium treatment 253 

110. "Ac-no keloid" of hack of neck 254 

111. Patient in Fig. 110 after radium treatment .... 255 

112. Keloid of face following a burn 256 

11)5. Patient in Fig. 112 after radium treatment . . . ' 257 

114. Flat angioma of the hairy surface. Before radiation 258 

115. Same angioma as in Fig. 114, after treatment with radium by the method of 

"selective reaction," i.e., without visible macroscopic inflammation . . 25!) 

516. Cavernous angioma of tip of nose 260 

117. Patient in Fig. 116 after radium treatment 260 

118. Cavernous angiomn of forehead 261 

119. 'Patient in Fig. 118 after radium treatment 261 

120. Cavernous angioma of lower lip 262 

121. Patient in Fig. 120 after radium treatment 263 

122. Flat angioma of side of face, neck, chin, and lower lip 264 

123. Patient in Fig. 122 after radium treatment 265 

124. Vascular nevus of face and neck 266 

125. Patient in Fig. 124 after radium treatment 266 

126. Angioma of side of face and head in patient aged six weeks ' 267 

127. Patient in Fig. 126 at age of one and one-half years, after radium treatment 207 

128. Slightly elevated angioma of side of face 2f>8 

129. Patient in Fig. 128 after radium treatment 269 

130. Angiosarcomn (?) of left arm 270 

131. Patient in Fig. 130 after radium treatment 271 

132. Large cutaneous and subcutaneous angioma of left side of neck in child 

aged 6 months 272 

133. Patient in Fig. 132 after radium treatment . . . . : 272 

134. Lymphangioma circumscriptum of right buttock and inner surface of right 

thigh .275 

135. Patient in. Fig. 134 after radium treatment 275 

136. Pigmented nevus of left lower eyelid and face 276 

l.'i". Patient in Fig. 1:16 after -radium treatment 277 

138. Pigmented hairy nevus of left eyebrow and forehead 278 

139. Patient in Fig. 138 after radium treatment 27S 

140. Linear nevus in patient aged 4 years 279 

141. Patient in Fig. 140 after radium treatment 279 

142. Tuberculosis verrucosa cutis of first phalanx of left middle finger .... 280 
li::. Patient in Fig. 142 after radium treatment 280 

144. Tuberculosis verrucosa cutis of first phalanx of left thumb 281 

145. Patient in Fig. 144 after radium treatment 281 

146. Lupus vulgaris of right cheek in girl aged thirteen 282 

147. Patient in Fig. 146 after radium treatment 283 

148. Lupus vulgaris of right cheek 284 

149. Patient in Fig. 148 after radium treatment 285 

150. Blastomycosis of left inner canthus 286 

151. Patient "in Fig. 150 after radium treatment 286 

152. Lupus erythematosus of nose and cheeks 287 

153. Patient in Fig. 152 after radium treatment 287 

154. Lupus erythcmatosus involving nose and cheeks 288 

155. Patient in Fig. 154 after radium treatment 289 

156.* Lupus erythematosus involving right cheek and upper lip 290 

'57. Patient in Fig. 156 after radium treatment 291 

15S. Lupus erythematosus of four years' duration 292 

159. Patient in Fig. 158 after radium treatment 293 

Hill. Sycosis viiljiaris '. 296 

I'il. Patient in Fig. 16(1 after removal of hair with radium 296 

162. The Freei- damp for the intralaryngeal application of radium 300 

!<>::. The applicator held in the jaws of the Freer clamp with the screen contain- 
ing radium emanation in the glottis as indicated by heavy dotted lines . 300 

Hil. Apparatus for intralaryngeal radiation 301 

lii"'. chronic lymphatic leukemia -"'"I 

Ki(i. Patient in Fig. 165 showing remission of the disease' after radium treatment 305 



RADIUM THERAPY 



CHAPTER I 
THE RADIOACTIVE SUBSTANCES 

THE DISCOVERY OF RADIOACTIVITY 

Soon after Roentgen's discovery in 1895 of the x-rays, several physi- 
cists began to experiment with various substances to determine whether 
similar rays might be emitted by chemical bodies spontaneously. Poin- 
care suggested that the production of x-rays, which penetrated matter 
opaque to ordinary light, might be connected with the phosphorescence 
and fluorescence excited by the cathode rays in the glass of the vacuum 
tube. It was natural at first, therefore, to examine substances that 
fluoresced under the action of ordinary light. Prof. Henri Becquerel of 
Paris soon found that the fluorescent salts of uranium emitted radiations 
that passed through a thin layer of silver and affected a photographic 
plate. It was at first supposed that the emission of these peculiar radia- 
tions was in some way connected with the fluorescent properties exhibited 
by some of the uranium compounds. Further experiments proved, how- 
ever, that the nonfluorescent salts and the metal uranium itself, which 
is also nonfluorescent, emitted the radiations. From this observation 
Prof. Becquerel concluded that the rays were due to the element uranium 
and were independent of phosphorescence or fluorescence. The announce- 
ment of this new property of matter so-called radioactivity was made 
to the Academy of Sciences at Paris on February 24, 1896. Later Prof. 
Becquerel showed that uranium radiations like x-rays were capable of 
discharging electrified bodies such as the electroscope. Rutherford, in 
1899, demonstrated that this effect was due to the "ionization" of the 
air in the electroscope by the radiations. This phenomenon will be re- 
ferred to more fully in our description of the method of measuring the 
gamma-ray activity of radium. 

THE DISCOVERY OF POLONIUM, RADIUM, MESOTHORIUM 
RADIOTHORIUM AND IONIUM 

Using the electroscopic method of investigation, different physicists 
then examined various other substances in order to determine whether 
they were radioactive. G. C. Schmidt and Mine. Curie, working inde- 

17 



18 RADIUM THERAPY 

pendently, discovered in 1898 that thorium, an element derived from 
monazite and previously well known, .possessed radioactive properties. 
M. and Mine. Curie then found that certain uranium ores exhibited a 
greater degree of radioactivity than could be accounted for by the pres- 
ence of either uranium or thorium. They assumed, therefore, that some 
unknown element or elements were present in the ores. Their labors 
finally resulted in the discovery of polonium which was named from 
Mine. Curie's native land, and later (1898) of radium. Polonium is now 
known to be merely Radium F., one of the decay products of radium 
itself. In 1900, Debierne obtained from pitchblende another radioactive 
product which he called "actinium" and in 1905 Hahn isolated mesothor- 
ium and radiothorium. Ionium was discovered in 1907 by Boltwood. Al- 
together more than 30 radioactive substances arc now known. 

TRANSFORMATION OF THE RADIOACTIVE SUBSTANCES 

It was at first supposed that the radioactivity of uranium, thorium 
and radium was a permanent attribute. Later, evidence of the decay 
and recovery of radioactivity was noted. Now all accept the hypothesis 
first advanced by Rutherford and Soddy which explains radioactivity as 
a spontaneous process of atomic transformation. This process goes on 
at a regular rate for each radioactive substance and is accompanied by 
the emission of rays and the production of new forms of matter, these 
new elements in time transforming, until finally a stable atomic form 
is reached. These changes go on with greatly varying degrees of rapidity. 
Some of the radioactive bodies are transforming themselves so slowly that 
no change in their radioactivity can be detected over a period of several 
years. Their radioactivity, therefore, is relatively constant. To this 
group belong uranium, ionium, radium and thorium. Other radioactive 
bodies, of which mesothorium 2 and thorium X are examples, transform 
themselves very quickly and cease to emit rays after a few hours or days. 
The rate of transmutation is constant for any given substance, but differs 
for the different radio-elements. The rate at which a substance decays 
follows an exponential law; i.e., the rate at which a substance is decaying 
at a given instant is proportional to the amount present at that instant. 
It is this factor of proportionality that is constant for any particular 
substance. The rate of loss of activity is usually spoken of in terms of 
the "period," or more properly the "half decay period" both expres- 
sions being used in an identical manner. The period of radium is ap- 
proximately 1680 years. By this is meant that after 1680 years, one 
half of the original number of atoms remains untransformed ; after 3360 
years (2x1680) one fourth remains; after 5040 years (3x1680) one eighth 
remains, and so on indefinitely. Radioactive transformations differ from 
ordinary chemical reactions in that the rate of degeneration or change 



RADIOACTIVE SUBSTANCES 

of one radioactive substance into another cannot be altered by any known 
physical or chemical means. The rate of transformation remains the 
same throughout extremes of temperature and pressure. As each radio- 
active substance transforms, it gives off radiations, which are of three 
different kinds and are known as alpha, beta and gamma rays. These 
will be described in a subsequent chapter. 



THE RADIOACTIVE FAMILIES 

At the present time, three parent substances are known uranium, 
actinium, and thorium each of which transforms itself into a series of 
substances until an end or stable product is reached. There are thus 
formed three families or series of radioactive substances, viz., the ura- 
nium series, the actinium series, and the thorium series. The knowledge 
of the fact that actinium and its decay products are always present in 
uranium minerals, leads to the belief that this product represents a small 
fraction (3 per cent) of the "uranium 2" atoms which transform into 
"uranium Y" rather than into ionium. We may interpolate a table at 
this point showing the members of each series of radioactive bodies, the 
rays each substance emits and its half value, i.e., the time required for 
% of a given quantity to disappear by spontaneous transformation. 

TABLK 1 
URANIUM-RADIUM FAMILY 



NAMK 


ATOMIC 
WEIGHT 


HALF DECAY 
PERIOD 


RADIATION 


I'l-aiiium I 


238 


5 billion years 


alpha 


Uranium X 


234 


24.6 minutes 


betafgamma 


Uranium X 


234 


1.15 minutes 


beta+gamma 


Uranium o 


234 


About 1,000,000 years 


alpha 


Ionium 


230 


About 100,000 years 


alpha 


Radium 


226 


1680 years 


alpha 


Radium Emanation (Niton) 


222 


3.85 .lays 


alpha 


Radium A 


218 


3 minutes 


alpha 


Kadium B 


214 


26.8 minutes 


beta+gamma 


Radium C 


214 


19.5 minutes 


beta+gamma 


(99.97%) (0.03%) 






(alpha) 


k.-icliiini C 

2 


210 


1.4 minutes 


beta+gamma 


(side reaction 0.03%) 








TCnd 0.03% 


210 






Radium C' 


214 


0.000001 seconds 


alpha 


(Main reaction 99.97%) 








Radium D 


210 


16.5 years 


soft beta 


liudium K 


210 


5.0 days 


soft beta 


Radium F (Polonium) 


210 


136 days 


alpha 


Radium U (Knd Product) 


206 




No rays 








Atoms stable 



20 



RADIUM THERAPY 

TABLE II 
ACTINIUM FAMILY 



NAME 


ATOMIC 


HALF DECAY 


RADIATION 




WEIGHT 


PERIOD 




u% of Uranium II 


234 


About 1,000,000 years 


alpha 


Uranium Y 


230 


1.5 days 


beta 


Protactinium 


230 


Estimated 1,200 to 


alpha 






180,000 years 




Actinium 


226 


About 30 years 


soft beta 


Radioactinium 


226 


19.5 days 


alpha 


Actinium X 


222 


11.4 days 


alpha 


Actinium Emanation 


218 


3.9 seconds 


alpha 


Actinium A 


214 


0.002 seconds 


alpha 


Actinium B 


210 


36.1 minutes 


beta+gamma 


Actinium C 


210 


2.15 minutes 


alpha 


Actinium D 


206 


4.71 minutes 


beta+gamma 


End Product 


206 














TABLE III 


THORIUM FAMILY 


NAME 


ATOMIC 


HALF DECAY 


RADIATION 




WEIGHT 


PERIOD 




Thorium 


232 


23 billion years 


alpha 


Mesothorium 


228 


6.7 years 


soft beta 


Mesothorluai 


228 


6.2 hours 


beta+gamma 


Badiothorium 


228 


1.9 years 


alpha 


Thorium X 


224 


3.64 days 


alpha 


Thorium Emanation 


220 


54 seconds 


alpha 


Thorium A 


216 


0.14 seconds 


alpha 


Thorium B 


212 


10.6 hours 


beta 








(65% beta+gamma 


Thorium G I 


212 


60 minutes 


to ThC 2 








35% alpha to ThD 


Thorium C, (Side Beaction) 


212 


Estimated 10'" seconds alpha 


End 


208 






Thorium D (Main Reaction) 


208 


3.1 minutes 


beta+gamma 


End 


208 











CHAPTER II 
RADIUM ITS ORIGIN AND CHEMICAL NATURE 

ORIGIN 

Radium was first extracted by M. and Mme. Curie in the form of 
radium bromide from pitchblende residues, obtained from St. Joach- 
imsthal in Bohemia. It was subsequently found to be present not only in 
all pitchblende ores, but also in all minerals containing uranium. 

The work of McCoy, Boltwood and others has shown that in the very 
old uranium minerals there is a strict proportion between the uranium 
and radium content. For each 3,000,000 grams (three metric tons) of 
metallic uranium there is one gram of metallic radium. This is very 
strong corroborative evidence of the disintegration theory of Rutherford 
and Soddy, according to which uranium is the parent of radium. In 
uranium-containing minerals of more recent origin, the amount of 
radium is 30 to 40 per cent less for the same amount of uranium than in 
the older minerals. There is, however, no mineral or ore known, con- 
'taining radium, which does not contain uranium. 

URANINITE AND CARNOTITE 

While many uranium-containing minerals are known, only two are 
of practical importance. These are uraninite and carnotite. In these 
ores, radium occurs in workable quantities. 

Uraninite is found in Bohemia, Cornwall, Colorado and many other 
localities. This mineral occurs chiefly in an amorphous modification 
known as pitchblende, a dense black substance of variable composition 
and therefore not to be described by a single chemical formula. Pitch- 
blende is essentially an oxide of uranium and contains in varying quan- 
tities nearly half of the known metals. 

Carnotite is an ore of much greater practical importance than uraninite. 
It is the chief substance from which radium is now obtained. Large 
deposits of carnotite have been found in Colorado and Utah. In the "car- 
notite belt" of Colorado it has been estimated that there are at least eight 
in ill ion pounds of uranium. From this it has been estimated that there 
may be extracted at least 1000 grams of radium element. 

Carnotite (named from the French chemist Carnot) was first described 
by two French mineralogists, Friedel and Cummenge, in 1899. It is a 
bright yellow powder composed of very minute crystals. Its chemical com- 
position is very complex, but, when pure, it appears to be a potassium uranyl 
vanadate. It occurs in nature in sandstone formations. Average carnotite 

21 



22 KADir.M THKKAl'Y 

siiiulstone contains about 1.5 per cent to 6 per cent T'.,O S and this yields 
from 3.5 to 15 rag. of radium element per ton. The extraction of radium 
from carnotite ore or from other minerals is a very complicated process. 
For the separation of one gram of radium element, approximately 500 
tons of chemicals and one thousand tons of coal are used. After a con- 
siderable amount of mechanical preparation ( crushing of ore, etc.) and 
chemical treatment, the radium and barium are isolated together as ra- 
dium barium chloride. From barium the radium is separated filially in 
the form of radium bromide, by a process of fractional crystallization. 

From this salt, all the other salts (chloride, sulphate, carbonate, etc.) 
are prepared. Radium bromide and radium chloride are soluble while the 
sulphate and carbonate are insoluble in water. 

In the radium solution contained in the glass flask from which radium 
emanation is to be extracted for therapeutic purposes the radium is in 
the form of soluble radium chloride. 

For making the various therapeutic applicators (tubes, glazed plaques, 
toiles, etc.) the insoluble radium sulphate is used. 

THE CHEMICAL NATURE OF RADIUM 

Radium is to be regarded as a chemical element (symbol Ra.) belong- 
ing to the group of alkali earth metals, which comprises the elements 
barium, strontium, calcium and magnesium. 

Demarcay found that radium gave a new and characteristic bright 
line spectrum similar to the spectra of barium, calcium and strontium. 
Its atomic weight, as determined by Mine. Curie, is 22(>.45. In its chem- 
ical behavior, radium is closely allied to barium, forming a series of 
analogous salts (bromide, chloride, sulphate, carbonate, etc.). It differs 
essentially from that element, however, in being radioactive. In general 
properties, it is analogous to the metals of the alkaline earths. 

It was not until 1910 that radium was isolated by Mine. Curie and 
Debierne in a metallic state. It was then found to be a pure white metal 
showing the radioactive properties that would be expected on the assump- 
tion that radioactivity is an atomic phenomenon. It produced radium 
emanation and its activity increased at the theoretic calculated rate. 
Metallic radium changes quickly when exposed to the air. It reacts with 
water, decomposing it into hydrogen with the production of radium 
hydroxide. 

THE OCCURRENCE OF RADIUM IN NATURE 

Besides occurring in more or less concentrated form in various ores, 
radium is found throughout the earth's crust as one of the most widely 
distributed of substances. Strutt, Joly, Knocke, and others have de- 
tected it in minute quantities in volcanic rocks and in sea and river 
waters. 



RADIUM ORIGIN AND CHEMICAL NATURE 23 

As to the natural occurrence of radium in the animal and vegetable 
tissues, experiments have been made by Lazarus-Barlow, Becquerel and 
others to determine this point. Evidence has been presented to show 
that radium in very minute quantities, but detectable by the electro- 
scope, exists in human tissues. Lazarus-Barlow has sought to show 
that in human tissues affected by malignant disease a slightly larger 
quantity is present than in normal tissues. This hypothesis cannot be 
considered as established, and since no radium salt is absolutely insol- 
uble, it is difficult to reconcile the concentration of radium in a tissue 
with any hypothesis that does not also involve the simultaneous increase 
in concentration of other elements such as calcium and magnesium, and 
if this be true, their chemical effects must also be considered. 

Prof. Becquerel concluded that if radium or any other radioactive sub- 
stance exists in plants, it is in such small quantities as to have no ap- 
preciable effect on their growth. 



CHAPTER III 
RADIUM EMANATION AND RADIOACTIVE DEPOSIT 

THE DECAY OF RADIUM INTO RADIUM EMANATION 

As has been previously said, radium atoms, like those of the other 
radioactive bodies, are not absolutely stable, but are constantly trans- 
forming and giving rise to a series of substances. The first of these 
substances is radium emanation a gas known to chemists as "niton." 
The amount of this gas that is found in equilibrium with one gram of ra- 
dium is a definite quantity and is known as the "curie." This is the unit 
of quantity and at standard temperature and pressure (0 C. and 760 mm.) 
may be expressed either as a unit of volume or of weight. At standard 
conditions, the volume of one curie is .63 cubic millimeters, and the 
weight is 6.2 micrograms. It is the heaviest gas known, having a density 
one hundred and eleven times that of hydrogen. 

Chemically, radium emanation behaves as an inert gas, i.e., it forms no 
chemical combinations. It may be regarded as an analogue of the other 
"noble" gases, helium, neon, argon, krypton, and xenon. 

Like radium itself, the emanation shows a characteristic spectrum, which 
is quite distinct, however, from that of its parent, radium. At low tem- 
peratures, the emanation can be condensed from the gas with which it is 
mixed. At very low pressures, the emanation condenses at -150 C., the 
temperature of liquid air. The boiling point at standard pressure is in 
the neighborhood of -65 C., and it has been found that the emanation 
cannot exist in the gaseous state below -71 C. Below this temperature, 
marked changes are observed in the appearance of the emanation. 

When the radium atom decays into the radium emanation atom, it gives 
off an alpha particle, which is in reality a helium atom with a double 
positive charge. Since the atomic weight of helium is 4, it follows that 
the atomic weight of the emanation should be equal to the atomic weight of 
radium minus that of helium, or 226 - 4=222. By actually weighing a 
known volume of the pure gas, Gray and Ramsay obtained the value of 
224, which is very close to the theoretical atomic weight. 

THE ABSORPTION OF RADIUM EMANATION BY DIFFERENT 

SUBSTANCES 

Radium emanation may be absorbed to some extent by various solids, 
especially porous substances such as charcoal and particularly by cocoa- 
nut shell charcoal and platinum black. 

24 



RADIUM EMANATION AND RADIOACTIVE DEPOSIT 25 

Liquids have varying powers of absorbing the emanation. Fresh water 
absorbs more than salt water, while organic liquids absorb it more 
readily than either. 

It was found by Rausch von Traubenberg that if air containing emana- 
tion was shaken up with water, the air and the water each soon contained 
a definite proportion of the emanation. In this respect the emanation 
follows Henry's law, for it is absorbed until a state of equilibrium is 
reached between the pressure of the emanation in the water and in the 
gas. 

The term "coefficient of absorption" has been used to express the 
extent to which the emanation is soluble in liquids. This term may be 
defined as the ratio between the concentration of the emanation in the 
liquid and in the gas after equilibrium has been reached. The value of 
this coefficient may be determined experimentally by the method of von 
Traubenberg, i.e., by shaking up the liquid and the gas containing the 
emanation, and then measuring with the electroscope the relative 
amounts of emanation in the liquid and in the gas. It has been found 
that the coefficient of absorption decreases rapidly as the temperature 
of the water rises, at least between the limits of and 39 C. At room 
temperature the coefficient has a value of .250 and at 37 C, a value of 
.165. The variation of absorption of radium emanation with the tem- 
perature of the water is of importance in connection with the emana- 
tion content of natural spring waters at various health resorts in Eng- 
land, Germany, the United States and other countries. The amount of 
radium emanation in different springs varies between 1 and 30 millicuries 
per million liters. 

While claims have been put forward for the health-giving qualities 
of the waters of certain resorts, no direct connection can really be traced 
between the radium emanation in the springs and physiologic effects. 
Definite biologic effects that have been observed to follow the thera- 
peutic administration of radium emanation or radium salts are due to 
quantities several million times greater than are to be found in any 
known natural springs. 

THE DECAY OF RADIUM EMANATION INTO RADIOACTIVE 

DEPOSIT 

Unlike the atoms of radium, which is a comparatively stable substance, 
the radium emanation atoms are very unstable and decay at a rapid 
rate to form atoms of a third substance known as Radium A. This 
change follows a simple exponential law, the half value period of radium 
emanation being 3.85 days. The transformation is thus so rapid that in 
about thirty days practically all of a given quantity of radium emanation 



26 RADII'M THKRAI'Y 

will have decayed. Later we shall insert a table showing the rate of 
decay of the emanation. 

When the emanation atom transforms, it gives off an alpha particle or 
ray. This particle is actually an atom of helium, which is also a gas. 
The substance remaining is an atom of a solid known as Radium A. 
Radium A in turn gives off an alpha particle and becomes Radium B. 
Radium B gives off a beta particle and becomes Radium C. Radium C 
in turn disintegrates but in a more complex manner than the other prod- 
ucts. Radium C may transform itself in two ways. A very small propor- 
tion gives off an alpha particle and becomes Radium ('._,. This latter sub- 
stance is a branch product and so far as we know comes to an end quickly. 
The remainder, and larger portion, of Radium C gives off beta and 
gamma rays and becomes Radium C,, which in turn gives off an alpha 
particle and becomes Radium I). Radium D gives off a beta ray and 
becomes Radium E, and this product by loss of a beta ray transforms to 
RaP, which is also known as polonium. Polonium then gives off an alpha 
particle and becomes the end product of the series, or Radium G, a 
substance chemically indistinguishable i'rom lead, but having an atomic 
weight of 206 while the atomic weight of ordinary lead is 207.1. 

THE RADIOACTIVE DEPOSIT 

The series of substances from RaA to RaF constitutes the so-called 
radioactive deposit. This latter term was derived from the fact that 
these substances are deposited on the walls of the tube or other con- 
tainer when the radium emanation, sealed in the tube, decays. The 
radioactive deposit may be considered as being composed of two groups 
of substances, the one group being known as that of "rapid change" 
and the other group as that of "slow change." Radium A, B, C consti- 
tute the radioactive deposit of rapid change, their half value periods 
being 3 min., 26.7 min., and 19.5 min., respectively; radium D, E, and F 
constitute the radioactive deposit of slow change, their half value pe- 
riods being 16.5 years, 5 days, and 136 days respectively. The penetrating 
radiations used therapeutic-ally are derived from the active deposit of 
rapid change and especially from Radium C. 

When a radium salt, such as radium sulphate, is sealed in a glass 
tube, it is evident that the emanation which is forming continuously can- 
not escape. At the same time the emanation is also disintegrating to 
form the series of products just described. After a certain time (about 
six weeks) the two processes have reached a stage at which the number 
of radium atoms disintegrating per second to produce emanation atoms 
equals the number of emanation atoms transforming to RaA. When 
this takes place, the radium is said to be in equilibrium with its emana- 
tion. It is not necessary, however, for the formation of the active de- 



KADH'M EMANATION AND KAD1OACT1VK DEPOSIT 27 

posit that the tube should contain radium at all. If the radium emana- 
tion alone is introduced into the tube and the tube is sealed, the active 
deposit is formed in precisely the same manner. When the emanation 
has all decayed, the active deposit of course ceases to form and the 
radioactivity of the tube is at an end so far as its therapeutic efficiency 
is concerned. As a matter of fact, radium D, E and P are still contained 
in the tube, but as their transformation is very slow, and as the gamma 
rays produced by them are of feeble intensity, these products are not 
of therapeutic interest so far as the local application of radium is con- 
cerned. 

The Atomic Disintegration Theory of Rutherford and Soddy 

The disintegration theory of Rutherford and Soddy explains in a ra- 
tional manner the transformation which radium and the other radio- 
active substances undergo. According to this theory substances exist in 
nature whose atoms, unlike those of most elements, are not stable but 
are constantly undergoing spontaneous disintegration. These are known 
as radioactive substances. The rapid disintegration or "explosion" of 
the atoms of such substances results in a rearrangement of the electrons 
composing the atoms. In a given time a certain definite proportion of 
all the atoms of a radioactive substance becomes unstable and breaks 
up. An alpha particle or ray or beta and gamma rays are given off in 
the process of disintegration. In a few cases, as in the case of actinium, 
which transmutes into radioactinium, disintegration of the atom appar- 
ently takes place without rays being given off. There is chemical evidence 
that leads to the belief that in these "rayless" changes there is really 
emitted a low speed beta ray which because of its low velocity escapes 
detection. When an alpha particle is given off, as a consequence of 
the disintegration of the atom, the resulting atom is always lighter than 
its predecessor and possesses different physical and chemical properties. 
This is well illustrated by radium and its next transformation product, 
radium emanation, which are strikingly dissimilar, as we have seen. 

From this viewpoint, we may now consider the breaking up of the 
radium atom to form the radium emanation atom, of the radium emana- 
tion atom to form the atom of radium A, etc. In the radium series 
there are 5 substances that give off alpha particles (helium atoms) as 
they disintegrate. These are, in order of occurrence, Radium, Radium 
emanation, Radium A, Radium 0, and Radium P. Assuming the atomic 
weight of radium to be 226 and that of helium to be 4, the final atom 
produced when Radium F disintegrates should have an atomic weight 
of 226 less 20 (i.e.. 5 x 4) or 20fi. This is slightly less than the atomic 
weight of lead and it is an isotope of this metal that is the final product 
in the radium disintegration series. In Table IV this point is made 
clear and certain other data are given for reference. 



RADIUM THERAl'Y 



TABLE IV 



RADIUM ATOMIC 
SERIES WEIGHT 


\VKIGHT I'EU 
GRAM OP 
RADIUM 


HALF-VALUE 
PERIOD 


RADIATION 


KANGE OF 
ALl'HA RAYS 
AT 15 C. 


Radium 
\ Radium 
^Emanation 
Radium A 
Bad him B 
Radium C 

Radium C 
Radium D 
Radium E 
Radium F 
Radium G 
(End Product) 


226 
222 

218 
214 
214 

210 
210 
210 
206 


1 gram 
5.7x10-6 gram 

3.1x10-9 gram 
2.7x10-8 gram 
2.0x10-8 gram 


1680 years 
3.85 days 

3.0 minutes 
J<>.8 minutes 
]9..j minutes 

1.4 minutes 
li>."> years 
5.0 days 
136 days 


alpha 
alpha 

alpha 
beta+gamma 
beta+gamma 
(alpha) 
beta+gamma 
soft beta 
soft beta 
alpha 


3.30 cm. 
4.16 cm. 
4.75 cm. 


6.57 cm. 


8.6x10-3 gram 
7.1x10-6 grain 
1.9xlO-< gram 






3.77 cm. 
No rays 
Atoms stable 









CHAPTER IV 

THE TECHNIC OF THE PREPARATION OF RADIUM EMANATION 
FOR THERAPEUTIC USE AND THE METHOD OF MEAS- 
URING ITS GAMMA RAY ACTIVITY 

THE PREPARATION OF THE EMANATION 

Radium emanation in tubes or applicators instead of the radium itself 
as a source of therapeutic radiations appears to have been used first in 
1912 by the London Radium Institute. The Debierne-Duane apparatus 
(Fig. 1) as modified by Failla of New York is used by the writer for 
the extraction, purification, and concentration of the emanation. This 
apparatus consists essentially of two modified mercury pumps of the 
Toepler type, familiar to physicists. The first pump draws the accumu- 
lated gases from the flask containing the radium solution and introduces 
them into the purification chamber. The second pump withdraws the 
purified emanation and concentrates it in a capillary glass tube. The 
radium in the form of radium chloride is dissolved in about two ounces 
of water to which has been added a small amount of dilute hydrochloric 
acid to prevent precipitation of the salt. From a practical point of 
view not less than % gram of radium element can be utilized economically 
in this manner. 

The glass flask containing the radium solution is kept in a suitable 
safe, and rests in a porcelain lined lead vessel in order to minimize the 
possibility of loss. The radium flask is not shown in the diagram but 
is connected by means of a glass tube (1, Fig. 2) to the pumping system 
of the emanation apparatus as shown in Fig. 2. 

Vessel 4 (Fig. 2) is ordinarily kept partly filled with mercury in order 
to prevent the entrance of emanation. If the emanation were allowed 
to stand in this vessel it would cover the walls with the active deposit 
and since the surface of the vessel is quite large, the operator would 
find it necessary to shield himself from the bombardment of the rays. 

The emanation that is formed by the disintegration of the radium is 
not the only gas formed in the solution. The radium rays, continually 
bombarding the water molecules, cause a decomposition of the water 
into its constituents, hydrogen and oxygen. These two gases form by 
far the largest part of all the gases produced. The total volume of all 
the different gases is many times the volume of the emanation. In order 
to concentrate the emanation into a small volume at a pressure of, e.g., 
20 cm. of mercury, the foreign gases must, for the most part, be removed. 
In order to accomplish this, all the gases in the radium flask are pumped 

29 



30 



RADIl'M THERAPY 



over into the purification chamber !t, JO, and //. Fig. 2. Here the sodium 
hydroxide (9), and phosphorus pentoxide (11) absorb carbon dioxide, 
moisture, etc., while the heated copper oxide spiral (10) causes the hydro- 




Fig. 1. Photograph of Debierne-Duane-Failia apparatus. The photograph shows the single 
type of apparatus. The duplex- type is usually installed so that either side of the system may be 
available in case of accident. 

gen and oxygen to recombine. The purified emanation is then made to 
pass into vessel 12, being finally compressed in the. tube at cock 16. It 
is then forced out into the capillary glass tube 18. The distal portion 



PBEPABATION OF RADIUM EMANATION 



31 



(1 or more cm., e. g.) of this tube containing the concentrated emana- 
tion is then cut off by a minute gas flame. 

The mechanical details of the process are as follows: The auxiliary 
vacuum pump that is attached to vessel 25 is started and stopcocks 22 
and 8 are opened in order to create a vacuum in the line 8-22 above the 
mercury in vessel 7. Stopcock 6 is now opened and the mercury in / 
falls to the level in 7 . This allows the emanation, hydrogen, oxygen, 
ozone and water vapor to come out of the radium flask through tube 1 and 
to fill 4 by diffusion. Cock 22 is now turned to permit air to enter the 
line 8-22 through the drying tube 23 containing calcium chloride. This 
forces the mercury up in 4, driving the gases ahead of it and past the 




Fig. 2. Diagrammatic plan of apparatus in Kig. 1. 

trap !> into the purification chamber (9, 10 and 11}. Cock 22 is again 
turned to connect the line 8-22 with the auxiliary pump and the mercury 
in / again falls, allowing another portion of the accumulated gases to fill the 
bulb. The mercury in trap .? prevents the backward passage of gases 
from !>, 10, 11 to /. This procedure of filling 4 with the gases and forc- 
ing them ii]) past the trap .? into the purification chamber is repeated 
until all the gases are pumped over. The completion of the process is 
easily detected by the fact that when there is no gas present, the rising 
mercury in / produces a sharp metallic click when it strikes the mercury 
in trap .?. 

Mefore the pumping process just described is started, the purification 
chamber (fl, 10 and //) is tested to insure the existence therein of a good 



32 RADIUM THERAPY 

vacuum. If gases are found to be present, they are pumped through 16 
and 17 into 26 by means of the mercury pump 12, 13, 14 and 15. From 
there they may be exhausted into the room through 24 by the auxiliary 
. pump and thence out of the room by means of a ventilating fan. 

When a high vacuum has been established in the purification chamber, 
an electric current is sent through the copper oxide coil 10, the strength 
of this current being just sufficient to bring the coil to a low dull-red 
heat. When the coil is hot, the purification chamber is ready to receive 
the gases from 4. As they meet the hot coil, the hydrogen and oxygen 
reunite and form water which is immediately absorbed by the phos- 
phorus pentoxide (P.,0.,) contained in 11. By this action most of the 
gas entering the purification chamber is eliminated. Tf any carbon 
dioxide, chlorine or hydrogen chloride are present, they are absorbed 
by the sodium hydroxide in 9. Thus by the time all the gases are pumped 
out of the radium flask into 9 ; 10, 11, consuming, let us say one hour of 
time, there is little left in the purification chamber except helium and 
the radium emanation itself, all other gases having been absorbed. 

The emanation is now ready to be pumped over into the capillary tube 
18. With the line 8-22 at atmospheric pressure, stopcock 20 is opened 
and the mercury is allowed to rise a few centimeters in the y -shaped tube 
above 19 to prevent communication between 17 and 26. During the 
purification process the bulb 12 is left partly filled with mercury in 
order to prevent its being filled with the gases that are to be purified. 
With a vacuum in the line 8-22, stopcock 14 is opened, the mercury falls 
in 12 and the emanation, expanding from the purification chamber, fills 
this bulb. Stopcock 22 is now turned to connect line 8-22 with atmos- 
pheric pressure. This causes the mercury to rise in 12 and as it nears 
the top of the bulb, stopcock 16 is opened and the emanation is forced 
out into 17 by running the mercury about 1 centimeter past 16. Stopcocks 
14 and 16 are then closed. Line 8-22 is again exhausted, stopcock 14 is 
reopened, and the mercury falls out of 12 which is again filled with 
emanation. In this manner practically all of the emanation may be 
pumped over into 17. 

When the mercury has been raised in 12 for the last time it is allowed 
to pass through 16 and up to 17. The emanation is then forced by means 
of the mercury in 21, by opening stopcock 20, into the capillary tube 18. 
The mercury rises in the capillary and when the desired concentration 
is effected, stopcock 20 is closed. The capillary glass tube is about 1 
millimeter in diameter, and can be sealed off very readily by means of a 
small pin-hole gas flame. The part of the capillary tube sealed off con- 
taining all the emanation is then divided by means of the same flame 
into as many pieces as are desired. In this manner, any percentage of 
the total amount of emanation is obtained for use in a small tube, of, 
e.g., 1 centimeter length. These small glass tubes are then inserted into 



PREPARATION OF RADIUM EMANATION 33 

TABLE V 

SlIOWIN-G THE KlSE OF GAMMA RAY ACTIVITY DUE TO RAC THROUGH 2 CM. OF LEAD 



TIME 


: 


ACTIVITY OF AN EMANATION TUBE MEASURED IN 
PERCENTAGE OF MAXIMUM VALUE: 










2 


min 


.025 


5 


1 1 


.32 


10 


" 


1.90 


20 


1 1 


8.9 


30 


( t 


19.0 


40 


< i 


30.0 


50 


< * 


41.2 


GO 


1 1 


51.3 


1 


hr. 30 min. 


.74.4 


2 


< 


87.8 


2 


" 30 min. 


94.7 


3 


1 1 


98.0 


4 


1 1 


99.9 



enameled silver tubes the ends of which are blocked with paraffine. 
They are then set aside for 3% hours before their activity is measured. 
The next day the same procedure is repeated in order to withdraw and 
concentrate the emanation which has accumulated in the preceding 24 
hours. 

When the emanation is first admitted to the capillary tube its activity, 
measured by the penetrating rays, is zero. As the emanation decays, 

TABLE VI 



SHOWING THE 

TIME 


RATE OF DECAY OF RADIUM EMANATION 
PERCENTAGE OF MAXIMUM ACTIVITY (THEORETICAL) 





100.00 


1 lir. 


99.25 


2 hrs. 


98.51 


3 " 


97.77 


4 " 


97.04 


5 " 


96.32 


6 " 


95.60 


12 " 


91.39 


1 day 
2 days 
3 " 


83.53 
69.77 
58.27 


4 " 


48.68 


5 " 


40.66 


6 " 


33.96 


1 week 


28.37 


2 weeks 


8.05 


3 " 


2.28 


4 


0.647 


10 " 


0.000337 



34 



RADIUM THKRAPY 



however, the active products, Radium A, Radium B, and Radium C are 
formed, producing an invisible film on the walls of the tube. The pene- 
trating radiations from these products gradually increase until the tube 
reaches its maximum activity. This takes place about 4 hours after the 
emanation has been sealed in the capillary glass tube. The growth of 
the activity of Radium C with time is shown in Table V. 

About one hour after the maximum value of the gamma radiation 
has been reached, the activity of the tube begins to decay with the 
same "time period" as that of the emanation. In other words, 
16 per cent of the activity is lost every 24 hours. The activity at any 
given time will be reduced to % the value at that time after 3.85 days 
have elapsed. 

Table VII shows the calculated decay of radium emanation tubes from 
day to day. For example: Let us find the number 78 in the single left 

TABLE VII 
RADITM EMANATION DECAY TABLE 



1 


1 


2 


3 




1 


2 


3 




1 


2 


3 


90 


75 


63 


52 


60 


50 


42 


35 


30 


25 


21 


17 


89 


74 


62 


52 


59 


49 


41 


34 


29 


24 


20 


17 


88 


74 


61 


51 


58 


48 


40 


34 


28 


23 


20 


16 


87 


73 


61 


51 


57 


48 


40 


33 


27 


23 


19 


16 


86 


72 


60 


50 


56 


47 


39 


33 


26 


22 


18 


15 


85 


71 


59 


50 


55 


40 


38 


32 


25 


21 


17 


15 


84 


70 


59 


49 


54 


45 


38 


31 


24 


20 


17 


14 


83 


69 


58 


48 


53 


44 


37 


31 


23 


19 


16 


13 


82 


69 


57 


48 


52 


43 


36 


30 


22 


18 


15 


13 


81 


08 


57 


47 


51 


43 


36 


30 


21 


18 


15 


12 


80 


67 


56 


47 


50 


42 


35 


29 


20 


17 


14 


12 


79 


06 


55 


46 


49 


41 


34 


29 


19 


16 


13 


11 


78 


65 


54 


45 


48 


40 


34 


28 


18 


15 


13 


10 


77 


64 


54 


45 


47 


39 


33 


27 


17 


14 


12 


10 


76 


64 


53 


44 


46 


38 


32 


27 


16 


13 


11 


9 


75 


63 


52 


44 


45 


38 


31 


26 


15 


13 


10 


9 


74 


62 


52 


43 


44 


37 


31 


26 


14 


12 


10 


8 


73 


61 


51 


43 


43 


36 


30 


25 


13 


11 


9 


8 


72 


60 


50 


42 


42 


35 


29 


24 


12 


10 


8 


7 


71 


59 


50 


41 


41 


34 


29 


24 


11 


9 


8 


6 


70 


59 


49 


41 


40 


33 


28 


23 


10 


8 


7 


6 


69 


58 


48 


40 


39 


33 


27 


2. 1 ! 


9 


8 


6 


5 


68 


57 


47 


40 


38 


32 


27 


22 


8 


7 


6 


5 


67 


56 


47 


39 


37 


31 


26 


oo 


7 


6 


5 


4 


66 


55 


46 


38 


36 


30 


25 


21 


6 


5 


4 


3 


65 


54 


45 


38 


35 


29 


24 


20 


5 


4 


3 


3 


64 


53 


45 


37 


34 


28 


24 


20 


4 


3 


3 


2 


63 


53 


44 


37 


33 


27 


23 


19 


3 


3 


2 


2 


62 


52 


43 


36 


32 


27 


23 


19 


2 


2 


1 


1 


61 


51 


43 


36 


31 


26 


22 


18 


1 


1 


1 





60 


50 


42 


35 


30 


25 


21 


17 















PREPARATION OF RADIUM EMANATION 



35 



hand vertical column. A tube having a strength of 78 me. decays each 
twenty four hours as follows 66 inc., 54 me., 45 me., i.e., reading horizon- 
tally to the right. By finding 45 in the second single vertical column the 
values for the following three' days are found to be 38 me., 31 me., 26 
me. By finding 26 in the third single vertical column the values of this 
tube for the following three days are found to be 22 me., 18 me., 15 me., 
and so on. 

MEASUREMENT OF THE GAMMA RAY ACTIVITY OF EMANA- 
TION TUBES 

The measurement of the activity of the emanation tubes is made after 
they have reached their approximate maximum strength. The measure- 
ment is most easily and accurately done by means of the gold leaf electro- 
scope. A diagram of this instrument is shown in Fig. 3. 



D 




E 



A 



Fig. 3. Diagram of electroscope. 

A is a plate of lead 1 centimeter thick used to eliminate all of the easily 
absorbable rays. K is a metal box containing the gold leaf system. When 
the system is charged through C, e.g., with positive electricity, the gold 
leaf, which in the uncharged condition hangs vertically, is forced out into 
a partially horizontal position being thus brought into the field of the 
microscope, D. 

In order to measure the quantity of a radioactive substance in a small 
capillary tubo, the latter is placed in the V-shaped holder at E. The 
penetrating gamma rays then pass through the lead plate, A, into the 
electroscope, B, and the air in the electroscope is thus made a conductor 
of electricity. This is known as "ionizing" the air. In other words, the 
radium rays generate small positive and negative "ions" or charges of 
electricity in the air. If the gold leaf is charged positively, it will attract 
the negative charges to itself. The negative charges will thus neutralize 
a part of the positive charges of the leaf. The leaf will then tend to come 



36 RADIUM THERAPY 

nearer into the uncharged or vertical position and will thus move across 
the field of the microscope. The rate of this motion is a measure of the 
number of "ions" formed per second in the air, and this in turn indicates 
the intensity of gamma or penetrating rays from the emanation tube. 
The larger the amount of emanation in the tube at E, the faster will be 
the movement of the gold leaf across the scale in the field of the microscope. 
The rate of motion of the leaf is ordinarily timed by means of a stop 
watch. 

In order to facilitate the use of the electroscope in measuring unknown 
quantities of radium emanation, it is necessary to have at hand a stand- 
ardized tube of radium. One then determines the rate of fall of the leaf 
in the electroscope caused by the known or standardized specimen. Men- 
tion may be made here of the International Radium Standard. This con- 
sists of 21.99 mg. of pure radium chloride containing 16.75 mg. radium 
element, which was prepared my Mme. Curie in 1910 at the request of 
the Brussels Congress of Radiology and Electricity. This was sealed 
in a glass tube and is kept at the International Bureau of Weights and 
Measures at Sevres, France. Other countries have standards as fol- 
lows: Austria, 31.17 mg., England, 21.13 mg., Germany, 19.73 mg., 
Japan, 9.80 mg., Portugal, 9.09 mg., Sweden, 9.73 mg., United States, 
20.18 mg. 

The unit in which quantities of emanation are expressed is called the 
curie. This has been defined as the quantity of emanation in equilibrium 
with one gram of radium element. For practical purposes a smaller 
unit, the millicurie, Vinoo of a curie, is used. The gamma ray activity 
of a millicurie corresponds to the gamma ray activity of one milligram 
of radium element. The miorocurie is Viooo of a millicurie and corre- 
sponds to one microgram of radium element. 

The number of milligrams of radium element in the "standardized" 
tube, divided by the number of millicuries of emanation in the unknown 
tube is equal to the ratio of the number of ions produced per second 
when the "standard" and the emanation tube are successively placed at 
E. This last ratio is equal to the inverse ratio of the time of fall of the 
gold leaf across the scale of the microscope. Therefore in order to measure 
an unknown quantity of emanation it is only necessary to obtain the relative 
rates of fall of the gold leaf when the "standard tube" is used and when the 
"capillary emanation tube" is used and multiply this ratio by the number 
of milligrams of radium element used as the "standard." If the activities 
of the standard and the emanation tube are of very different magnitudes, 
the natural leak of the electroscope must be taken into account in calcu- 
lating the activity of the emanation. 

If for any reason the error due to natural leak is not considered great 
enough to affect seriously the result, the following simple formula is used 
as a basis for the calculations involved. 



K = 8-r- where 



PREPARATION OP RADIUM EMANATION 37 

' .E = activity of emanation tube. 

s = activity of standard. 

a = time of passage of leaf over any desired number of scale divi- 
sions under action of standard. 

6 = time of passage over same number of scale divisions under action 
of emanation tube. 

Let us suppose, for example, that we have as a "standard" a tube con- 
taining 15 milligrams of radium element (the activity being therefore 
equivalent to that of 15 millicuries), and an unknown emanation tube, 
the activity of which is to be measured. The "standard" is placed at any 
convenient distance from the electroscope and the latter is charged, so that 
the leaf diverges. The time of passage of the leaf, e. g. 40 divisions, is 
observed. Let us assume this elapsed time to be 1 minute (a). The 
emanation tube is now substituted for the "standard" and a similar ob- 
servation taken. We will assume the time in this case to be 50 seconds 
(6). Substituting in the above formula the values of s, a and 6 which are 

now known we find E = 15 y -= 18 me. 

50 

It will be observed that, within certain limits, the distance of the 
"standard" and the emanation tube from the electroscope during the cal- 
culation is immaterial. The number of scale divisions, over which the 
reading is made, is likewise unimportant. But whatever the distance or 
number of scale divisions chosen, observance of the following precautions 
is vital to the securing of dependable results: (1) The standard and the 
emanation tube must, in turn, be placed at exactly the same distance from 
the electroscope. 

(2) While readings are being made on one tube, the other tube should be 
placed 30 or 40 times as far away and preferably behind a heavy lead 
screen. 

(3) The same number of scale divisions over the same region of the 
scale must be used in each reading. If, as has been suggested above, 
the rate of natural leak of the electroscope is sufficiently great to have 
an appreciable effect on the results, allowance for this must be made in 
the calculations. In this case the formula takes the form : 

aft 
a- 

K 

<ib 
b 

e 

Here c is the time taken by the leaf when no tube is present .in passing 
over the number of scale divisions chosen for the readings. Let us sup- 
pose, ;is is the c:-ise in our laboratory, that this is of the order of 25 min- 
utes; the formula then becomes: 



38 RADIUM THERAPY 

ab CO X 50 
~c~ 25 X 60 ~ 

fiO-2 



=18.13 



_ 
50-2 

This error (.13) (less than 1 per cent) for many purposes is negligible, 
at least in small tubes, and, as a rule, in cases similar to this the correction 
would not need to be made. But if the activity of the "standard" and 
the tube to be measured is not approximately the same, failure to make 
the correction would lead to a considerable error. For example, assuming 
s, a and c to have the same values as before, but assuming b = 10 seconds, 
then 

60 
E = 15 X _ =90 (uncorrected) 

ab 60 X 10 
~~c~ 25 X 60 ~ 

60 -.4 



=93.12 



- 
10- .4 

This would lead to an error of considerably over 3 per cent if the correction 
were not applied. 

The Preparation of the Active Deposit. As we have previously stated, 
it is sometimes desired to collect a quantity of active deposit on a sheet 
of metal foil. In order to accomplish this, a piece of lead foil of about 
0.1 mm. thickness is rolled in such a way as to fit snugly into a glass 
tube, closed at one end. This tube, containing the foil, is then sealed 
in a vertical position, to the emanation apparatus at 17 instead of the 
usual capillary tube. (See Fig. 2). After the air has been pumped out, 
the purified emanation is forced into the tube by means of mercury raised 
to the lead foil. After 3 or 4 hours, when the maximum amount of active 
deposit has been formed and deposited on the foil, the mercury is lowered 
and the emanation allowed to pass into another part of the apparatus to 
be collected in the usual manner. When the tube is cut off and the foil 
carefully removed, its activity may be measured by means of a gamma 
ray instrument. As in the case of the emanation, the unit of quantity 
is the millicurie. This foil may be used as a uniform source of radiation 
of short duration. 

When a radioactive solution is required for injection into the blood, 
it may be prepared in the following manner: A small amount of common 
salt (NaCl) is packed into a small glass bulb. This bulb is heated in 
a gas flame in order to thoroughly dry the salt, and is then sealed to the 
emanation apparatus at 17 (see Fig. 2) just as in the preparation of 
active deposit on the lead foil. After the air is pumped out, the purified 



PREPARATION OF RADIUM EMANATION 39 

emanation is forced into the salt, by means of mercury raised to the 
small bulb. In 3 or 4 hours, when the maximum amount of active deposit 
has formed and collected on the salt grains, the mercury is lowered again. 
The emanation is allowed to pass into another part of the apparatus to 
be collected in the usual way. The bulb is then cut off and distilled 
water is forced in with a hypodermic syringe in sufficient amount to 
make approximately a normal physiological salt solution. The "active" 
water is subsequently withdrawn in the syringe. 

As in the former case, the amount of active deposit in the syringe 
is determined by the gamma-ray instrument. The activity of the syringe 
is usually determined before and after the injection of the solution, in 
order to estimate the exact quantity of active deposit administered. 
The quantity administered will be the difference in these 2 values. Proper 
allowance for the decay of the active deposit must be made. 



CHAPTER V 

TIIK RADIATIONS FROM RADIUM AND ITS DECAY PRODUCTS 

Rutherford states that from a theoretical standpoint it is desirable 
to restrict thp term "radioactive" to substances that undergo spontaneous 
atomic transformation. From this point of view, a few substances may 
be said to be radioactive which apparently emit no radiations at all but 
which do transform themselves spontaneously and give rise to new sub- 
stances. From our present standpoint, however, we may fairly delinr 
a radioactive substance as one that, while undergoing atomic transfor- 
mation, spontaneously and continuously emits peculiar rays. These rays 
are invisible but are known to be present because of certain phenomena 
which they cause. Among the interesting properties possessed by these 
radioactive rays arc their power to ionize a gas, to affect a photographic 
plate similarly to the actinic rays of sun light, to cause certain sub- 
stances to fluoresce in the dark, and, most important of all, from our 
present standpoint, to cause the modification or destruction of vital tis- 
sues exposed to their influence. While radium itself emits the easily 
absorbed alpha rays, its decay products, Ra B and Ra C emit the more 
penetrating beta and gamma rays. The beta and gamma rays from 
Ra B are less penetrating than those from Ra C. Confined in a tube for 
therapeutic use, the only real function of radium or its next decay 
product, radium emanation, is to produce Radium A, B, and C as fast 
as the latter products disintegrate. 

ALPHA, BETA, AND GAMMA RAYS 

There are three different kinds of radiations emitted by the radio- 
active substances. These are known as alpha, beta, and gamma rays. 
The table previously given (see list of radioactive substances) will suffice 
to make clear the particular ray that each of the products emits. 

It will be helpful to describe at this point the properties of the different 
kinds of rays. 

Alpha Rays 

Alpha rays are material particles having a double positive charge and 
a mass four times that of the hydrogen atom. In fact, they are merely 
positively charged helium atoms shot out from the radium atom, as it 
transmutes, with an initial velocity of 9,000 to 12,000 miles per second. 
They have a very great ionizing power, but are readily absorbed, the 
thinnest layer of metal or a sheet of note paper being sufficient to stop 
them. The "range" or greatest distance that an alpha particle from any 

40 



RADIATIONS FROM KADir.M AND ITS DECAY PRODUCTS 41 

of the radioactive substances can travel in air, depends upon its initial 
velocity and the temperature and pressure of the air. For an alpha 
particle of radium in air at standard conditions of temperature and 
pressure, the range is 3.3 cm. In other words, the alpha rays of radium 
are completely absorbed or stopped by 3.3 cm. of air and beyond this 
distance their characteristic effects cannot be detected. Alpha rays 
are analogous to the canal rays of a Crookes tube, and like them may be 
deflected slightly by a very powerful magnetic field. While usually re- 
ferred to as alpha rays, the term alpha particle is perhaps preferable. 

A gram of radium in equilibrium with its decay products, Ra Emana- 
tion, Ra A, B, and C, emits energy with its rays at the rate of 136 calories 
per hour. Of this energy 125 calories are borne by the alpha rays, 4.5 
Calories by the beta rays and 6.5 calories by the gamma rays. 

Beta Rays 

Beta rays are swiftly moving, negatively charged electrons and are 
identical in type with the negatively charged particles constituting the 
cathode rays of the f'rookes tube. They are about %S40 the mass of the 
hydrogen atom. Soft, medium and hard beta particles may be dis- 
tinguished according to their velocity and power of penetration. The 
slowest beta particles are comparable to alpha rays in penetrating power 
and are known as soft beta rays. The swiftest beta particles have about 
the velocity of light and have one hundred times the penetrating power 
of alpha rays. These are known as hard beta rays. The velocity of the 
hard beta rays from Ra C is 96 per cent of the velocity of light and it 
is estimated that to give an electron this initial velocity requires a 
difference of potential of 2,000,000 volts (approximately a 16 foot spark 
in air). Between the softest and hardest beta rays there is a series of 
so-called medium beta rays, which are intermediate in their power of 
penetration. The beta rays derived from Radium B and Radium C are 
one half absorbed after passing through 55 cm. of air at atmospheric 
pressure and room temperature. The beta rays from Radium C are half 
absorbed by 170 cm. of air. Beta rays may also be deviated in a mag- 
netic field but in an opposite direction to the deviation of the alpha rays 
because the beta ray is the negative electron. Beta rays are also de- 
llccted much more than alpha rays because their mass is very much less 
than that of the latter. As we have previously mentioned in the case 
of the "alpha rays," the term "beta particle'' is preferable. In defer- 
ence to custom, however, the term "beta ray" is retained. 

Gamma Rays 

These are undulations of the ether, or electro-magnetic waves, and are 
similar to x-rays, except that their wave length is much shorter than 
that of the latter. The velocity of the gamma rays is the same as that 
of light. 



42 RADIUM THERAPY 

The production of gamma rays is due to the very intense electronic vibra- 
tions which are set up in the structure of a radio atom from which a 
high speed beta ray is escaping. The forced vibrations of the electrons 
give rise to very high frequency or short wave length electro-magnetic 
waves or gamma rays. Thus it is seen that the gamma ray is a secondary 
phenomenon, and the energy of the gamma rays represents energy lost 
by the beta ray as it escapes from the atom which gives it origin. The 
absorption of gamma rays is an electronic property of matter, as contrasted 
with atomic or molecular absorption of longer wave lengths such as ultra 
violet and visible light. When the gamma ray pulse encounters an elec- 
tron in matter which can vibrate in harmony, energy is transferred to 
the electron and it thereby takes up a high velocity and becomes a 
"secondary beta ray. 1 ' This phenomenon of energy transfer from a wave 
to a particle has a very good analogy which is familiar to most of us in 
the sound vibrations which the striking of a certain note on an instru- 
ment will set up in a loose bit of woodwork, etc., in a music room. Here 
the energy borne on air waves is transferred to the particle which can 
vibrate in harmony with the rate of the air waves. In the case of gamma 
rays, so few electrons are encountered that can vibrate in harmony, that 
the gamma ray pulse must pass through enormous numbers of electrons, 
(i.e., great masses of matter) before it loses much energy. This interpre- 
tation explains the "hardness" or penetration of the gamma rays. In 
the case of x-rays, which have a much lower rate of vibration, more elec- 
trons are encountered that can vibrate in harmony ; therefore the x-ray 
pulse loses its energy more easily, or, as we say, is more easily absorbed 
in matter. 

The terms soft, medium and hard gamma rays are used to indicate differ- 
ent degrees of penetrating power, just as in the case of the beta rays. In 
general, gamma rays are from ten to one hundred times more penetrating 
than beta rays, and consequently have a smaller ioni/ing power. The 
gamma rays are half absorbed after passing through one hundred and 
fifteen meters of air. Like the x-rays, the gamma rays cannot be deflected 
by a magnet. 



CHAPTER VI 

ABSORPTION AND FILTRATION OP RAYS 

We have already referred to the fact that the radiations are capable 
of penetrating opaque matter in varying degrees, certain types of rays 
being easily absorbed while other types are stopped with the greatest 
difficulty. In this chapter we shall consider some of the practical ad- 
vantages of filtering or absorbing certain types of rays by means of screens. 

ABSORPTION OF RAYS 
Alpha Rays 

It has already been stated that the alpha rays from radium are very 
easily absorbed. The glass wall of the emanation tube, a sheet of note 
paper, the film of a soap bubble or a layer of moisture on the skin is sufficient 
to stop them. 

Beta Rays 

Hard beta rays according to Rutherford may be half absorbed by 0.1 
mm. and may be completely absorbed by 2 mm. of lead. The absorption 
of the beta rays by various kinds of matter follows closely an exponential 
law. 

For example, if one half of a given quantity of beta rays of a certain 
type is absorbed by 0.2 cm. of aluminum, % of the original amount of 
rays will be unabsorbed after passing through 0.4 cm. of aluminum, % 
of the original amount will be unabsorbed after passing through 0.6 
cm., and so on until complete absorption. As we have stated before, the 
beta rays are heterogenous and have different penetrating powers. The 
relative absorption of beta rays depends therefore upon the type of rays 
that is chosen for experiment. The hardest or most penetrating beta 
rays are absorbed to the extent of 93.8 per cent by 1 cm. of epithelial 
tissue. Their intensity after passing through 1 cm. of epithelial tissue, 
is. therefore, only 6.2 per cent of that exhibited at the surface of the 
skin. This estimation does not take into account the diminution of in- 
tensity due to divergence of the rays with distance from the source. The 
intensity of the beta radiations from radium C is reduced to % the 
initial intensity after passing through 17 meters of air, at ordinary room 
temperature and atmospheric pressure. 

Gamma Rays 

The hard gamma rays from radium C are half absorbed by 14 mm. of 
lead. Just as in the case of the beta rays, the gamma rays from radium 

43 



44 RADIUM TIIKKAPV 

are absorbed approximately in accordance with an exponential law. This 
law is followed, however, only in the event of the rays being allowed to 
pass first through a few millimeters of lead, the softer gamma rays 
being thus absorbed. 

According to the measurements of Giraud, which have been mentioned 
previously 20.4 cm. of water will absorb % of the gamma rays from radium. 
For theoretical purposes, water may be considered as the equivalent of 
soft tissues in absorbing power. 

Gudzent states that 4 per cent of the successively remaining gamma rays 
are absorbed by each centimeter of tissue traversed. 

According to Rutherford 26.5 cm. of soft tissue would be required for 
the half absorption of the hardest gamma rays from radium. 

These estimations may be compared with the penetrating power of 
x-rays which are half absorbed, according to Colwell and Russ, by 4.9 
cm. of soft tissues. As to the diminution of their intensity with dis- 
tance, hard gamma rays are reduced to one half their initial intensity 
after passing through Il5 meters of air at ordinary conditions of room 
temperature and atmospheric pressure. 

Secondary Radiations 

All three types of rays alpha, beta and gamma produce secondary 
radiations when they impinge upon matter. We may briefly consider 
the secondary radiations produced by each of the three types of rays. 

(a) The secondary rays produced by the alpha rays are slow beta 
particles and are sometimes called "delta rays." The secondary rays 
due to alpha rays are naturally without practical importance from the 
therapeutic standpoint, (b) Just as the cathode rays, striking the target 
of the x-ray tube, set up x-rays, so the primary beta rays from radium 
when they strike matter set up a type of gamma radiation. The intensity 
and penetrating power of these secondary gamma rays increase greatly 
as the atomic weight of the substance impinged upon increases, since 
these gamma rays correspond to the characteristic x-rays for the par- 
ticular element, and the higher the atomic weight of the element, the 
more penetrating are the characteristic x-rays. The quantity of secondary 
gamma rays that are produced depends upon the amount of beta, radia- 
tion that is absorbed and the thickness of the material that is radiated. 
(c) When the primary gamma rays from radium strike matter, a part of 
the original beam is scattered in all directions although the quality of the 
beam "is not altered. Just as in the case of the primary beta rays second- 
ary radiations are also set up by the primary gamma rays. These con- 
sist of secondary gamma rays and secondary rays of the beta ray type. 
Our knowledge of the secondary gamma rays is very imperfect. The 
secondary beta rays have a penetrating power that is nearly equivalent 
to that of the primary beta rays. When heavy elements such as lead 



ABSORPTION AND FILTRATION OF RAYS 45 

are impinged upon by gamma rays the secondary beta radiation is some- 
what more penetrating than when lighter elements such as brass or 
aluminum are radiated. 

FILTRATION OF RAYS 

The principle of filtration and the use of screens in the treatment of 
diseased tissue may be referred to at this point. Wickham, Degrais and 
Dominiei were apparently the first to use and advocate the employment 
of rays obtained by filtration. By interposing between the radioactive 
substance and the tissue to be treated, various metallic and nonmetallic 
materials, the less penetrating rays may be absorbed, i.e., removed by 
filtration. Substances used for absorbing radiations are known as screens 
or filters. In the treatment, for example, of a tumor below the surface 
of the skin, we may absorb by means of screens the undesirable types of 
rays before they reach the skin, allowing only the more penetrating rays 
to pass through the screen and affect the tissues. The skin, being thus 
relieved of the absorption of the less penetrating rays, will receive a 
minimum amount of injury, while the deeper layers of tissue under 
proper conditions, may receive nearly as much radiation as the superficial 
layers. 

If we wish to absorb the alpha rays we may theoretically place between 
the radium and the skin a screen of % 00 millimeter of aluminum or a 
sheet of writing paper. In reality, however, the alpha rays do not pene- 
trate the walls of the glass tube or other apparatus in which the radium 
is confined. 

If we wish to intercept most of the beta rays we may interpose between 
the radium and the tissues a screen of 1 millimeter of lead. This filters 
out more than !)!) per cent of the beta rays. One may 'thus use nearly 
pure gamma rays, which will not be absorbed but will pass through the 
screen. "When massive doses of deeply penetrating rays are used, it is 
desirable to absorb in addition part of the softer gamma rays. Brass 
screens 2 mm. thick may then be used. It is quite evident that a whole 
series of metallic screens of different thicknesses and densities may be 
used in order to absorb or filter out varying portions of the beta and 
gamma rays and that the results of treatment will vary accordingly. 

Screens 

The screens used for all types of therapeutic applicators may be de- 
scribed here. Screens are ordinarily made of silver, gold, platinum, 
brass, lead or aluminum. For external applications, brass or silver 
screens answer almost every purpose. It is believed that the secondary 
radiations from brass are not so irritating as those from denser metals. 
It is best to use rather simple and uniform screening until familiarity is 
obtained with the effects of radium on the tissues. 



46 



RADIUM THERAPY 



When treating the interior of the various natural cavities of the body, 
sueh as the uterus, esophagus, etc., gold or platinum screens have a cer- 
tain advantage as their great density permits the use of a much thinner 
screen than if brass or silver were used. In such case the desirable 
effect of distance in reducing the intensity of the rays is sacrificed. This 
may be compensated at times by the use of thicker nonmetallic cover- 
ings such as rubber of 2 or 3 mm. thickness. While theoretically screens 
of almost any material or thickness may be employed, it is' often advisable 
in actual practice to employ a few different thicknesses of the same 
metal in order to simplify the technic. Silver screens having a thickness 
of 0.1 mm., 0.5 mm., 1 mm., and 2 mm. are probably the most generally 
useful in the routine application of radium. Screens of these thicknesses 
will absorb approximately 50 per cent, 96 per cent, 99 per cent, and 100 
per cent of the beta rays. The skilled technician may use a greater 
variety of screens. In addition to those already mentioned the follow- 
ing screens are useful. 

Lead Vioi ''Mo, 1, and 2 mm. thick. 

Platinum %o and % n mm. thick. 

Aluminum ' % 00 , % 00 , % n mm. thick. 

Brass % , 1, 2, 2.5 mm. thick. 

For practical purposes it is sufficiently accurate to say that the ab- 
sorbing power of a metal for a given type of beta or gamma ray in- 
creases in proportion to its density. 

Table VIII will suffice to indicate the relative density and consequent 
ray-absorbing power of various materials, some of which are used as 
screens. 

From a consideration of this table it is an easy matter to calculate 
the thickness of different materials which would be required to absorb 

TABLE VIII 



KAY ABSORBING 

SUBSTANCE : 


DENSITY THICKNESS REQUIRED 

(APPROXIMATE) TO ABSORB 50% or 

THE HARD BETA RAYS 


THICKNESS REQUIRED TO 
ABSORB 99.9% OF THE 
HARD BETA RAYS 


Gum rubber 


1.0 


1.00 mm. . 


8.50 


mm. 


Water 


1.0 


1.00 " 


8.50 


* < 


Soft tissues 


1.0 


1.00 " 


8.50 


1 1 


Bone 


1.7-2.0 


0.60 ' ' 


5.00 


1 1 


Common glass 


2.6 


0.40 ' ' 


3.30 


tt 


Aluminum 


2.7 


0.40 ' ' 


3.20* 


1 1 


Steel 


7.7 


0.14 " 


1.15 


( t 


Brass 


8.5 


0.13 " 


1.10 


1 1 


Nickel 


8.7 


0.13 " 


1.10 


( t 


Silver 


10.6 


0.10 " 


0.80 


1 1 


Lead 


11.3 


0.10 " 


0.80 


1 1 


Gold 


19.3 


0.06 ' 


0.50 


1 1 


Platinum 


21.5 


0.05 ' ' 


0.40 


1 1 



ABSORPTION AND FILTRATION OF RAYS 47 

a given amount of the hard beta rays. Let us suppose, e.g., that we 
wish to use a series of brass screens which would equal % mm., % mm., 
1 mm., and 2 mm., of silver. A simple calculation of the relative density 
of the metals shows that brass screens equivalent to silver screens of 

1 C\ C 

the above thicknesses, must be-^- of % mm., % mm., 1 mm., and 2 

o.o 

mm.: i.e., approximately % mm., % mm., 1.25 mm., and 2.5 mm. thick. 
Similar calculations may be made for other materials in the table. 

It has been found that different thicknesses of silver will absorb the 
proportions of the hard beta rays indicated in Table IX. 

TABLE IX 



THICKNESS OF 
SILVER SCREEN 


PER CENT OF HARD 
BETA RAYS ABSORBED 


PER CENT OF HARD 
BETA RAYS LEFT 


0.1 mm. 


50. 


50. 


0.2 " 


75. 


25. 


0.3 " 


87.50 


12.50 


0.4 " 


93.75 


6.25 


0.5 " 


96.88 


.3.12 


0.6 " 


98.44 


1.56 


0.7 " 


99.22 


0.78 


0.8 " 


99.61 


0.39 


0.9 " 


99.81 


0.19 


1.0 " 


99.91 


0.09 



Upon examining the table it may be seen that the percentage of 
absorption by a given thickness of the metal follows an exponential 
law; i.e., if 50 per cent of the hard beta rays remain nnabsorbed after 
passing through 0.1 mm. of silver, % of the original amount will remain 
unabsorbed after passing through 0.2 mm., % of the original amount 
will remain unabsorbed after passing through 0.3 mm., and so on until 
its complete absorption. 

Depending upon the apparatus with which they are to be used and 
the lesions that are to be treated, screens of different shapes and sizes 
may be required. For the glazed plaques, pieces of metal of the material 
and thickness desired may be cut to fit the face of the apparatus. The 
metal screens may be round or square or of any other shape desired. 
While they may be made extemporaneously, it is much more convenient 
to use screens that have been previously fitted to suit each apparatus. 

For the tubes containing radium or radium emanation, a set of cylin- 
drical metal screens of different patterns is also essential. It is con- 
venient to have certain screens made in such a way that part of the wall 
is cut out to form a window ("window screen"). One may thus treat 
a certain part of a lesion opposite the window with a greater volume of 
rays than the other parts. 



48 RADIUM THK1; U^ 

Secondary Radiations 

In the practical use of screens or fillers we meet with difficulties on 
account of the secondary radiations (Kays of Sagnac) that are formed 
in these screens. As these secondary radiations are less penetrating than 
Ihe primary radiations that produce them they always tend to defeat 
the object of the screen. While the secondary radiations may not seriously 
affect the skin surface, it is customary, as we have said before, to inter- 
pose between the metallic screen and the skin, one or more millimeters 
of nonmetallic substance, such as gauze, rubber, filter paper, or wood, 
in order to absorb them. Filter paper is excellent and, be-in composed 
of pure cellulose of low density, does not appreciably absorb the gamma 
rays. Cork or soft wood is commonly used by the writer because of its 
greater convenience. According to llayward Pinch, a layer of aluminum 
0.2 mm. in thickness completely absorbs these secondary "rays of Sagnac." 



CHAPTER VII 

THE ABSORPTION OF GAMMA RAYS IN WATER 

In this chapter we shall give the results of some of our experimental 
work on the absorption of gamma rays. 

In these experiments, which were undertaken primarily to determine, 
if possible, the absorption of gamma rays in tissues, it was, of course, 
impossible to place the ionization chamber used in determining the in- 
tensity of the radiations beneath the skin itself. 

Water was therefore used in our experiments as being the most suit- 
able medium, inasmuch as it is similar in absorbing properties to the 
tissues. This medium was previously employed by Kroenig and Friedrich 
for determining the absorption of x-rays. 

The main problem that we undertook to solve was whether the scat- 
tering of the gamma rays causes any change in the intensity of the rays 
at various depths below the surface of the skin and if so what the 
change is. 

So far as the physical side of the problem of absorption and scattering 
of radiations is concerned, almost all the previous work mentioned in 
the literature has been done by simply interposing thin sheets of absorb- 
ing material between the source of radiation and the electroscope. In 
some cases an ionization chamber was used. Of such nature, for example, 
was the work of Hewlett, who discusses the mass absorption and mass 
scattering coefficients of radiations of wave length .13 to 1.05 A in 
various substances including water. He found the mass absorption co- 
efficient by finding the ratio of the filtered to the unfiltered beam. The 
results indicated excess scattering for the shorter wave lengths. 

Kovarik treats of the effect of different types of ionization chambers. 
He used an amplification of the current with a three electrode tube. 

Christen treats the problem of measuring "intensity" and "dose" 
from a theoretic standpoint. Kroenig says that the capacity can be made 
low by using a very fine center electrode, but if this is done, the satura- 
tion voltage is high. 

Kroenig and Friedrich, in their work "Physikalische und Biologische 
Grundlagen der Strahlen-therapie," deal extensively with x-ray measure- 
ments of this nature. We may, therefore, give some of the details of 
their experiments. In his experiments with x-rays Friedrich used an 
apparatus of practically the same form as the first type of chamber which 
we employed ; the only difference consisted in the fact that in his appa- 
ratus the connecting tubes were much larger and were insulated with rubber. 
The method that he employed has the great advantage of being flexible 

49 



50 



KADI I'M THERAl'Y 



hut the insulation probably could not have been as satisfactory as in our 
apparatus. The size of the cable gives it a smaller capacity, but may 
render the scattering different. 

Friedrich used a Wulf string electrometer, which has a very small 
capacity but is very insensitive. In fact, he found it impossible even to 
calibrate his apparatus with seventy milligrams of radium, because the 
other errors due to leaks were so large. He was forced to use a gram of 
radium and even under these circumstances did not take data under 
water. 

For almost all of his measurements of gamma rays Friedrich used 
only an electroscope, not an ionization chamber. His apparatus was 
placed on a wooden table in the middle of a room in order to avoid 
"scattering." 

Friedrich also had trouble with polarization of the dielectric; i.e., 




Fig. 4. Diagram showing electrical connections for null method of using ionization chamber. 
El, electrometer or electroscope; R, rheostat; 1C, ionization chamber; E, earth; C, condenser; 
' 



El, 

B, B', batteries. 

charges crept out of it as one first used it; this had also been observed 
with our own apparatus which we shall describe below. 

Friedrich constructed an ionization chamber of aluminum having found 
that this material was the one of the lowest atomic weight that was best 
suited for his purpose. He also constructed a chamber made of horn coated 
with graphite. He used carbon for the electrodes. Friedrich calibrated 
his aluminum chamber with the horn chamber for comparison of different 
hardnesses of x-rays. 

Makower and Oeiger ("Practical Measurements in Radioactivity") 
give a null method of using an ionization chamber. This method consists 
in balancing the current to be measured (in the ionization chamber) 
with the charge induced on a condenser, arranged in the manner shown. 
by varying the voltage applied to the other plate of the latter. (Fig. 
4.) The principle of the apparatus consists in keeping the gold leaf 



ABSORPTION OF GAMMA KAYS IX \YATKK 51 

or mirror as nearly stationary as possible by moving the variable con- 
tact on the rheostat, and in measuring the time necessary for a given 
amount of motion of the latter. 

There appeared to us to be but two methods open for experimentation 
if we were to be successful in measuring the gamma ray intensity of 
radium beneath the surface of water. By one method it was possible for 
us to put the electroscope itself under the water; by the other method 
we could use an auxiliary chamber which could be connected in some 
manner with the electroscope. The first method involves making a 
water-tight electroscope with an insulated and leak-proof connection to 
the outside for charging. It also requires that observations be made 
through the water with the consequent necessity of bringing the observing 
telescope and support near to the point at which the intensity is to be meas- 
ured. The latter point seems important although the scattered radiation 
must follow the inverse square law; hence the amount of radiation reach- 
ing the electroscope would be approximately proportional to the inverse 
fourth power of the distance from the source under the conditions assumed. 

The second method consists in placing an ionization chamber at the 




Fig. 5. Diagram of first type of ionization clramber. al, aluminum; s-s, sulphur; i-c, inner electrode; 

g.t., guard tube. 

point at which the intensity is to be measured. The chamber may then 
be connected with an electroscope which is thus in an easily accessible 
position. 

The second method was chosen as being most suitable for our purpose. 

A water-tight ionixation chamber, '! cm. long, 1.56 cm. in interior 
diameter, with walls .8 mm. thick was constructed of aluminum (Fig. 
5). The inner electrode was made of No. 22 aluminum wire, insulated 
from the chamber walls and guard tube with sulphur. The guard tube 
running from the chamber had an interior diameter of 6 mm. and was 
filled with sulphur. The other end of the chamber was closed with an 
aluminum plate. The length of the wire electrode inside the chamber 
was about 2.5 cm. 

In addition, a water-tight box 55 cm. square and 35 cm. high was con- 
structed (Pig 6). The ionization chamber was placed in the center of 
the box and about 15 cm. from the bottom, with the guard tube extending 
out through one side. 

A wooden support for the radium applicator, that was capable of 
movement, was constructed so that the shelf for holding the radium to 



52 



RADII'M THERAPY 



be used could either be brought down to touch the ionizatiou chamber 
or could be raised to a height of 25 cm. above it. The shelf could also 
be moved 25 cm. to the side in either direction. We thus obtained for 
the shelf a freedom of vertical motion amounting to 25 cm.; of sidewise 
motion 50 cm. in two directions. Later a string was found sufficient 
for changing the position of the radium and was therefore used to sus- 
pend the apparatus at different heights. 

The level of the water and also the height of the radium applicator 
above the surface of the water could thus be varied. The ionizatiou 
chamber itself was fixed. 

The ioni/ation chamber was first tested. A wire about four meters 
long covered with cotton insulation ran from the inner electrode, (con- 
necting with the wire passing through the guard tube) to an ordinary 
gold leaf electroscope. With this arrangement the speed of leak was 
found to be extremely large and also variable. One seventh of a milli- 
gram of radium was sufficient to produce a considerable change in the 



we 



1C. 



W 



Fig. 6. Diagram of apparatus used for measuring absorption of gamma rays in water. W.E., 
Wilson tilted electroscope; H, ground; B, source of high potential; Sw, Sui*, switches; W, water; 
LW , level of water; R.-l, radium applicator; S, adjustable support; I.C., iouization chamber. 

leak, but, of course, the actual current in the chamber itself was entirely 
too small to be measured. 

The use of sulphur supports which were encased in glass for the wire, 
did not materially lessen the size and variability of the leak. The wire 
was therefore encased in aluminum tubing filled with sulphur. 

The first microscope used was of low magnification; hence the read- 
ings correspond to a large change in voltage. 

It was found that the electroscope could be placed much closer to the 
radium than had been expected without introducing a leak due to the 
ionization in the electroscope comparable with the other leaks in the 
apparatus. A switch was introduced to separate the ionization chamber 
and the tube from the remaining parts of the conductor. 

The switch that we vised consisted of a very small glass cup inbedded 
in sulphur and filled with mercury, into which the wires dipped. 



ABSORPTION OP GAMMA KAYS IN WATER 53 

First Observations of Intensities With First Hype of lonization Chamber 

Readings were taken with a very high potential on the leaf. The 
speeds of fall with the switch closed compared to those with the switch 
open varied almost inversely as the capacities of the two systems, thus 
showing that the reading was almost all leak and that there was little 
if any true current. 

Readings were extremely irregular. It made a great difference how 
high the leaf was charged to start with; the leaf had to be kept charged 
for some time before taking readings ; movements of the air affected 
results, etc. 

The leak was minimized by using various devices until finally it was 
of the order of five minutes under very favorable conditions. Complete 
confidence could not be placed in the results of the readings, however. 
A voltage of about 430 volts, of which the scale corresponded to 25 or 
30, was then used. The natural leak with radium present was still greater 
than the effect to be measured. 

To get rid of this leak, an entirely different ionization chamber (Fig. 
7) that could be used with a Wilson tilted electroscope was finally de- 



Fig. 7. Diagram of second type of ionization chamber. S, sulphur; AL, aluminum: A, amber. 

vised. The inner chamber was made with approximately the same ex- 
ternal dimensions as the previous chamber but heavy aluminum 3 mm. 
thick was used in its construction. The whole space between the inner 
and outer cylinders was filled with sulphur, except for the end at which 
the innermost electrode entered ; this end was fitted with an amber 
washer. The guard tubes extending from each end were filled with sul- 
phur as in the first type of chamber. 

The advantages of this second type of chamber are evident. In the 
first place, the walls of the interior chamber can be charged to a high 
potential and the rise of the potential of the inner electrode from the 
ground potential up can be obtained. Under these circumstances, the 
only leak that can possibly occur in this part of the apparatus is from the 
inner electrode and the connecting wires to the ground. There can be 
no leak over the sulphur from high potential to the inner electrode be- 
cause that is prevented by the guard ring. The current that may flow 
from high potential to the ground does not affect the electroscope. The 
only other leak possible is in the electroscope itself from the high poten- 
tial to the leaf. The high potential difference is thus effective in producing 
the desired current, but only the low difference is effective in producing 
li'iiks. 

This second type of chamber is also particularly suited for work with 



KADI I'M TIIKUAl'Y 



the Wilson tilted electroscope, since the latter measures the rise in 
potential above that of the ground. The Wilson type of electroscope has 
the advantage of great sensitiveness; indeed the sensitiveness is very 
great if the electroscope is properly adjusted. Instead of the thirty or 
forty volt change in potential used with the ordinary electroscope,' a 
voltage change of three or four volts or less can he used. Furthermore 
it has a low capacity; and the volume of gas contained is small. 

Second Series of Observations with First Type of lonization Chamber 

An attempt was now made with the old chamber to apply the method 
which we proposed to use witli the new chamber; i.e., the outer case 



II 



tiiii;:iE; i n 



Fig. 8. Intensity in water. Uasv of applicator 3 cm. above surface. 



ABSORPTION OF GAMMA RAYS IN WATER 



55 



of the chamber was kept at high potential and the rise of the potential 
of the inner electrodes and leaf was noted. Unfortunately the results 
were not entirely trustworthy. The difficulty with the application lay 
in the fact that the guard tube for a distance of about twenty centi- 
meters was necessarily at high potential, giving considerable opportunity 
for leaks across the end. However, the following results are at least 
qualitative as they indicate the manner in which the field in air, and at 
different distances below the surface of the water, varies. 

Fig. 8 indicates that the intensity below the surface of the water no- 
where approaches that at the surface, but decreases quite rapidly as 
one goes down. This is obviously to be expected, merely from the opera- 







net btlw Sun ica // cm. J $ 



?. Intensity lie-low Mtrfaic <,! uatir. JSasu of applicator 6 cm. shov 



56 



RAblUM THERAl'Y 



tion of the inverse square law alone. The curve is taken with the base 
of the applicator directly over the spot at which the field was measured, 
and at a constant distance of three centimeters from the surface of the 
water. It gives the intensity at various depths below the surface of the 
water. 

Fig. 9 indicates that similar results were obtained when the base of the 
applicator was six centimeters above the surface of the water. The inten- 
sity at the surface was of course less to start with, and the decrease 
was more gradual due to the action of the inverse square law. This is 
evident from the fact that with a point source the intensity changes 



Fig. 10. Field 5 cm. below surface of water. Base of applicator 1 cm. above water. 



ABSOUl'TION OF GAMMA KAYS IN WATER 



57 



fourfold in going from five to ten centimeters; one must go, however, 
a distance of twenty centimeters before the intensity changes again 
fourfold; i.e., a movement of five centimeters in the first and ten centi- 
meters in the second case is necessary. Furthermore the actual change 
(not the ratio) is much less in the latter case. 

The next series of curves shows the change in the field at a given dis- 
tance below the surface of the water as we go laterally from a point 
directly below the center of the radium applicator. The first of these 
curves (Fig. 10) shows the field at a depth of five centimeters. The 
decrease here, as one goes out from the axis is rather abrupt, as AVC 



i 




ii:i im;: 



Pig. 11. Field 10 cm. below surface of water. Base of applicator 1 cm. from water. 



58 



RADH'M THERAPY 



should expect, since 13- +.5 2 --= 194, 13 2 + 10 2 == 269, i.e., a factor of 1.39 
is present from the operation of the inverse square law in the change 
from five to ten centimeters. 

Fig. 11 shows the field at a depth of 10 cm. The decrease is more 
gradual. 18 2 + 5 2 = 349, 18 2 + 10 2 =424. The ratio between these two 
numbers gives a factor of 1.22. (These factors are not actually the 
numbers by which the intensities at 5 cm. and 10 cm. distance from the 
axis should differ, since the radium was not at a point, and there is 
absorption and scattering). 

Fig. 12 shows the field at a depth of 15 cm. The decrease is here more 



ih 



i f 



Fig. 12. Field 15 cm. below surface of water. Base of applicator 1 cm. from water. 



ABSORPTION OF GAM. MA KAYS IN \VATKK 



59 



gradual still. We find that 23 2 + 5- == 554, 23- r 10- == 62!). The ratio 
between these two numbers gives a factor of 1.13. The distance changes 
relatively (and also actually) less as we go out, perpendicularly to the 
axis, than when the distance along the axis is small. 

Fig. 13 represents the field on the surface. The difference between 
this curve mid the curve in Fig. 12 is extremely marked. The factor 
here would be 1.84. (8 2 + 5 2 = 89, 8 2 + 10 2 = 164.) 

The foregoing scries of curves (Figs. 10 to 13) was taken with the base 
of the radium applicator 1 cm. from the surface of the water; i.e., the 
radium tubes were a little over 8 cm. from the surface of the water. 



Fig. 13. Intensity on surface of water. P.;isc of ap]ilii-atnr 1 cm. from water. 



60 



RADIUM THEKAl'Y 



The curve in Fig. 14 is taken under the same conditions as the pre- 
vious curve, but is plotted to a different scale horizontally and vertically 
from the other curves. The distances are taken diagonally from the axis 
of the applicator. 



Slih: 



Fig. 14. Intensity on surface of water. Base of applicator 1 cm. from water. 

First Observations of Intensities with the Second Type of lonization 

Chambers 

We may now discuss the series of curves taken with the second type 
of ionization chamber. One of these curves was taken as a calibration 
curve for the chamber. The leak across from the inner electrode to 



ABSORPTION OF GAMMA RAYS IN WATER 



61 



the ground was not small enough to make conditions favorable ; it 
changed markedly the values obtained from the reciprocals of the times. 
A theoretic deduction of the correction to be applied is as follows: 
Let c be the current due to the ionization chamber, i.e., that which is to 



Fig. 15. I'ielil in air. /, parallel to plane of tubes at 3.5 cm. distance. //, perpendicular to plane 

of tubes, along axis. 

be measured: c'V that due to the leak from the inner electrode to the 
ground; V being the voltage to which the leaf has become charged; c" 
(V'-V) that from high potential to leaf, V being the high potential. 
Then, neglecting a constant capacity factor, 



62 



RADIUM THERAI'Y 



dV 
~dt 

(e+e"F')-(c'+c")F 

/U 1 /^ j 

f ft rlt 


j o (c+c"l")-(c'+c")r Jo 1 


cs-c'T' 
c+c r _ (f ' +C "> r 


1-e -<''+''"> 


< 

'F' 


l- e -'-"" 














































S , 


1::::::: 














-_L__ j . __,._. , 
































































::::: ii :::^: :: 












I E: ^ 


_ -5 , .. __ 




T^^t^ 

^"i j: - N . -p. 



in air, pi-rjifiidirnlar to plane of tubes. 



Al'.SOKI'TION" OF GAMMA RAYS IN WATER 63 

TABLE X 

INTENSITIES AT VARIOUS DISTANCES ALONG THE LINE PERPENDICULAR TO THE CENTER 
OF A 6xfi CM. PLAQUE, WITH 9 TUBES CONTAINING 100 MC. IN ALL 



DISTANCES 
IN CM. 


INTENSITIES (THEORETIC 
AT DIFFERENT POINTS ON 


VALUES) 

THE AXIS 


8.5 


1.29 




9.5 


1.0.3 




10.5 


.866 




11.5 


.727 




12.5 


.619 




13.5 


.533 




14.5 


.464 




15.5 


.407 




16.5 


.360 




17.r, 


.321 




18.5 


.288 




19.5 


.259 




20.5 


.235 




21.5 


,214 





TABLE XI 
INTENSITIES AT VARIOUS DISTANCES FROM THE LINE PERPENDICULAR TO THE CENTER 

OF A 6x6 CM. PLAQUE, WITH 9 TUBES CONTAINING 100 MC. IN ALL 
ALL VALUES ARE TAKEN AT A DISTANCE OF S.5 CM. FROM THE PLANE OF THE TUBES 



DISTANCES 
IN CM. 


THEORETIC 
VALUES 


EXPERIMENTAL VALUES 
(CORRECTED BY CALIBRATION CURVE) 





1.29 


1.28 


1 


1.28 


1.28 


2 


1.23 


1.21 


3 


1.17 


1.10 


4 


1.09 


1.04 


5 


1.00 


.93 


6 


.91 


.85 


7 


.82 


.77 


8 


.73 


.67 


9 


.65 


.63 


10 


.58 


.56 


11 


.52 


.50 


12 


.47 


.46 


13 


.42 


.43 


14 


.38 


.40 


16 


.34 


.35 


16 


.31 


.32 



The other curves were then corrected by means of the calibration curve 
and for air were found to agree very well with the theoretic values. 

In Fig. 15, Curves I and II were taken in air. They show the funda- 
mental characteristics of such curves. Curve I is taken at a constant dis- 
tance from the plane of the tubes and at different distances from the axis. 
It shows zero slope to start with, gradually increasing gradation, then a 
point of inflection, and ;i gradual decrease in slope. 



64 



RADIUM THERAPY 



Curve II is taken along the axis; the slope is at first large and gradually 
decreases. 

All curves in air can be regarded as combinations of these two types. 

Fig. 16 is the original curve for Fig. 15 II. It was by correcting Fig. 
16 to the latter that the calibration was obtained. 

Second Series of Observations with the Second Type of lonization 

Chamber 

The apparatus was now set up a second time. Data were taken which 
resulted in Fig. 17 for the field in water. The calibration curve obtained 




Fig. 17. Field in water, perpendicular to plane of tubes, o, Experimental values; .r, values cal- 
culated on the basis of no absorption; A, values calculated on the basis of fi .033. 



ABSORPTION OF GAMMA RAYS IN WATER 



65 



in air was almost identical with that obtained previously ; it is practically 
linear, 7 = 140 +.253 fitting the calibration curve with a maximum error 

~~T 
of a few per cent. 

Data were taken later for depths down to ten centimeters. The applicator 
used was 10 cm. square and 10.7 cm. high. The base of the applicator was 
kept at a distance of 3 cm. from the surface of the water, and hence the plane 
of the tubes in every ease was 14 cm. above the surface of the water. 

The first column in Table XII gives the distance of the point at which 
the intensity was measured from the plane of the tubes ; the second its dis- 
tance below the surface of the water. The third column gives the observed 
value of the intensity. The fourth, the value calculated without allowing 
for any absorption by the water, i.e., the value which it would have had if 
there had been no water present. The fifth column is the per cent differ- 
ence between the value observed and the value calculated on the basis of 
no absorption. The sixth and eighth columns assume absorption coefficients 
of .033 and .05 for the water respectively, while the seventh and ninth 
columns give the percentage differences between the values calculated on 
these assumptions and the values observed, 

TABLE XII 



DIS- 
TANCE 


DIS- 
TANCE 


OB- 
SERV- 


CALCULATED 
VALUES. 


CALCULATED 


FROM 


BELOW 


ED 














PLANE 


SUR- 


VAL- 


S " 

AIR. 


% DIF- 


/t=.033 


% DIFF. 


M 05. 


% DIFF. 


OP 


FACE 


UES. 


NO AB- 


FERENCE 




OBS 'D. 




OBS 'D. 


TUBES. 


OP 




SORP- 


BETWEEN 




CAL 'CD. 




CAL 'CD. 




WATER. 




TION. 


OBSERV- 


















ED AND 


















CALCU- 


















LATED. 










i::.r,(i.-in. 


.05cm. 


.r,7D 


.506 


13 


.506 


13 


.506 


13 


15.55cm. 


2. cm. 


.408 


.388 


5 


.363 


12 


.351 


16 


16.85cm. 


3.3 cm. 


.325 


.334 


-3 


.299 


9 


.285 


14 


18.35cm. 


4.8 cm. 


.257 


.284 


-10 


.242 


7 


.223 


15 


20.30cm. 


6.75cm. 


.217 


.234 


-8 


.187 


16 


.167 


30 


20.65cm. 


7.1 cm. 


.210 


.226 


-7 


.178 


18 


.158 


33 


-l.r.Vm. 


8.2 cm. 


.198 


.204 


-3 


.155 


28 


.135 


47 


23.15cm. 


0.6 cm. 


.181 


.181 





.131 


38 


.112 


62 


23.95cm. 


10.4 cm. 


.165 


.170 


-3 


.120 


38 


.101 


69 



Hence the same general conclusion was reached in the second series 'of 
observations as in the first ; viz., that the intensity below the surface of the 
water was practically the same as though no water were present. This 
conclusion was now found, however, to remain true down to a depth of ten 
centimeters. In other words, the increase due to the scattering, under 



66 RADIUM THERAPY 

the conditions used, almost exactly neutralizes the decrease due to the 
absorption. 

As regards the difference between the observed values and those cal- 
culated on the basis of p = .033, the percentage of difference varies from 
approximately 10 per cent from the skin surface down to a depth of 5 cm. 
up to 38 per cent at a depth of 10 cm. 

Using an absorption coefficient of .05, the variation is from about 15 
per cent to about 70 per cent. 

Final Series of Observations with the Second Type of lonization Chamber 

Other readings taken with various types of radium applicators and 
different amounts of radium arranged in various ways appeared to give 
the same result with the type of chamber used ; viz., there was seemingly 
little change in the gamma ray intensity due to the presence of water. 
There was possibly a change of about ten per cent in a few readings down 
to a depth of ten centimeters. Below 10 cm. a slight decrease below the 
value that would have been obtained in air was noted. 

Fig. 18 shows the relatively insignificant effect of the presence of a layer 
of water 3 cm. thick as compared with a change of 3 cm. in the distance of 
the radium from the point at which the intensity was measured. All the 
curves give the variations in the field as one passes (parallel to the plane 
of the tubes) laterally from the axis of the applicator. 

Curve I (Fig. 18) is taken with the base of the applicator 2 cm. above 
the water and 5 cm. from the ionization chamber, i.e., with the ionization 
chamber 3 cm. deep in the water. The water was then lowered 3 cm. keep- 
ing the radium in the same place (i.e., base of applicator 5 cm. from water 
and ionization chamber, latter being on surface of water). Curve II (Fig. 
18) was then taken. The total effect due to three cm. of water (with no 
change in distance of radium) between the radium and the object radiated 
would thus appear to be small. 

The applicator was then lowered 3 cm. (i.e., base 2 cm. above water and 
ionization chamber). Curve III Fig. 18 was then taken. This curve shows 
the relatively large effect due to this change in distance. 

Curves I and II thus refer to the same distance of chamber from radium, 
and differ only in the amount of water between the two. Curves I and III, 
on the contrary, refer to the same distance of surface of water from radium, 
and differ only in the depth at which the chamber was placed. 

That the difference in the rate of variation of the field depends markedly 
on the distance of the radium is shown very well by Curves II and III. 
The rate of change, is, for a point source, as one leaves the axis, inversely 
proportional to the square of the distance from the radium along the axis, 
while the relative change varies inversely as the distance. 

On trying to apply the null method mentioned by Makower and Geiger 
(previously referred to) it was found that with the condenser at hand the 



ABSORPTION OF GAMMA RAYS IN WATER 



67 



leak over the surface of the insulation (which was of ebonite) was very 
great compared to the current to be measured. As a result we gave up 
for the time being at least, what seemed to be a promising method of get- 
ting rid of every leak except that in the electroscope. With a proper con- 
denser the method should be as good as any yet worked out. 




Fig. 18. Diagram showing change in intensity due to distance as compared with change in in- 
tensity due to absorption in water. 

Other possible improvements in the technic of the experiments may be 
mentioned. The electroscope could be evacuated, or shielded with a lead 
screen. The capacity of the whole system could be decreased by using 
larger connecting tubes or finer wires; by joining successive wires di- 



68 RADIUM THERAPY 

rectly and pouring sulphur over the connections the insulation would he 
improved. The use of thinner tubing would decrease the weight of alumi- 
num in the guard tube. 

One possibility of error must now be mentioned. In case the ioniza- 
tion chamber allows secondary beta rays from the water to enter in 
sufficient quantity to modify the readings, the results of the foregoing 
tests may be misleading, since the effect would be to increase the values 
in water relative to those in air. This does not, however, seem tp be 
probable. 

The whole series of experiments could be repeated with an ionization 
chamber made extremely thin in order to intercept and measure the beta 
rays instead of the gamma rays. 

The chamber suggested would not be thick enough to scatter the gamma 
rays appreciably as may happen with the type of chamber that we have 
been using. 

Although under these circumstances both beta and gam ma rays would 
take effect, the error due to the gamma rays would probably be so small 
as to be practically negligible. 



CHAPTER VIII 
PHYSICAL AND CHEMICAL EFFECTS OF RADIUM RAYS 

In this chapter will be considered briefly some of the physical and 
chemical effects that the radiations from radium may cause. Most of 
these effects are due to the action of the alpha and beta rays although 
they may also result from the gamma rays. 

1. IONIZATION OF GASES 

The rays have the power of discharging electrified bodies such as the 
electroscope, the rate of discharge depending on the intensity of the 
radiations. In order to explain this phenomenon the theory has been 
advanced that the rays produce in the air negatively charged carriers 
called "ions" which render the air a good conductor of electricity. This 
property of producing "ions" is known as that of ionization. The alpha 
rays have a marked ionizing effect; the beta rays have only one or 
two per cent of the ionizing effect of alpha rays, while the ionizing effect 
of the gamma rays is only a few per cent of that of the beta rays. Locally 
alpha rays have intense ionizing power. Beta and gamma rays have 
a less intense local action but this is distributed over a larger space. The 
total ionizing effect of each of the three kinds of rays is probably about 
the same. The ionizing effect of the gamma rays is probably due to the 
secondary beta rays which are produced by the absorption or "stop- 
ping" of the gamma rays. In the chapter on measurement of the beta- 
gamma ray activity of the radiations this subject has been considered 
in more detail. 

2. PENETRATION OF OPAQUE MATTER 

The degree of penetration possessed by the radiations may be shown 
by the electroscope. A radium salt exposed freely in an electroscope 
causes a very intense ionization of the air and the charged gold leaf 
moves quickly across the field of the microscope. If the radium prepa- 
ration is covered with a piece of aluminum foil or merely with a sheet 
of note paper, the ioni/ation is much less intense and the gold leaf moves 
much less rapidly. With ten sheets of note paper covering the salt the 
ionization is about one half as intense as with one sheet. It is evident 
that the interposition of the note paper cuts off the most readily absorb- 
able rays which have a marked ionizing effect. By covering the radium 
salt with various thicknesses of metal, rays of widely different pene- 
trating power may be distinguished. The rays most easily absorbed 

69 



70 RADIUM THERAPY 

are known as the alpha rays, those less easily absorbed are the beta 
rays, while those least easily absorbed arc known as the gamma rays. 

Alpha rays are absorbed by about .089 mm. of epithelial tissue. They 
are therefore of little or no therapeutic importance. The most pene- 
trating beta rays are half absorbed by 0.1 mm. of lead and to the extent 
of 99.9 per cent by 1 mm. of lead. According to Rutherford they are 
completely absorbed by 2 mm. of lead. The hardest beta rays, after 
penetrating 1 cm. of epithelial tissue, lose about 94 per cent of their 
energy. In other words, on account of absorption their quantity after 
passing through 1 cm., of tissue, is only about 6 per cent of that at the 
surface. The gamma rays arc absorbed to the extent of 40 per cent by 
one cm. of lead and to the extent of 99.4 per cent by 10 cm. of the same 
material. The gamma rays from thirty milligrams of radium can still 
be detected by the electroscope after passing through 25 cm. of lead or 
30 cm. of iron. According to the investigations of Giraud, gamma rays 
are reduced to one-half their intensity after passing through 20.4 cm. of 
water, 18.3 cm. of blood serum, 14.4 cm. of blood or 7.6 cm. of muscular 
tissue. 

Using lead as a test of absorbing power, hard gamma rays are about 
thirty times as penetrating as hard x-rays from the Coolidge tube. Using 
water (tissues) as a standard of comparison hard gamma rays are 
slightly more than four times as penetrating as hard x-rays. 

Advantage may be taken of the fact that the alpha, beta and gamma 
rays are stopped Or absorbed by varying thicknesses of metallic and non- 
metallic substances. By placing between the radium and the tissues 
different thicknesses of such materials, varying portions of the beta and 
gamma rays may be filtered out. The biologic effects of the rays will 
evidently vary according to the type and quantity of rays that penetrate 
the screen and are absorbed by the tissues. 

3. PRODUCTION OF HEAT 

Radium liberates heat spontaneously and continuously. Compounds 
of radium maintain themselves at a temperature several degrees higher 
than the surrounding atmosphere. In one hour one gram of radium 
element spontaneously generates sufficient heat to elevate the tempera- 
ture of 136 grams of water one degree centigrade. 

"The emission of heat from radium and other radioactive substances 
is in a sense a secondary effect for it is a measure of the energy of the 
radiations expelled from the active matter which are absorbed by the 
active matter itself and the envelope containing it." (Rutherford.) 

The alpha particles produce the greatest heating effect, furnishing 125 
calories of the 136 calories produced by one gram of radium in one hour. 
The beta rays bear 4.5 and the gamma rays 6.5 of the remaining 11 
calories. 



PHYSICAL AND CHEMICAL EFFECTS OF RADIUM RAYS 71 

4. EMISSION OF LIGHT 

All radium compounds are feebly self-luminous in the dark. This 
phenomenon is probably due to the presence in preparations containing 
radium of impurities which phosphoresce under the constant bombard- 
ment of the rays. This luminosity varies under different conditions. 
Radium preparations lose a large amount of their luminosity upon ex- 
posure to damp air, but regain it again when the salts are dried. 

5. PHOSPHORESCENCE AND FLUORESCENCE 

Various bodies phosphoresce or fluoresce under the influence of radium 
rays. The large majority of substances, that exhibit this property belong 
to the alkali metals or alkali earths. 

Among the many different substances that become luminous when 
exposed to the rays arc willemite (zinc silicate), kunzite and sparteite, 
barium platinocyanide, hexagonal zinc blende, certain kinds of dia- 
monds, etc. The property possessed by radium rays of inducing phos- 
phorescence has been taken advantage of by Crookes in devising the 
spinthariscope. In this little instrument a minute quantity of radium is 
enclosed in a tube which has a zinc sulphide screen at one end and a mag- 
nifying lens at the other. Upon looking through the lens in the dark the 
screen appears as a dark field lighted up by rapid scintillations. The lat- 
ter are due to the continuous shooting out of alpha particles which cause, 
by impact, the zinc sulphide to fluoresce. 

Certain bodies, e.g., fluor-spar, when exposed to. radium rays become 
luminous only when heated this phenomenon being known as "thermo- 
luminescence." 

The alpha rays are the most active in causing fluorescence, the beta 
and gamma rays being much less powerful in this respect. 

6. PHOTOGRAPHIC ACTION 

All three types of rays have a marked action on the photographic 
plate, the beta rays being less energetic than alpha rays and the gamma 
rays less active than either of the others. Radiographs made with gamma 
rays, however, are better defined than those made with beta rays mixed 
.with gamma. Radiographs made with x-rays are much more clear and 
distinct than those made with radium radiations. 

7. COLORATION OF VARIOUS SUBSTANCES 



Ordinary sod;i ybixs is colored violet or even black after long continued 
exposure to the rays. Other kinds of glass may become brown or yellow. 
The capillary glass tubes in which the emanation is confined for thera- 



Jli RADIUM THERAPY 

peutic use as well as certain parts of the glass tubing of the emanation 
apparatus itself thus turn violet after prolonged use. Plates of mica 
may be colored brown or black. Joly showed that the "pleochroic 
halos" of mica were due to radioactive effects. Diamonds may tem- 
porarily be colored rose, yellow, blue or green. It was at one time 
thought that the change in color produced by the rays in barium platino- 
cyanide might serve as an index to the therapeutic effects of the rays just ;is 
x-rays may be measured by the Saboraud-Xoire pastiles. No practical 
results have been obtained, however, from this method of measurement. 

Coloration effects are due especially to the alpha particles but the beta 
and gamma rays may also act in producing them. 

The change in color due to alpha rays is limited to a surface layer, as, 
e.g., in the case of glass when it .is exposed, while the beta and gamma 
rays color the deeper layers of the substance as well. 

8. OTHER CHEMICAL EFFECTS 

In addition to the coloration of certain bodies just referred to, radium 
rays, especially the alpha particles, may produce various chemical 
changes in numerous substances. Only a few of these effects will be 
mentioned here. 

Ozone may be produced from oxygen. Various metals, such as lead, 
mercury, etc., when exposed in air, are rapidly oxidized. 

Water is decomposed by the radiations into hydrogen and oxygen. 
Organic matter, in general, is decomposed gases being given off. In the 
apparatus for the extraction and purification of radium emanation for 
therapeutic use stopcock grease is not used, owing to the decomposition 
of the grease by the radiations with the production of carbon dioxide. 

Paper, rubber and other fabrics exposed constantly to the radiations, 
crack and become reduced after a time to powder. The flexible type 
of radium applicator made of linen or rubber becomes more or less dis- 
integrated after some months and must be remade. Many other chemical 
reactions due to the radiations have been observed but for details of these 
and many other interesting phenomena the reader is referred to special 
works on radioactivity. 



CHAPTER IX 
BIOLOGIC EFFECTS OF RADIUM RAYS 

"^fc 

EFFECTS OF RADIUM RAYS ON LIVING CELLS 

Numerous experiments have demonstrated the effects of radium rays 
on living cells of both the vegetable and animal kingdoms. In this and 
the succeeding chapter we shall give the results of some purely experi- 
mental investigations which have a direct bearing, however, on the use 
of radium in disease. 

1. Effects on Bacteria 

Aschkinass and Caspari, Chambers and Russ, Green, Pfeiffer and Fried- 
berger, Hoffman, Strebel, Strassmann, and many other investigators have 
carried out experiments to determine the effect of the rays or of the 
emanation on bacteria. 

Pfeiffer and Friedberger exposed gelatin cultures of cholera and ty- 
phoid bacilli and of anthrax spores to 25 mg. of radium bromide at a dis- 
tance of 1 cm. The beta and gamma rays were used. The growths within a 
certain superficial area were destroyed in 16, 48, and 72 hours, respec- 
tively. Strassmann studied the effect of the rays from 10 mg. of radium 
bromide upon various organisms. The time required to kill B. prodi- 
giosus, streptococcus, staphylococcus, and B. tuberculosis was found to 
be 24, 24, 48, and 108 hours, respectively. Chambers and Russ prepared 
emulsions of various organisms in distilled water. Emulsions of B. coli 
commiinis, staphylococcus pyogenus aureus, B. pyocyaneus, B. anthrax 
and B. tuberculosis were exposed either to a known intensity of beta 
rays or to a measured concentration of radium emanation. The beta rays 
from as small a quantity as 7 mg. radium bromide were found to have a 
bactericidal effect. In estimating the effect of the emanation a known 
volume of the emulsion of the organism was removed from the influence 
of the emanation at different periods and planted upon agar-agar. With 
a concentration of the emanation amounting to 5 me. per c.c., the number of 
organisms being approximately one million per c.c., a sterilizing effect 
was noted on the above organisms in periods of from sixty-five minutes 
to four hours. A possible error in these conclusions lies in the fact that 
the emanation produces ozone which may be the bactericidal factor. From 
these and the general trend of many other experiments it has been con- 
cluded that the rays from radium have distinct bactericidal properties 
\vlicii allowed to act in sufficient doses outside of the body of the host. 
As to the effect on bacteria in 1 1ssues, however, no results have been ob- 
tained experimentally that would indicate that bacteria may be actually 

73 



74 RADIUM THERAl'Y 

destroyed by radium rays '"Without serious injury to the tissues them- 
selves. It may be mentioned, however, that Flemming and Krusius ob- 
served inhibition of the growth of bovine tubercle bacilli placed on the 
cornea or in the anterior chamber of the eye. 

In military surgery beneficial effects in checking suppuration in deep 
wounds have been noted. Improvement has been noted by (he writer and 
others following the introduction of radium tubes into tuberculous si- 
nuses, etc. Certain chronic ulcers discharge less freely after radiation. 
These favorable effects are probably to be attributed, however, to the 
effect on the tissues rather than to the actual bactericidal effect of the 
rays. With our present knowledge of the effect of the rays on the higher 
types of living cells no practical results in the actual destruction of 
bacteria in tissues without destroying the tissues containing them can 
be expected. Long before the bacteria, which are highly resistant vege- 
table organisms, can be destroyed, the more sensitive tissues of the 
animal organism will be irreparably damaged. 

2. Effects on Seeds and Plants 

Abbe, Matout, Molisch, Fabre and many others have recorded interest- 
ing experiments on seeds and plants. Abbe exposed wheat grains to 
mixed beta and gamma rays for different lengths of time and at varied dis- 
tances. "The universal effect was a depression of growth exactly in 
proportion to both time and distance." Matout exposed the seeds of 
cress and white mustard to the beta-gamma rays for a week and found 
that they had lost their power of germination. Molisch exposed the 
buds of syringa vulgaris to the beta rays and found that their growth 
was favored when in the resting stage but hindered when in the growing 
state. Fabre found that a flowering lily, irradiated with strong doses, 
had its development stopped completely. 

Further illustrations of the effect of the rays on various forms of 
vegetable life may be found in special articles referred to in the bibli- 
ography. 

3. Effects on the Lower Forms of Animal Life 

Observations of the effects of the radiations on certain lower forms of 
animal life (protozoa, etc.) have been made by Bohn, Halberstaedter, 
Will cock, Zuelzer and many others. Only a few of these experiments 
can be referred to here. 

Halberstaedter and his coworkers radiated trypanosomes and observed 
particularly the effect both on their subsequent motility and their power 
of infecting animals. With the doses used, the motility of the trypan- 
osomes was apparently unaffected. The rays cheeked, however, their 
power of reproduction so that infection did not, as a rule, occur. From 
this it was inferred that the rays acted particularly on the nuclei which 
are the elements responsible for the propagation of the trypanosomes. 



BIOLOGIC EFFECTS OF RADIUM RAYS 75 

Halberstaedter, therefore, inferred that the radiations affected and de- 
stroyed the reproductive functions of the organisms before the nutritive 
functions were injured. 

The effects on the developing forms of some of the lower animals have 
been observed by Bohn, 0., G. and P. Hertwig, Thur, and many others. 
Bohn investigated the effects on the spermatozoa, ova and larvae of the 
sea urchin. Spermatozoa were rendered less active and finally killed. 
Ova and larva? developed more slowly and irregularities of development 
and form were observed. 

Paula Hertwig investigated the effect of radiations on the development 
of the ova of ascaris megalocephala, particularly with respect to the 
nuclear changes. Development was slower than normal and irregu- 
larities of form were noted. The chromatin of the nuclei was especially 
affected and even destroyed. 

Thur observed the effect of radium rays upon chick embryos and later 
upon the embryos of the gold fish. Retardation and irregularities of devel- 
opment and the production of monstrosities were noted. 0. and G. Hertwig 
have made an extensive series of observations upon the spermatozoa, ova and 
larva? of frogs. Sufficiently long exposures disorganized the chromatin of 
the spermatozoa. Ova that had been fertilized with normal spermatozoa 
and then irradiated developed much more slowly than normally and ex- 
hibited many irregularities of development. Ova that were fertilized 
with irradiated spermatozoa also showed many abnormalities of develop- 
ment. It is of interest to note that 0. Hertwig found that certain chem- 
ical agents produced irregularities of development and abnormalities of 
form that were nearly identical with those due to radiation. 

Radium cannot therefore be regarded as producing changes in these 
developing forms that are absolutely characteristic. 

For a fuller account of these and many other interesting observations 
of the effects of the rays on various organisms the reader is referred to 
the articles mentioned in the bibliography. 

4. Effects on the Various Tissues of the Higher Animals 

Broadly speaking, all three types of radium rays, if allowed to act in 
sufficient doses, produce inflammation and even destruction of the ir- 
radiated tissues. In a subsequent chapter devoted to the subject of "re- 
action" we shall refer to two different kinds of response on the part of 
the tissues that are to be observed after the application of radium to the 
skin. We shall then emphasize the fact that very important modifica- 
tions of vital tissues may be brought about either by a selective or by 
an inflammatory effect of the rays. We mention this at this point in 
order to correct an erroneous belief that radium rays in order to cause 
pathologic tissues to disappear necessarily cause inflammation. Most 
of the histologic examinations of irradiated tissues have been made in 



76 RADIUM THERAPY 

cases in which a more or less intensive inflammatory effect had been 
produced. The "selective" effect of the radiations, resulting in modi- 
fications of tissue that are not associated with visible inflammation is 
just as important, however, from a clinical point of view, as the in- 
flammatory effect. 

EFFECTS OF THE RAYS ON THE SKIN 

The macroscopic or clinical appearance of the inflammation of the skin 
due to. radium rays will be discussed in the main in a later chapter under 
the subject of "reaction." Here we may consider the histologic changes 
occurring in the skin after experimental radiations. 

These changes have been observed and described by Halkin, Thies, 
Guyot, Dominici and Barcat, and many others. The animals used in the 
various experiments were pigs, guinea pigs and mice. Thies exposed an 
area of human skin. 

We may first briefly epitomize the histologic findings of Dominici and 
Barcat who have accurately stated the conditions of their experiments. 
These two authors made their investigations with six mg. of radium 
bromide contained in a "varnish plaque" and spread over a circular 
surface two cm. in diameter. In one series of experiments no screen 
was used, the radiations consisting, therefore, of mixed beta and gamma 
rays (beta rays probably 90 per cent, gamma rays 10 per cent). Ten 
exposures of five minutes each were given on successive days, guinea 
pigs being used. The clinical effects appeared ten days later. These 
consisted of erythema followed by ulceration and crusting. The crust 
fell off between the fifth and sixth week. The healed irradiated area 
then appeared as a depigmented, hairless, smooth and supple scar. 

Histologic Findings Eight or Ten Days after the Commencement of 

Exposures 

In the epidermis, evidences of inflammation were noted. The nuclei 
of the epithelial cells showed enlargement or irregularity of outline to- 
gether with thickening of the chromatin fibrils and the nucleolus. In- 
tercellular edema was present. 

Histologic Findings Ten or Fifteen Days after the Commencement of 

Exposures 

Epidermal dcsquamatioii was noted and there were evidences of a 
granular and pigmentary degeneration in the sweat and sebaceous glands 
and in the hair follicles. During this same period the corium was the 
seat of an intense congestion and of a beginning embryonic transfor- 
mation. 



BIOLOGIC EFFECTS OF RADIUM RAYS 77 

Histologic Findings Thirty or Forty Days after the Commencement of 

Exposures 

Two phases were noted. (1) "The phase of embryonic regression" 
and later (2) "the phase of fibrosis. " During the first phase the epi- 
dermis was restored but the hair follicles and glandular structures were 
permanently destroyed. The corium had undergone such changes that 
its normal structure was apparently lost. There was a temporary rever- 
sion to an embryonic type. The connective tissue and the elastic tissue 
underwent a transformation, giving place to innumerable branching 
connective tissue cells. These had ramifying and anastomosing proc- 
esses. The smooth muscle fibers underwent similar changes, being in- 
distinguishable from the other embryonic tissue cells. The small blood 
vessels showed a tendency to revert to embryonic forms. The endotho- 
lium acquired the plasmodial character of the embryonic type. The walls 
of the vessels themselves appeared to be made up of fusiform and stel- 
late cells continuous both with the extrinsic proliferating connective 
tissue cells and with the endothelium itself. In short, the connective 
tissue and vascular system of the corium became converted into an 
embryonic and angiomatous type of tissue. 

In the second phase, fibrous connective tissue redeveloped. There was 
a tendency toward the formation of a fibrous scar which differed, how- 
ever, both from the normal corium and from the usual postinflammatory 
sclerotic tissue. From the former it was distinguished by the regularity 
of the superimposed connective tissue fibers and the intervening cells 
and by the fact that the fibrous tissue formed lines parallel with each 
other and with the surface. From the latter it was distinguished by the 
remarkable regularity of the sclerotic tissue and by "the absence of 
fibroid perivascular rings and of vascular obliteration." Six or seven 
months after the commencement of the exposures, connective tissue fibers 
largely replaced the cellular elements but there was the same remarkable 
regularity and parallel arrangement of the sclerotic tissue. 

In a second series of experiments carried out by Dominici and Barcat 

"the same radium plaque screened with 0.5 mm. of silver was used. As 
this screen filtered out more than 96 per cent of the hard beta rays, the 
gamma rays were responsible for the main changes. After an exposure 
of fifty minutes no changes were observed. After an exposure of four- 
teen hours, there were found histologically an enlargement of the nuclei 

' of the cells of the epidermis and evidences of congestion of the corium. 
The latter condition was accompanied by a slight hypertrophy of the 
nucleus and cytoplasm of the connective tissue cells. After an exposure 
of two or three days there was superficial but temporary destruction of 
the epidermis. The corium displayed histologic changes that were not 
to be distinguished from those occurring after an exposure of fifty min- 
utes to the unscreened apparatus. 



78 RADIUM THERAPY 

Lazarus-Barlow has carried out a series of experiments to determine 
the histologic effects of radium rays on columnar and squamous epithelium. 
Two tubes, one containing 92 milligrams and the other 38 milligrams of ra- 
dium bromide (about 49 milligrams and 17 milligrams of radium element) 
were chosen and allowed to act under the conditions described below for 
thirteen and one-half and thirty minutes, respectively. The two tubes, hav- 
ing nearly the same screening of platinum and acting under the above con- 
ditions ( i.e., a larger quantity for a shorter time and a smaller quantity for 
a longer time) produced the same total amount of ionization. From this 
standpoint, therefore, the dose was considered as being the same from each 
tube. Each tube was inserted into the rectum of a series of rats so that 
3 different areas covered by 3 different kinds of epithelium were affected, 
viz., the rectum (columnar epithelium), the anus (moist squamous epi- 
thelium) and the under surface of the tail (dry squamous epithelium). 
The animals were killed so that the effects on the first, second, third, 
seventh, eighth and ninth days after exposure could be studied. The 
chief effects were the following: 

Columnar epithelium region : 92 mg. acting for 13% minutes produced 
in general less inflammatory changes than 38 mg. acting for thirty minutes. 
This was found to be the case during every period first to ninth day of the 
examination. 

Immediately adjacent to the tube, more disturbance of mitosis but less 
inflammatory reaction was observed from the effects of the 92 milligram 
tube. At a short distance from the tube, less disturbance of mitosis and 
less inflammatory action was produced by the 92 milligram tube. De- 
generative effects, however, such as desquamation, mucous formation, 
mucoid degeneration, and nuclear changes were more marked as a result 
of the action of the 92 milligram tube. 

In the moist squamous epithelium region the reverse of the above find- 
ings was noted. Thirty-eight milligrams acting for thirty minutes pro- 
duced more changes in the cells reduction in number of mitoses, swell- 
ing of the nuclei and loss of staining qualities than 92 milligrams acting 
for thirteen and one half minutes. There were no inflammatory changes. 

In the dry squamous epithelium region also the 38 milligram tube in 
thirty minutes produced more marked alterations in the cells, such as 
inhibition of mitosis and loss of staining qualities, than the 92 milligram 
tube in thirteen and one-half minutes. The sphincter ani muscle under- 
lying the epithelium was also more affected by the 38 milligram tube 
acting for thirty minutes. 

In another series of experiments, the effect of rays of different char- 
acter, obtained by varying the thickness of the screens covering the 
tubes, was studied. The 92 milligram tube was used but was covered 
with platinum screens varying in thickness from 0.5 mm. to 2 mm. When 
a thickness of 0.5 mm. of platinum is used the hard beta rays accompany 
the total gamma radiation. When a thickness of 2 mm. of platinum is 



BIOLOGIC EFFECTS OF RADIUM RAYS 79 

used the hard beta and soft gamma rays are eliminated, only the 
hard gamma rays acting. The radium was maintained at the same dis- 
tance from the tissues in the different experiments by coating the screens 
with paraffine wax so that their outside diameter was uniformly 8 mm. 
The time factor of the exposures was varied so that each dose produced 
the same total ionization. The difference in the exposures therefore 
consisted only in the different quality of the rays employed. Under 
these conditions, the epithelium and subepithelial tissues showed greater 
damage as a result of exposures made with the thinner screens (hard beta 
plus gamma rays) than with the thicker screens (hard gamma rays). 

In still another experiment, the same two tubes containing 92 and 38 
ing., respectively, were used. The 92 milligram tube was allowed to 
act for one hundred and eight minutes and the 38 milligram for two 
hundred and forty minutes. Measured by the total amount of ionization 
produced, the dose with each tube was the same. Each tube was in- 
serted into the lower end of the rectum of a rat so that both this part 
of the rectum and the adjacent parts of the tail were exposed to the 
rays. The two animals were killed on the ninth day after the exposure. 
The chief effects were the following: 

In the columnar epithelial cell region the 38 milligram tube acting for 
two hundred forty minutes produced more destructive effects than did 
the 92 milligram tube acting for one hundred eight minutes. The mucous 
membrane in contact with the tube in some places sloughed away. 

In the squamous epithelial cell region the effects were reversed. Here 
the 92 milligram tube produced more marked inflammatory changes and 
destruction of squamous cells in one hundred eight minutes than did 
the 38 milligram tube acting for two hundred forty minutes. 

The following inferences may be drawn from these experiments : In- 
asmuch as less damage was ordinarily done to the normal columnar epi- 
thelium regions when the quantity factor was large and the time factor 
small, this general method of procedure may be adopted in making 
therapeutic applications to these regions. 

In the case of squamous epithelial cell regions, the reverse effects were 
noted, i.e., less damage' was done to normal tissues by the smaller quantity 
acting for a longer time. In the treatment of these regions therefore 
it is probable that a smaller quantity allowed to act for a longer time 
may be theoretically used with advantage. It must, be emphasized, how- 
ever, that conclusions drawn from these and similar experiments must 
not be accepted too literally. 

Practical experience has shown conclusively that not less than 50 
milligrams of radium element and in some instances more than twenty times 
tliis quantity should be used in dealing with malignant conditions. One 
must not be misled, therefore, into assuming that very small quantities 
of radium are capable of seriously affecting large masses of malignant, 
tissue no matter how prolonged may be the exposure. According to 



80 RADIUM THERAPY 

some authors, too small a quantity of radium may even do serious harm 
by stimulating cellular activity. 

EFFECTS ON THE SPLEEN, LYMPHATIC GLANDS AND BONE 

MARROW 

The action of radium rays on the normal spleen, the lymphatic system 
and the hone marrow has been investigated by Thies, Heinecke and many 
others. Thies irradiated white mice "in toto" with 20 milligrams of 
radium bromide for various periods. After a prolonged exposure (nine 
to eleven days) he found that the spleen, the lymphatic glands, and 
solitary lymph follicles showed an absence of lymphocytes. The spleen 
Avas diminished in size and small masses of pigment Avere found through- 
out the pulp and especially around the arteries. The supporting con- 
nective tissue Avas increased. Heinecke found similar changes in the 
spleen as the result of irradiations. This author irradiated the exposed 
spleen of rabbits and guinea pigs for as short a period as five seconds 
and detected pronounced destruction of the nuclei of the cells. The 
same length of exposure produced no change Avhatever in the skin. He 
found also that radiation of the abdominal Avail for one hour with twenty 
milligrams of radium bromide caused pronounced destruction of the 
lymphocytes in the abdominal cavity. Gudzent investigated the effect 
on the spleen and other organs of injections of large doses of thorium 
X. The results Avere very similar to those produced by external radia- 
tions. According to this author, following the injections the entire spleen 
exhibits marked hyperemia. Its volume is later diminished. The cells 
of the spleen pulp decrease in numbers and in some places disappear al- 
together. On the other hand, the capsule and trabeculae are thickened 
and appear more prominent. Deposits of pigment are seen throughout 
the entire organ. 

As to the change in the bone marroAv, Thies found, in the experiments 
previously referred to, that in some cases, the marroAv cavity of the bones 
was packed Avith erythrocytes Avhile hemorrhages were common. In other 
cases, the bone marroAv shoAved almost no cellular elements although an 
occasional polymorphonuclear or mononuclear cell was seen. 

The favorable effects on the spleen and the blood picture, such as de- 
crease in size of the spleen, decrease in leucocytes, etc., noted in cases 
of leukemia subsequent to radiations of the spleen, are referred to in a 
later chapter. In general it may be inferred from the experiments 
mentioned above as well as from a great deal of clinical evidence, that 
the spleen, lymp'hatic glands and bone marroAv are extremely sensitive 
to radium radiations. 

EFFECTS ON THE BLOOD 

The blood either "in vivo" or "in vitro" may be affected by the rays. 



BIOLOGIC EFFECTS OF RADIUM RAYS 81 

Blood "in Vivo" 

Only a few of the numerous experiments undertaken to determine the 
action of radium on the blood "in vivo" will be mentioned. Bouchard, 
Curie and Balthazard found that a marked decrease of the leucocytes 
occurred in mice which were made to inhale large quantities of radium 
emanation. Von Noorden and Falta found that inhalations of emanation 
caused primarily an increase of the leucocytes but later a decrease was 
sometimes noted. On the other hand, if a considerable quantity of emana- 
tion (100 me. dissolved in 20 c.c. of normal salt solution) is injected 
subcutaneously no marked changes will occur in the blood (Price Jones, 
cited by Colwell and Russ). Brill and Zehner injected soluble radium 
salts subcutaneously into dogs. In one case, .184 mg. and in another case 
.064 mg. of radium chloride was used. They found that an increase both 
in the number of red cells and of leucocytes resulted. The effect of large 
doses was to decrease the number of leucocytes. 

In the experiments of Thies, who irradiated white mice "in toto," a 
marked diminution in the number of leucocytes in the blood resulted. 
The polymorphonuclears were very scanty and the mononuclears were 
almost absent. 

Aubertin and Delamosse found that radiations of animals produced 
a transient leucocytosis followed by a long continued leucopenia. 

In a case of myelogenous leukemia, reported by Renon, Degrais and 
Thibaut, the splenic area was rayed although the spleen had been pre- 
viously removed. Changes in the blood, such as diminution of leu- 
cocytes, etc., were produced that were practically identical with those 
found when the spleen is present and subjected to radiations. One may 
almost certainly conclude that these changes were due to the direct 
effects of the rays on the blood itself during its circulation through the 
abdominal cavity. 

The effect on the blood of the internal administration of radium will be 
further considered in the chapter devoted to radium in internal medicine. 

From the experiments already mentioned we may draw the following 
conclusions as to the effect of the rays on the blood : 

Radium may affect the blood whether given internally or allowed to 
act externally. 

As a result of the internal administration of radium or its derivatives, 
either by injections or inhalations, a pronounced effect may be produced 
on the blood and especially on the leucocytes. By this method of admin- 
istration the whole organism and especially the hemopoietic organs re- 
ceive a general though slight bombardment by the rays. 

By means of external radiation of the whole body, or of the spleen 
especially, similar effects may be produced. The effect, in general, 
on the blood, of therapeutic doses acting internally or externally is to 
produce a leukopenia, which follows an initial transient leucocvtosis. 



82 RADIUM THERAPY 

The red blood cells and hemoglobin are frequently increased. While the 
exact mechanism of the action of radium on the blood is not thoroughly 
understood, it seems probable that the rays may act both directly on the 
elements of the circulating blood and also indirectly by affecting the 
hemopoietic organs. 

Effect on Blood Coagulation 

According to von den Velden, small therapeutic doses of radium in- 
ternally cause the blood "in vivo" to coagulate more quickly. This 
result was noted in a case of hemophilia. The effect is only temporary. 
As the result of the administration of large doses of radium, causing a 
pronounced leucopenia, Kohom (cited by Gudzent) found that the blood 
coagulated more slowly. Von Domarus and Salle observed the same 
effects from large doses of thorium X. 

Blood "in Vitro" 

Blood "in vitro" may also be affected by exposing it to the radiations. 
According to Chambers and Russ, the red blood cells may be hemolyzed, 
especially by the alpha rays. Citrated blood exposed to radium emana- 
tion (.52 me. per c.c.) was almost completely hemolyzed at the end of 
forty-eight hours. 

According to the same authors, the phagocytic power of the leucocytes 
is reduced by exposure to the emanation, while prolonged exposure re- 
sults in their complete disintegration. When blood serum is exposed to 
alpha rays, the properties of opsonin and hemolytic complement are lost. 

Effects of the Rays on the Blood Vessels 

The changes in the vessels that may be caused by radium rays have 
already been mentioned. Halkin, Thies, Horowitz and many others have 
described the changes produced in normal vessels. In general, the endo- 
thelium of blood vessels is extremely sensitive to radium rays. The 
eiidothelial cells swell up tremendously so that the lumen of the vessel 
may be obliterated. Later, degenerative changes take place and the cells 
disappear. The tiinics of the vessels become infiltrated with leucocytes. 
Capillary hemorrhages may occur and later complete vascular oblitera- 
tion may take place. 

EFFECT OF THE RAYS ON CONNECTIVE TISSUE, MUSCLE AND 

CARTILAGE 

Thies found that the white fibrous connective tissue, when exposed to 
the rays, underwent destruction. This effect was in direct contrast to 
the effect on the yellow elastic fibers which even after prolonged expo- 



BIOLOGIC EFFECTS OF RADIUM RAYS 83 

sures remained apparently intact. Dominici and Barcat confirmed the 
resistance of the yellow elastic fibers to the rays. According to the latter 
two authors, elastic fibers reappear in considerable proportion as a post 
radiation process. The smoothness and suppleness of the radiation scar 
is explained by this fact and also by the absence of excessive connective 
tissue formation in the scar. 

Striated muscle degenerates under the action of the rays, the muscular 
fibers being replaced by connective tissue. 

Hyaline cartilage may be initially destroyed but later there may be 
observed pronounced hypertrophic changes in the cartilage itself. The 
earlier observations of Thies on this point were later confirmed by 
Horowitz. 

EFFECTS OF THE RAYS ON THE THYROID AND THYMUS 

GLANDS 

No reports of purely experimental investigations as to the effect of 
radium rays on the thyroid and thymus glands have yet appeared. We 
may mention here the experiments of Krause and Ziegler and of Rave as 
to the effects of x-rays on the thyroid gland of animals. These authors 
did not detect either macroscopic 'or microscopic changes in the thyroid 
gland due to x-ray radiation. From a clinical point of view, however, 
very marked effects on the thyroid gland have followed x-ray exposures 
even though the tissue changes were negligible. The clinical effect of 
radium on the thyroid was shown first by Abbe and later by Dawson 
Turner, Aikens and many others. As a result of radiations with radium, 
the thyroid has been noted to decrease in size and functional disturbances 
have improved. This topic will be considered again under the discussion 
of the treatment of goiter. 

The thymus gland in animals has been radiated experimentally with 
x-rays by Rudberg, Pigache and Beclere, Regaud et Cremieu and 
Eggers. In general it may be stated that atrophy of the organ occurs 
as a result of x-ray radiations. The excellent clinical results of Brayton 
and Heublein in producing atrophy of the pathologically enlarged thy- 
mus in children by means of radium 7-adiations will be referred to in a 
later chapter. 

EFFECTS OF THE RAYS ON THE STOMACH, LIVER, SALIVARY 
GLANDS, PANCREAS AND KIDNEYS 

Delbet, Herrenschmidt and Mocquot performed gastrostomy on dogs 
and exposed the gastric mucosa to fifty milligrams of radium bromide, 
screened with 0.5 mm. of silver, for twenty-four hours. Hard beta and 
gamma rays were thus used, the latter preponderating. After a latent 
period of eight days, hyperemia and blood extravasation involving the 



84 RADIUM THERAPY 

mucosa were noted in the irradiated area. Eight to fifteen days after the 
exposure marked destructive effects throughout the whole thickness of 
the mucosa were found. At the site of application of the radium, the 
superficial epithelial cells and the cells of the glands of the mucosa were 
destroyed. In the adjacent areas there were evidences of stimulation of 
these cells. The connective tissue of the mucosa and submucosa showed 
hyperplastic changes. No changes were observed except in a small area 
3 cm. in diameter which was the site of the attachment of the radium tube 
to the stomach wall. 

Thies, Horowitz and Mills have described the changes resulting from 
exposure of the liver to radium rays. Thies applied 20 mg. of radium 
bromide for six hours to the surgically exposed liver of a guinea pig. 
The radium was practically unscreened. Examined at intervals between 
the first and fourteenth day, the main histologic changes were early 
hyperemia and hemorrhages in the liver lobules, followed later by necro- 
sis of the liver cells with separation and compression of the necrotic areas 
by newly formed connective tissue. 

Horowitz exposed surgically the submaxillary gland and also the pan- 
creas of rabbits and inserted 1 mg. of radium bromide unscreened. Local 
destruction of glandular tissue, followed by connective tissue repair, was 
noted. The same author used 20 mg. of radium bromide for experiments on 
the kidneys of rabbits. Inserted into the kidney for ten days, localized areas 
of necrosis were produced. Short radiations produced merely marked 
hyperemia. 

EFFECTS OF THE RAYS ON THE TESTIS AND OVARY 

Thies found that exposure of the testis of adult guinea pigs to 20 mg. 
of radium bromide for twenty-four hours resulted in destruction of the 
seminiferous epithelium. Fourteen days after exposure, no spermatozoa 
could be detected. Horowitz has confirmed Thies' experiments. Horo- 
witz exposed the ovary of a rabbit to one mg. of radium bromide for ten 
days. This resulted in atrophy of the graafian follicles. 

EFFECTS OF THE RAYS ON THE NERVOUS SYSTEM 

Danysz exposed surgically the brains and spinal cords of mice, guinea 
pigs and rabbits and observed the effects of small amounts of radium 
(1 mg. radium salt) upon the central nervous system. Symptoms of 
paralysis, etc., appeared later and although no histologic changes were 
detected in the actual nerve elements, hemorrhages were noted. This 
observation led to the somewhat erroneous conclusion that the central 
nervous system was very easily affected by radium rays. Later Ober- 
steiner, in many experiments on white mice, found marked inflammatory 
and degenerative changes in the vessels of the central nervous system. 



BIOLOGIC EFFECTS OF RADIUM RAYS 85 

He concluded that the symptoms of nerve derangement were fully ac- 
counted for by the vascular changes. 

Horsley and Finzi experimented on the brains of monkeys. After 
trephining the skull, 55 mg. of radium bromide screened with 0.5 mm. of 
platinum and 1 mm. of rubber were placed on the brain substance and 
allowed to remain for two and one-half hours. The gamma rays were 
evidently responsible for the principal effects. No changes in either 
the nerve cells or the neuroglia could be made out at the end of twenty- 
six and thirty-one days, respectively. Marked vascular changes, how- 
ever, such as thromboses and hemorrhages, were found. These authors 
also concluded that nerve tissue itself was relatively insensitive and that 
the vessel disturbance accounted for any nerve derangements. 

As to the peripheral nerves, Okada and Scholtz found no alteration of 
the nerve substance after irradiating the sciatic nerves of rabbits. Horo- 
witz, however, found in similar experiments, atrophic changes in the 
axis cylinders and destruction of the myelin sheath. 

EFFECTS OF THE RAYS ON THE EYE 

Birch-Hirschfeld studied the effects of 20 mg. of radium bromide when 
applied over the closed eyes of rabbits for periods of 4 to 6 hours. The 
effects were identical with those due to exposure to x-rays. After a 
latent period inflammatory changes appeared consisting of blepharitis, 
conjunctivitis, interstitial keratitis, and iritis. After several weeks these 
disturbances disappeared. Thirty-nine to 60 days after the exposures, 
retinal degeneration or optic atrophy or both effects occurred, differing 
according to the conditions of the experiments. 

Certain physiologic optical effects may be referred to here. Hardy and 
Anderson have confirmed the earlier observations of Giesel and others 
as to certain optical effects of the radiations. The sensation of light pro- 
duced in a dark room by bringing a radium preparation in front of the 
closed eyelid is due to the action of the gamma rays (the closed eyelid 
absorbing the beta rays) on the retina. The same effect is produced in 
the blind if the retina is intact. 

The lens and retina of the eye are markedly phosphorescent upon ex- 
posure to both beta and gamma rays. If the phosphorescence of radium 
itself is obscured by black paper in a dark room, the open eye may still 
detect luminosity due, it is believed, to the phosphorescence produced in 
the eye ball. 

Certain general conclusions may be deduced from a consideration of 
the observed effects of radium rays on vital tissues. 

1. A latent period is always present after the application of radium. 
This period may last for several days or weeks. Histologk changes can 
be detected usually in a few days but clinical changes may be deferred 



86 RADIUM THERAPY 

for 2 or 3 weeks. After exposure to beta rays (mixed with gamma) the 
latent period is shorter and signs of inflammation are more pronounced 
than when gamma rays alone are used. The use of considerable quan- 
tities of radium shortens the latent period. 

2. Radium rays have a "selective" or as some would prefer to call 
it a "differential" action on vital cells. Col well and Russ have suggested 
the term "selective absorption." The latter term suggests "that the 
more the rays are absorbed the greater the action they have." The phys- 
ical evidence would indicate that two tissues of the same density will 
absorb the same quantity of gamma rays, while the clinical results in the 
two types of tissue of the same dose of rays may vary widely, depending 
on the sensitiveness of the cell to the rays. All cells may be influenced 
and modified and may even be destroyed by the rays if the dose is great 
enough. 

As we have previously said, vascular endothelium is particularly 
sensitive to the rays. In tissues rich in vessels, therefore, there is little 
doubt that at least part of the effects observed are due to the action of 
the rays on the blood vessels. The sensitiveness of vascular tissue to 
radium rays accounts for the excellent results obtained in angiomata. 
Sometimes these tumors can be made to retrogress without macroscopic 
evidences of inflammation. 

EFFECT ON BLOOD-MAKING ORGANS 

The hematopoietic organs spleen, lymphatic glands and bone mar- 
row are the most sensitive of all the tissues to the rays. 

An important generalization as to the effect of x-rays has been made by 
Bergonie and Tribondeau. There is evidence to indicate that the same 
general law holds for radium rays. According to these authors, imma- 
ture cells and cells that are actively dividing are more susceptible to 
x-rays than adult cells or cells that have already acquired the functional 
and anatomical characteristics of complete maturity. 

THE METHOD OF ACTION OF RADIUM RAYS ON NORMAL CELLS 

Various theories have been advanced to account for the changes in 
tissues that have been subjected to radiations. According to G. Schwarz, 
the radiations cause in the cells a chemical change, the main feature of 
which is the disintegration of lecithin. The lecithin theory, however, has 
not been confirmed by other researches. Wohlgemuth, Loewenthal and 
others have advanced the theory that the effect on the cell ferments is 
the essential factor in causing tissue changes. Later researches indicate 
that the radiations do not affect the ferments. 

Ricker's theory, formulated as the result of his experimental studies 



BIOLOGIC EFFECTS OF RADIUM RAYS 87 

on the ear and kidney of the rabbit, is the following: As the result of 
the radiations the nerve supply of the blood vessels is first stimulated. 
This is followed by vascular dilatation and stasis. The cellular changes 
result from these effects. This theory neglects the fundamental studies 
of Hertwig which show that the nucleus of the cell is the first point of 
attack of the rays. 

Another purely hypothetical suggestion, which is not supported by 
any experimental evidence, is that the plasmatic colloids of the skin are 
changed so that the ions of the surrounding medium enter into the cells 
and thus injure or destroy them. Gudzent has summed up our present 
knowledge of the nature and cause of the cellular changes produced by 
radiations as follows: "We may recognize both histologic and func- 
tional primary changes in irradiated cells. Histologically, the nucleus of 
the irradiated cell shows a 'foamy or honey-combed swelling.' In some 
cases there may be a shrinking and disintegration of the nucleus. The 
cytoplasm either shows no change at all or a slight 'foamy swelling' 
which may be secondary to the nuclear change. The more actively 
mitotic or reproductive the cell is, the more radiosensitive it is found 
to be. 

"Heinecke called attention to the effect of the rays on certain highly 
radiosensitive cells such as lymphocytes and certain cells of the bone 
marrow. In these cells there was found to be practically no latent period 
after radiation. Within an hour after exposure to the rays, the nuclei 
of the lymphocytes showed signs of complete disintegration. This was 
shown by the presence of pycnotic globules and nodules which were at- 
tacked by phagocytes and in twenty -four hours disappeared almost com- 
pletely. The same changes were observed in the cells of lymphosarcoma, 
which is also highly radiosensitive. 

"One is forced to the conclusion that in these cases, at least, the essen- 
tial primary effect of the rays is the direct action on the nucleus of the 
cell, causing its destruction. The cytoplasm of the cell is injured, also, 
but to a lesser degree. 

"Functionally, the change in irradiated cells is shown by various experi- 
ments, such as those of Halberstacdter with reference to the effect of the 
radiations on trypanosomes and of von Wassermann on mouse carcinoma. 
These experiments tend to show that the primary functional change in the 
cells consists in the loss of their power of propagation. The nutritive 
powers of the cells are affected secondarily. 

"We may thus conclude, in a word, that anatomically, the nucleus is the 
direct point of attack of the rays on the cell, and functionally, the repro- 
ductive power of the cell is the first to suffer. As to the ultimate nature 
or the exact character of the changes in the cell, we are still without ade- 
quate knowledge." This topic will be referred to again in the discussion 
of the changes in irradiated malignant cells. 



88 RADIUM THERAPY 

EFFECTS OF THE DIFFERENT TYPES OF RAYS 
Alpha Rays 

The alpha rays, being practically always absorbed by the radium con- 
tainer, are never used therapeutically to the exclusion of the beta and 
gamma rays. Theoretically they could be employed by using Radium F. 
(polonium) as a source of the radiations inasmuch as this substance 
emits only alpha rays. According to Gudzent, the effect on the skin of 
radiations with polonium are similar to those observed after beta or 
gamma rays are allowed to act, i.e., an inflammatory skin reaction is 
produced. According to Becton and Russ, certain experiments done first 
with all the rays and then subsequently with the combined beta and 
gamma rays indicate that certain effects are due only to the alpha rays. 
Thus the disappearance of Altmann's granules in cells of healthy tissue 
is noted after using all the rays but this does not occur when beta and 
gamma rays are used. Gudzent states that by injections of thorium X, 
the organism is subjected mainly to an alpha ray effect. This topic will 
be considered again in a later chapter. 

Beta Rays 

In therapeutic applications in which the effect of the beta rays is espe- 
cially desired, unscreened radium is applied to the tissues. Beta rays 
are always mixed, however, under these conditions, with gamma rays. 
Most of the experimental work undertaken to determine the action of the 
radiations on tissues has been done with mixed beta and gamma rays, 
although unfortunately the exact conditions of the experiments have 
not always been stated. As we have already shown in considering the 
subject of screens and filtration, varying portions of the beta rays may 
be employed depending on the thickness of the screens used. 

Abbe deflected the beta rays by means of a strong magnet, and was 
thus able to use them alone unmixed with gamma rays. He achieved good 
results in various skin diseases. The practical difficulty in this procedure 
will probably prevent extensive use of this method, although it is inter- 
esting from a scientific standpoint. In the ordinary varnish or glazed 
plaques, devised for therapeutic applications, beta rays form about 90 per 
cent of the total radiation escaping from the instrument, when no screen 
is used. In applications lasting from several minutes to several hours, 
therefore, the effect of the beta rays greatly preponderates. 

Gamma Rays 

After filtering out the beta and some of the softer gamma rays by 
2 mm. of lead the hard gamma rays alone act on the tissues. The experi- 
mental effects of these have been studied by a few authors and especially 



BIOLOGIC EFFECTS OF RADIUM KAYS 89 

by Dominici. The problem as to whether all three types of rays alpha, 
beta, and gamma have an identical effect on the tissues is not entirely 
settled. Colwell and Russ state that "different rays give rise to quite 
different effects upon one and the same variety of cell." Pappenheim, 
Pleseh and Silva Mello, also, from their studies of the results of injections 
of thorium X, the effects of which are due largely to alpha rays, believe 
there is a difference between these effects and those of the beta and 
gamma rays. Heinecke, however, who subjected the entire organism of 
animals to x-ray exposures sees a great similarity in the biologic effects 
of thorium X and x-rays. In Heinecke 's experiments with x-rays just 
as with injections of thorium X, the hematopoietic organs spleen, lym- 
phatic glands and bone marrow were especially injured. All other 
organs were much less affected. 

In an attempt to settle the problem of the identity of the biologic 
effects of alpha, beta and gamma rays, Oudzent and Levy carried out a 
series of comparative histologic examinations. The different organs, 
such as the spleen, bone marrow, lymph glands, liver and kidney of rats 
were sectioned, the animals having been killed by injections of thorium 
X, by roentgen rays, and by radium radiations, respectively. They con- 
cluded that the histologic effects of alpha, beta, and gamma rays were 
the same. 

In contradistinction to some of the authors mentioned above, Gudzent, 
therefore, feels justified in assuming that the effect of the different rays 
depends solely upon the sensitiveness of the cells. The idea of an elec- 
tive action of the different rays, by which each type of ray acts differ- 
ently on the same cell, is thus not borne out. This author comes to the 
conclusion that the same explanation of the biologic effects of the rays 
may be given as for its physical and chemical effects. The radiated body, 
through ionization, becomes practically an electric field, which comprises 
the positively and negatively charged parts of the radiated material. In 
this ionization of the radiated tissues lies the explanation of the biologic 
effect of the rays. 

From the clinical point of view it would appear to the writer that the 
same cells may react differently to different types of rays, in accordance 
with the belief of Colwell and Russ. Thus the angiomata, as a class, are 
very sensitive to both the beta and gamma rays from radium, sometimes 
yielding to doses that produce no visible inflammation. On the other 
hand, angiomata are not at all sensitive to x-rays yielding only to destruc- 
tive doses with the latter agent. 

Other examples, illustrating the different effects of different rays upon 
the same type of cell, might be cited but the full elucidation of this 
topic must await further investigations. 



CHAPTER X 
BIOLOGIC EFFECTS OF RADIUM RAYS (CONTINUED) 

EFFECTS OF RADIUM RAYS ON MALIGNANT CELLS 

Effects of the rays on rat and mice tumors. Certain tumors of rats and 
mice, it is \vell known, can ordinarily be transplanted from one animal 
to another by subcutaneous inoculation. These tumors afford, therefore, 
good material for experimental observations. The effects of the rays on 
these growths have been investigated by Apolant, Bashford, Murray and 
Cramer, Chambers and Russ, von Wassermann, Wedd and Russ, Wood 
and Prime and many others. It is possible to refer here to only a few of 
these experiments. 

Apolant, who was one of the earliest investigators, found that radium 
applied to certain types of mice carcinoma "in vivo," i.e., in the body of 
the animal, caused the tumor to disappear in most cases and to diminish 
in size in others. As the result of histologic investigations, Apolant 
attributed the destruction of the tumor to the direct action of the rays 
on the cells. The connective tissue proliferation noted in the tumor was 
regarded as a secondary process. 

Bashford, Murray and Cramer, in their experiments with Jensens 
mouse tumor, observed disappearance of the growths after radiations 
but did not detect any microscopic changes in the tumor cells. The 
marked connective tissue proliferation and frequent hemorrhages, noted 
by these authors, were regarded as the primary changes and the disap- 
pearance of the tumor cells was believed to be a secondary process. 

Wedd and Russ and Chambers and Russ showed that portions of mice 
tumors if excised and exposed "in vitro," i.e., outside the body of the 
animal, to a sufficient dose of radium rays could no longer be inoculated 
successfully into other animals. Smaller doses checked but did not pre- 
vent the growth of the inoculated tumor. They concluded therefore, that 
the change or changes set up in the tumor cells themselves were respon- 
sible for the failure of the inoculated tumors to grow. The beta rays 
seemed to have a more powerful inhibitory effect on the tumor growth 
than the gamma rays. 

Von Wassermann irradiated small pieces of mouse cancer "in vitro." 
In certain experiments the tumor retained its vitality when inoculated 
but did not develop. From this he concluded that while the rays acted 
directly on the tumor cells, they did not actually kill the cells but rather 
impaired their proliferating power. In other words, the rays acted chiefly 
on the propagating function and to a less extent on the nutritive function 
of the cell. This observation gave rise to the hypothesis that the actual 

90 



BIOLOGIC EFFECTS OF RADIUM RAYS 91 

death of the cancer cells was brought about either by the natural aging 
of the cells or by the cytolytic powers of the organism itself. This view 
has not been generally accepted, however, most observers believing that 
the action of the rays on the tumor cell itself and especially on its nucleus 
is responsible for its death. This topic will be referred to again in a sub- 
sequent section when dealing with the question of immunity. 

Wood and Prime have carried out a series of experiments to determine 
the action of the rays on certain rat and mice tumors. These authors 
have stated quite exactly the experimental conditions under which they 
worked with reference to (a) the amount of radium element used and 
the kind of container, (b) the screens, (c) the distance of the radium 
from the tissues, and (d) the length of exposures. 

Tumor cells were exposed both outside and within the bodies of the 
animals to the action of the rays. Different types of tumors were used 
in the experiments. These included the Flexner-Jobling rat carcinoma, 
mouse carcinomata No. 11 and No. 180 of the Crocker Fund series and 
the Ehrlich spindle cell mouse sarcoma. 

In one series of experiments, tumor tissue was excised and exposed 
outside the body of the animal to the radiations from capillary glass 
tubes containing 100, 83 and 17 mg. of radium element, respectively. As 
only the thin glass wall of the radium tube intervened between the 
radium and the tissue, practically all of the beta rays in addition to the 
gamma rays were effective. As proved by subsequent inoculation, the 
time required to kill the tumor cells was 10 minutes for both 100 and 
for 83 mg., and 20 minutes for 17 mg. The great destructive power of 
the softer beta rays was thus well illustrated. 

In another series of experiments the tumor cells were also exposed 
outside of the body of the animal. The quantity of radium element 
contained in the glass tubes in the different experiments was 100, 83, 30, 
20, 17 and 10 mg. respectively. The screening was 0.4 mm. of brass 
plus 0.65 mm. of glass. As this screening absorbed the alpha and softer 
beta rays, the hard beta mixed with gamma rays were effective. The 
distance was 1.05 mm. (0.4 + 0.65). The time required for a lethal dose 
for tumor cells under these conditions was 45 minutes with 100 mg., 60 
minutes with 83 mg., 90 minutes with 30 mg., 150 minutes with 20 mg., 
180 minutes with 17 mg., and 300 minutes with 10 mg. 

In still another series of experiments the conditions were the same as 
in the last experiment but in order to filter out the beta rays and employ 
as far as possible pure gamma rays the screening was increased to 1.2 
mm. of brass. In addition 5 mm. of filter paper were used between 
the tube and the tissues. This additional screening increased the dis- 
tance of the radium from the tissues to 6.9 mm. Under these conditions, 
100 mg. destroyed the tumor cells in 7 hours, 83 mg. in the same length 
of time, 30 mg. in 15 to 18 hours, 17 mg. in 20 hours and 10 mg. in 36 



9'2 RADIUM THERAPY 

hours. In this last experiment it is seen that the time required for beta 
rays to kill tumor cells was approximately 6 to 8 times as long as that 
required for beta rays when mixed with gamma rays as described in the 
previous experiment. From this observation the authors concluded that 
there was a lack of sharpness in the lethal action of the gamma rays as 
compared with beta rays. It may be noted, however, that the distance 
of the radium from the tissues was about 6 times as great when gamma 
rays were used alone as when beta rays mixed with gamma rays Avere 
employed. 

In still another series of experiments the authors used 83 mg. screened 
with 0.4 mm. brass, employing hard beta and gamma rays for 2 hours 
over a tumor "in vivo." Exposures longer than 2 hours were not given 
on account of the difficulty of further prolongation of the anesthetic. 
Upon subsequent inoculation into other animals, some slowing of growth 
was noted as compared with the controls, but the irradiated cells, even 
directly under the tube, were not killed. This failure was attributed 
to the fact that "in vivo," there was a supply of fresh nutriment to the 
cells. In addition any chemical products formed by the radium in the 
tissues were probably promptly removed. Tissue directly under the 
radium tube, but 1.1 cm. away from it, grew, when inoculated into other 
animals, as well or perhaps better than the controls. As the beta rays 
are absorbed by \ cm. of tissue, this experiment apparently showed that 
the gamma rays from 83 mg. could not destroy cells "in vivo" in 2 hours, 
although "in vitro" such cells were destroyed in 1 hour. 

The following are among the conclusions of the authors. 

1. The hard beta rays, mixed with gamma rays, have about 8 times 
the lethal effect of the pure gamma rays on malignant cells. Inasmuch, 
however, as the beta rays are absorbed by 1 cm. of tissue, the gamma rays 
must be used for deep effects. 

2. Sublethal exposures S!OAV the growth of tumor cells for a certain 
length of time while still shorter treatments seem to stimulate the cellular 
activities. 

3. The dose of radium rays required to destroy tumor cells "in vivo" 
is greater than that necessary to destroy isolated cellular elements. 

This observation explains the fact that an exposure capable of destroy- 
ing a small metastatic carcinoma nodule in man is quite ineffective in 
the case of a well-vascularized primary carcinoma. 

EFFECT OF THE RAYS ON HUMAN CARCINOMA 

The clinical part of our work deals fully with this topic. It will be 
of interest, however, to mention here a few experiments which have 
been made to determine the dose of radium rays necessary to destroy 
human carcinoma. 

F. C. Wood has made some investigations with reference to the effect 



niOLOGIC EFFECTS OF RADIUM RAYS 93 

of the gamma rays on metastatic skin nodules in cancer of the female 
breast. He found that exposures of 6 to 8 hours with 83 to 100 mg. of 
radium element, screened with 1.2 mm. of brass and 5 mm. of filter paper, 
caused, in many instances, permanent disappearance of the nodules. 
Shorter applications showed the rate of growth of the tumor cells but 
did not kill them. Still shorter exposures or smaller quantities of radium 
had a stimulating effect on the cells. Dr. Henry Schmitz has also carried 
out a series of experiments to determine the effect of gamma rays in 
connection with recurrent breast cancers in the human body. He applied 
to carcinomatous nodules 50 mg. radium element, screened with 1.2 mm. 
of brass and placed at a distance of 1 cm. for periods varying from 4 to 
13 or more hours. The distance of the nodules from the skin surface 
was carefully noted. After 10 days, various nodul.es were removed for 
microscopic examination. He concluded that carcinoma tissue within 
a distance of 1 cm. was destroyed by the gamma rays from 50 mg. of 
radium element after an application of about 12 hours, i.e., 600 milligram 
hours. The experiments of Kroenig and Friedrich, referred to in a sub- 
sequent chapter in which breast carcinoma was found to be about 1.15 
times more susceptible to x-rays than the middle epidermal layer, are 
also of great interest. 

Histologic Changes in Irradiated Malignant Tumors 

We may now direct attention to the histologic changes that have been 
observed in irradiated malignant tumors. We shall mention also some of 
the various interpretations of these changes. 

Extensive histologic observations have been made by Aschoff, Kronig 
and Gauss, Barcat, Bumm, Degrais and Bellot, Dominici, Ewing, Faure- 
Beaulieu, Morson, Rubens-Duval, Schmitz, Wickham and Degrais and 
many others. 

According to von Hansemann and Schottlaender, nothing is to be seen 
liisfnlogically in irradiated tumor tissue that might not also be observed 
in rapidly growing and disintegrating nonirradiated tumors. Ewing, 
on the other hand, states that "the series of morphologic changes which 
take place after successful radium application is specific and that when 
these changes are present in undisturbed course it is possible to recognize 
tumor tissue treated by radium." 

According to Dominici and Rubens-Duval, radium rays act upon car- 
fiiioma cells in two different ways. By one method, the cells are killed 
<>iitri.'li1, without any histologic change occurring that can be detected. 
By another method, definite histologic changes occur and can be ob- 
served prior to the death of the cell. These changes consist of nuclear 
hypertrophy and budding; hypertrophy of the cell body; an increase in 
the number and size of the so-called "pseudoparasitic" bodies. In the 
case of squamous-cell carcinoma, as of the lip, keratinization may ac- 
company the above changes. 



94 RADIUM THERAPY 

These authors believe that while some of the cancer cells are destroyed 
by the rays, others simply have their powers of proliferation arrested. 
Other authors subsequently expressed the same belief. 

Bumm has reported a case of inoperable carcinoma of the uterus in 
which surgical operation was performed after intense radiation of the 
tumor. During the operation, carcinomatous nodules were observed 
outside of the operation field. Fifteen months afterward, however, the 
patient was in good health. Bumm suggested that these outlying cancel- 
cells were damaged so that they could not proliferate although histo- 
logically the damage could not be detected. Subsequently, in a study of 
the morphologic appearance of cancer clinically cured by radium and 
x-rays, Levin and Joseph cited several cases in which clinical arrest of 
malignancy was apparently brought about by radium radiations, al- 
though no morphologic change in the tumor cells could be detected. 
These authors also suggested that the first effect of the rays probably was 
to inhibit the proliferating power of the cells. Cell degeneration and 
death thus occurred, not as the direct result of the action of the rays, but 
in the natural course of the life cycle of the cancer cell. 

The view that radiation may, so to speak, have a sterilizing effect on 
the cancer cells and inhibit their proliferating power without directly 
killing them receives some support from the investigations of von Was- 
sermann on mouse cancer. These experiments have already been re- 
ferred to. 

Ewing has given the following description of the histologic changes 
occurring in irradiated epidermoid carcinoma of the cervix. "Within 
from three to five days after the application in the cervical canal of 
300 me. of radium emanation in a platinum tube, there is hyperemia of 
the tissues, beginning exudation of the lymphocytes and polymorpho- 
nuclear leucocytes and swelling of all the cells. 

"In the second week, the cords of tumor cells present a characteristic 
appearance. The nuclei are swollen, homogeneous and hyperchromatic. 
The cell bodies are enlarged, the cells loosened, hydropic vacuoles appear 
in the cytoplasm and fusion giant cells form. 

"In the third week, the number of cells is greatly reduced. Many ap- 
pear to suffer liquefaction necrosis. Others are invaded and mechani- 
cally broken up or compressed by lymphocytes and proliferating stroma. 

"From the fourth to the fifth weeks only pycnotic nuclear fragments or 
an occasional giant cell are visible or no traces whatever remain. Mean- 
time the stroma has been active and appears to take an active part in 
the process. Leucocytes become overabundant, the capillaries proliferate 
actively and the stroma is transformed into granulation tissue in which 
numerous new capillaries penetrate and excavate the tumor cell nests. 
The gathering of leucocytes, lymphocytes, plasma cells and polyblasts 
in the later stages of radium reaction may be extremely profuse and in 
this respect the reaction is somewhat specific. 



BIOLOGIC EFFECTS OF RADIUM R.WS 95 

"Eventually the site of the tumor is occupied by granulation tissue from 
which slight sprfuis and cellular exudate is discharged. Later epithelium 
grows over the denuded surface, completing the repair. 

"All manner of variations occur in the reaction of tumor tissue to 
radium. Complete simple necrosis follows over action of radium. Bulky 
tumors may present large areas of simple necrosis in which cysts form by 
liquefaction. The stroma as well as the tumor may be destroyed in which 
event extensive scarring will result. In the foregoing scheme of changes 
it would appear that just enough radium had been employed to cause 
slow degeneration of tumor cells and stimulate regenerative growth of 
granulation tissue." 

Morson imbedded radium, contained in a platinum tube, in the sub- 
stance of carcinomata, allowing the tube to remain for periods of from 15 
to 24 hours. The thickness of the wall of the tube was such that only 
the gamma rays were effective. Sections of the irradiated growths were 
examined at various intervals after the exposure. In some cases, his- 
tologic changes, consisting of nuclear irregularity and fragmentation, 
could be detected in the cancer cells, especially in those adjacent to the 
tube, as early as 15 hours after the commencement of the exposure. In 
certain cases, 48 hours from the commencement of the exposure, sections 
showed cancer cells in different stages of degeneration lying in a disor- 
ganized mass of tissue. In many cases, 14 days after the exposure, there 
were no evidences of carcinoma cells. In other cases, however, carcinoma 
cells could still be detected at the end of 2 months. These cells, never- 
theless, showed degenerative changes, such as enlarged nuclear and 
vacuolated cytoplasm, while they were encircled by dense connective 
tissue. 

Gudzent says: "In the histologic changes due to the radiations, we 
must place in the foreground the injury and destruction of the nucleus 
of the carcinoma-cells. According to the investigations of Grasnick on 
embryonal tissue, we must assume that in the nuclei which are under- 
going mitotic changes the effect takes place immediately after the radia- 
tion and without any latency. These injuries are not disclosed however 
until a latent period of several days has elapsed. In the completed 
stage, all signs of the disintegration of the nuclei can be observed, such 
as decrease of the staining power, swelling with vacuol-formation. and 
shrinking and dissolution. The injury to the nuclei undoubtedly causes 
the death of the cells. To what extent the cell plasma is injured, is not 
as yet known, but one can observe that the cells decrease in numbers 
and finally disappear. In addition to these primary changes, others mani- 
fest themselves which are of far-reaching importance in the curative 
process. Very soon after the first injury to the nucleus and the cell 
makes its appearance, extensive proliferation of the connective tissue 
sets in. One observes the young connective tissue permeating the swell- 



96 RADIUM THERAPY 

ing in all directions. This connective tissue breaks open the cell com- 
plexes of the parenchyma, encircles single complexes, pressing them to- 
gether and strangling them. Sometimes cells with several nuclei are 
formed. Klein and Duerk have called these 'conglutinal giant cells.' 
These exhibit a lessened power of growth and diminished vitality. One 
is led to infer that the connective tissue is actively combating the car- 
cinoma cell, limiting and even destroying its vital processes. In a later 
stage, the connective tissue shows signs of maturity ; the number of 
cells is diminished, while the connective tissue fibers coalesce and become 
sclerotic. The cause of the new formation of connective tissue may be 
found in the effect of the radiation. We must assume, then, that the 
same amount of radiation which causes the disintegration of the cells, 
has a stimulating effect on the connective tissue cells. This assumption 
is very hard to bring into harmony with the researches of Root. This 
author found the fixed connective tissue cells very radiosensitive. To 
regard the new formation of connective tissue as a reaction which serves 
as an intermediate substance for interstitial spaces cannot be accepted 
for the reason that it proliferates very early and in its later stages 
especially shows various signs of the influence of the radiation. In all 
probability both assumed causes play some part in this, but this must be 
cleared up through future research. 

"In connection with this connective tissue proliferation, the injury 
and destruction of the blood capillaries, whose radiosensibility is well 
known, must be considered. Thus the hemorrhages occurring soon after 
radiation are explained. It seems to be clear that the interruption of 
the blood supply causes severe injury to the carcinoma cells. In the 
later stages, proliferation and new formation of capillaries set in. These 
accompany especially the newly formed connective tissue bundles. Between 
the cell bundles of the parenchyma and those of the supporting tissue, cells 
of hematogenous origin, leucocytes, lymphocytes and so-called leuco- 
cytoides, can be observed, at a certain stage. According to Klein and 
Duerk, the fragmentary nucleated leucocytes especially seem to have 
the important role of removing the cell particles which have been de- 
stroyed. It can be seen that these cells, like phagocytes, cling to the 
protoplasmic bodies which are more or less isolated from their epithelial 
cell complexes, and practically gnaw off fragments here and there, so 
that a concave shaped loss of substance can be noticed. Sometimes single 
epithelial cells are densely covered by these phagocytes, which undoubt- 
edly are hard at work causing their reduction and dissolution. This 
phagocytic process is to be regarded as secondary and provoked by the 
dissolution of the radiated cells. 

"If the destruction of all carcinomatous cells has been attained, the 
connective tissue completely fills up the interstitial spaces. In due 
time it matures, becoming poor in cells and more sclerotic than the con- 



BIOLOGIC EFFECTS OF RADIUM RAYS 97 

nective tissue which fills up interstitial spaces caused by other con- 
ditions." 

Dominici has given the following description of the histologic changes 
occurring after radium treatment in a very vascular myeloid sarcoma. 
From the commencement of the treatment to the complete disappearance 
of the growth there elapsed a period of a little over 4 months. It is 
noteworthy that Dominici inferred from his studies that not merely were 
the malignant cells destroyed by the action of the rays and replaced by 
fibrous tissue, but a peculiar evolutionary process was set up in the sar- 
coma cells themselves, so that they became, at least in part, converted 
into cells indistinguishable from normal connective tissue. The nuclei 
of the sarcoma cells became more spindle shaped. Atrophic changes 
could also be made out. The protoplasm of the giant and sarcoma cells 
became replaced by connective tissue fibers which Dominici believed 
arose from the alteration of the protoplasm itself. Adjacent to the 
nuclei, however, a portion of the protoplasm remained intact. This 
unaltered protoplasm formed, with the nuclei, typical connective tissue 
cells. The processes just described occurred throughout the growth. 
The lumen of the blood vessels became smaller so that they appeared 
like capillaries lying in the midst of fibrous tissue. It seemed that the 
malignant sarcoma cells were transformed into fibrous cells. The 
fibroma-like structure remained stationary or became smaller, showing 
no tendency to increase as in ordinary fibromata. The arrangement of 
the connective tissue fibers was remarkably regular. 

THE METHOD OF ACTION OF RADIUM RAYS ON MALIGNANT 

CELLS 

While there has been much speculation as to the mechanism of the 
action of radium rays on malignant cells, little is definitely known. The 
changes to be observed histologically do not differ from those already 
described as occurring in normal cells. The same theories of the action 
of the rays which have been referred to in the previous chapter have 
also been advanced to explain the morphologic and functional change in 
malignant cells. As yet, however, no explanation has been made that 
is entirely satisfying and indeed none is likely to be made until our 
knowledge of intracellular metabolism is complete. 

According to Ewing "it is a reasonable assumption that the gamma 
rays while traversing the tissues give rise to secondary beta rays, elec- 
trons, which act on the cells. That the action is electrical, accelerating 
cell ferments, ionizing gases, altering lipoid emulsions, etc., may be 
conceived but is not demonstrated. These questions may well serve to 
stimulate and aid in the study of the physics, chemistry, and finer mor- 
phology of the cell. 



!)8 RADIUM THERAPY 

"Interpreted from the pathologic standpoint, the observed changes in 
cell morphology indicate an action directly on the tumor cell and es- 
pecially on its nuclear mechanism, with profound and progressive chem- 
ical changes in the nuclear proteins, attended by the formation of acid 
products and by the absorption of material, probably water. The ap- 
pearance of the cell cytoplasm suggests hydrolytic cleavage of cell pro- 
teins and these seem to excite leucocytic emigration. 

"The growth of capillaries may be explained as a regenerative process 
following a loss of tissue equilibrium, or it may involve a direct stimu- 
lating action of the radium on endothelium and fibroblasts. In any event 
the process is very complex and in many cases there are strong hints 
;:t a restoration of normal resistance of the connective tissue against 
lawlessly proliferating tumor cells." 

Summing up the various findings and interpretations, the available 
evidence merely suggests the probability that some kind of an intra- 
csllular and especially an intranuclear chemical change is produced by 
the action of radium rays on malignant cells. The exact nature of this 
change still remains a secret. The nucleus of the cell is injured first 
and this injury is attended by the loss of the power of mitosis. As a 
rule malignant cells are much more susceptible to irradiations than the 
cells of most normal tissues. This peculiar sensitiveness forms the 
foundation of radium therapy in malignancy. 

THE QUESTION OF STIMULATION OF TUMOR GROWTH BY 
INSUFFICIENT RADIATION 

According to some authors, radiations that fail to kill the tumor cells 
may even stimulate their activity and cause increased tumor growth. 
This is a problem of the greatest importance and one about which there 
is much difference of opinion. Wood and Prime thought that certain 
mouse tumors treated with radium and then inoculated into other animals 
grew more rapidly than the controls. Ewing remarks, however, that 
"their results were quite inconstant, and the extirpation of the exposed 
cells removed them from the attack of lymphocytes and granulation 
tissue, which are the main agents of tumor destruction set to work in 
the curative process excited by radium." 

Reference may also be made to the experiments of Hastings, Mac- 
Cormac and Woodman. These authors exposed cancerous skin nodules, 
secondary to mammary carcinoma, to the radiations from pitchblende. 
This mineral contains several radioactive bodies, but the radiations 
from a given quantity are at least a million times weaker than those 
from the same quantity of radium. One might infer, therefore, that 
malignant cells would probably be stimulated by exposure to pitchblende 
rays on the assumption of inadequate dosage. The treated carcinomatous 
skin nodules, however, showed no recognizable clinical differences from 



BIOLOGIC EFFECTS OF RADIUM RAYS 99 

the untreated nodules after the lapse of several months. Histologically 
the treated nodules disclosed evidences of the effect of even these weak 
radiations. Nuclear changes in the cancer cells occurred, the principal 
change observed consisting of the partial disappearance of chromatin 
which was at the same time condensed about the nuclear membrane. 
In addition, delicate connective tissue fibrils appeared between the cancer 
cells so that they became separated into small aggregations. 

We may refer also to the studies of A. and 0. Hertwig. These authors 
have shown that mitosis of cells is inhibited by radiations of even the 
weakest intensity. 

From the clinical side, many observers, including the writer, have 
not been able to convince themselves of an actual stimulation of tumor 
growth by radium rays. One may doubt if such stimulation occurs under 
the modern method of very large primary doses. If it could be shown 
conclusively to occur it would constitute one of the many limitations 
of radium treatment to be guarded against as far as possible by power- 
ful radiations directed especially toward the periphery of tumors. One 
should not forget, however, that very massive treatments with heavily 
screened radium may even defeat their own object by causing such 
extensive injury to normal tissues as to result in serious harm to the 
patient. This fact tends to limit the usefulness of radium in the treat- 
ment of very extensive and deeply situated cancerous masses. 

The Problem of Immunity 

It would be beyond the scope of this work to consider in detail 
the complex problem of immunity to malignant tumors. Tyzzer has 
recently published a resume of the subject and the reader may be 
referred to his monograph. Additional references will also be found 
in the bibliography. A few experiments that bear on the production 
of immunity by radiations with radium may be referred to. Contamin 
was apparently the first to show that if cancer cells were irradiated 
for a short time with radium or x-rays and were subsequently 
inoculated into mice a degree of immunity was produced. He also ob- 
served that an excessive exposure to x-rays destroyed the immunity 
conferring power of the cells. Wedd, Morson and Russ confirmed the 
general trend of these observations. These authors irradiated "in vitro" 
tissues from the Twort tumor (adenocarcinoma) with a measured dose 
of beta rays. The radiation was sufficient to prevent the formation of 
growing tumors when the radiated tissue was reinoculated into mice 
although the tissue, after persisting for several days, was absorbed. 
Some days later the animals were inoculated with the usual strain of 
tumor tissue which had not been irradiated. As the second graft of 
tissue did not develop, an immune condition of the animal was inferred. 
By gradually increasing the length of exposure, it was found that a 



100 RADIUM THERAPY 

point was reached at which the irradiated tissue when inoculated no 
longer conferred immunity. Those authors also found that if normal 
and radiated tumor cells were inoculated simultaneously no immunity 
was produced. In commenting on these experiments, Colwell and Russ, 
while recognizing that no generalization can he made on account of the 
limited number of the experiments, state that "excessive irradiation of 
a tumor may therefore very easily abolish any immunity that the ab- 
sorption of irradiated cells may be capable of giving rise to. It would 
appear that the best condition for producing immunity is for the cells 
to receive an exposure that will insure their gradual degeneration and 
disappearance." 

It has been asserted by some clinicians that the irradiation of a tumor 
such as a breast cancer may cause not only the irradiated tumor but 
also distant metastases such as axillary nodules to shrink. 

In order to explain this alleged effect, the hypothesis has been ad- 
vanced that substances are set free from the irradiated growth which 
act on the secondary deposits of the tumor. Rohdenburg and Bullock 
have shown however that an established transplanted tumor, i.e., one 
that has excited a stroma reaction and obtained a blood supply, is not 
susceptible, even though radiumized, to immunity reactions. They have 
pointed out that it is much less likely, therefore, that an unradiumized 
tumor is in any way sensitive to the immunity process. It is probable, 
therefore, as these authors state, that the disappearance of tumors if 
they really do disappear situated at a distance from the radiated growth 
is due to some other process than the influence of substances set free by 
radiation. If the shrinkage of such tumors really occurs, it may be due 
to the disappearance of inflammatory edema in the nodules and the 
destruction of lymphoid elements which are very sensitive to radiation. 

The writer would take sides with those who doubt the probability of 
any effect of radiation on tumor deposits outside of the field of radiation. 
So far as our observation goes, radiumization of a tumor has no effect 
whatever on metastatic deposits in other parts of the body. 

Rohdenburg and Bullock have also pointed out that the problem of 
immunization and cure of animal tumors on the one hand and of human 
tumors on the other is a very different one and that the results so far 
achieved in developing immunity in animals cannot be transferred to 
man. 

In man, the problem is to cure or produce immunity against a spon- 
taneous tumor. 

In animals, immunity has only been produced against transplanted 
tumors. According to these authors, an animal cannot be immunized 
against its own tumor. 

The following observations of Murphy and Norton bear on the problem 
of the nature of the immunity process. While the experiments of these 



BIOLOGIC EFFECTS OF RADIUM RAYS 101 

authors have evoked great interest, it must be said that they have not 
been completely confirmed. Sittenfield's experiments, e.g., do not sup- 
port their conclusions as to the importance of the lymphocyte in the 
defensive mechanism of the organism. 

Murphy and Norton, in their investigations of the effect of x-rays on 
the resistance to cancer in mice, have apparently shown that the resistance 
to heteroplastic tissue depends on the activity of the lymphocytes. The 
chick embryo normally lacks the ability to destroy a heteroplastic tissue 
graft. If a small amount of lymphoid tissue from an adult is supplied, 
it becomes as resistant as the adult. On the other hand, if an adult 
animal has the main part of its lymphoid system destroyed by repeated 
x-ray radiations, it loses the power of destroying a graft of heteroplastic 
tissue. Histologically, the main characteristic of a failing heteroplastic 
graft is a marked local accumulation of lymphocytes. The same his- 
tologic picture is seen in a failing cancer graft in an immune animal of 
the same species. Simultaneously with the production of the cancer im- 
munity and while the lymphocytes are accumulating around the cancer 
graft, a lymphocytic crisis occurs in the circulating blood. This crisis is 
lacking in animals susceptible to the cancer graft. It has been noted 
that while repeated small doses of x-rays will destroy the lymphoid ele- 
ments of an animal, one small dose will stimulate it and cause a lympho- 
cytosis. Bearing in mind these facts, which had previously been demon- 
strated, the authors studied the relation of the resistance of mice to their 
own spontaneous tumors. Among their experiments, all of which were 
carried out with suitable controls, were the following: The cancer was 
removed by operation from the animal. The animal was then given a 
stimulating dose of x-rays. Immediately afterward, a graft of the 
original tumor was placed in the groin of the animal. In a series of 52 
animals so treated, 50 per cent were rendered immune to their own 
cancer and in the other 50 per cent the return of the disease at the opera- 
tion site was greatly retarded. The authors suggest that if one dose of 
x-rays causes this effect, a more pronounced effect might be caused by a 
second stimulating dose at a subsequent time. 

The foregoing experiments have a special interest in connection with 
the frequent clinical observation that malignant tumors in humans re- 
spond differently to radiation, -some being easily affected while others, 
of apparently the same type, are much more resistant. It may be pos- 
sible that the different response of similar tumors to radiations depends 
to some extent upon the systemic defensive powers of the organism. It 
would appear from these experiments that while the radiosensibility 
of the tumor cells is probably the chief factor, the lymphocytic system 
is also of some importance in connection with the disappearance of 
malignant growths under the influence of the radiations. An important 
practical lesson may be drawn from these experiments. In cases de- 



102 RADIUM THERAPY 

manding powerful radiations, frequent observations of the leucocytes 
should be made. A marked reduction in the number of leucocytes is a 
signal for caution in proceeding with further treatments until the leu- 
cocyte count is improved. When the spleen, lymphatic glands and bone 
marrow, which are especially radiosensitive, are likely to receive heavy 
doses either intentionally or incidentally in the course of the treatment, 
it is particularly necessary to proceed with care. 



CHAPTER XI 

THE RADIUM REACTION 

Broadly speaking, all of the biologic effects of radioactive substances 
when applied externally or introduced into the organism are due to the 
radiations and are manifested by various disturbances which may be 
termed reactions. 

In this chapter we shall consider only the biologic effect, i.e., the re- 
action due either to (1) surface radiations or to (2) the introduction of 
radioactive material into tumors. The effects of radioactive material 
administered by mouth or introduced intravenously or subcutaneously 
will be discussed in the chapter on radium in internal medicine. 

1. SURFACE RADIATIONS 

These are radiations that are used on the surface of the skin. They 
may produce (a) a constitutional reaction or (b) a local reaction. 

(a) Constitutional Reaction Due to Surface Radiations 

In patients who have received relatively large doses such as may 
be delivered by 250 milligrams of heavily screened radium applied for 
fifteen hours or more, nausea and vomiting, a feeling of depression 
and even prostration may occur toward the end of the treatment or 
after the radium is removed. A metallic taste is often complained of. 
These symptoms usually pass off within twenty-four hours. In some 
instances they may last for weeks. Elevation of temperature during or 
subsequent to such an exposure is unusual in our experience although 
tliis phenomenon has been described by some authors. In using less 
intense doses of surface radiations such as may be given for a small epi-. 
thelioma of the skin, no constitutional effects are ordinarily observed. 

(b) Local Reaction Due to Surface Radiations 

Wickham and Degrais were the first to point out that important modi- 
fications of vital tissue such as resolution of a tumor may be caused by 
the surface application of the rays without the supervention of visible 
inflammation. Hence, they called this action of the rays a "selective 
action." Later this term was used to indicate that the rays affect cer- 
tain types of cells in a "selective manner" regardless of the presence or 
absence of macroscopic inflammation. Inasmuch as all vital tissue may 
be affected to some extent, the term "differential action" has been pro- 
posed by other authors to indicate the fact that the rays affect some tissues 

103 



104 RADIUM THERAPY 

more markedly than others. Cohvell and Russ have suggested that the 
thing irradiated is of as much importance as the rays and have proposed 
the term "selective absorption." This term implies that certain tissues 
absorb more rays than others. Hence "the more the rays are absorbed 
the more the tissues are affected." 

It is difficult to express in a single term both the complex action of 
the rays and the response of the tissues. 

It would appear that the rays have a "selective" or "differential" 
action on vital tissue. This expression means that the rays affect cer- 
tain normal tissues such as the spleen and lymphatic glands more 
readily than others such as connective and elastic tissue. The rays 
also affect certain tumors such as lymphosarcomata much more readily 
than some other types of new growth, such as squamous cell epithelioma. 

This "selective action" of the rays makes possible radium therapy in 
malignancy for experience has shown that many types of malignant 
tissue are more readily affected than most normal tissues. 

On the other hand, the response of the tissues to the action of the rays 
may perhaps best be indicated by the terms "selective reaction" and 
"inflammatory reaction." 

By "selective reaction" it is meant that under the influence of radium 
rays abnormal tissues may undergo a retrograde metamorphosis without 
visible inflammatory changes. This reaction is illustrated by the re- 
sponse to radiation of certain epitheliomata, keloids and angiomata which 
may sometimes retrogress and disappear without visible inflammation. 

By the term, "inflammatory reaction" we designate the ordinary 
changes characteristic of inflammation which may easily be produced by 
radium. Inflammatory reaction usually appears between the seventh and 
fifteenth day, but it may appear as early as two or three days after ex- 
posure, and in some cases it may be delayed for as long a period as 
four weeks. 

For convenience, four degrees of "inflammatory reaction" may be dis- 
tinguished, although these degrees or stages of reaction pass insensibly 
into each other. These are, first simple erythema; second erythema 
followed by desquamation; third vesication or superficial ulceration; 
fourth deep ulceration. 

We may now describe the clinical effects of radium rays upon the skin 
and mucous membranes when doses sufficiently intense to produce in- 
flammation with superficial destruction are used. 

After the application of radium to the healthy or noninflamed patho- 
logic skin, there is a latent period during which no apparent effect is 
seen. The duration of the latent period depends upon the amount of 
radium used, i.e., upon the intensity of the rays; the type of rays, i.e., 
whether beta or gamma rays preponderate ; and to some extent upon the 
sensitiveness of the tissues. If a one-fourth strength glazed applicator 
containing about 20 mg. of radium element is applied unscreened directly 



THE RADIUM REACTION 105 

to the skin for one or two hours, the latent period is very short some- 
times not over twelve to thirty-six hours. The beta rays form about 90 
per cent and the gamma rays about 10 per cent of the total radiation from 
the apparatus used in this manner. If the same apparatus is screened 
with 2 mm. of lead so that only the hard gamma rays are effective and is 
applied at a distance of 1 cm. for thirty hours the latent period may last 
for from seven to fifteen days. Speaking very generally, the larger 
the quantity of radium and the more the beta rays preponderate, the 
shorter the latent period is found to be. The first evidences of the in- 
flammatory reaction are slight redness and swelling of the skin which 
itches and becomes tender. A crust of yellowish or greenish gray aspect 
then gradually forms. Vesicles or bullse may occasionally precede the 
formation of the crust. The tissues underneath the crust may be dry 
or moist depending on the degree of the reaction. The crust may last 
for days or weeks, sometimes falling off or being accidentally knocked 
off but usually reforming several times before healing occurs. The gen- 
eral appearance of a well-developed crust has been compared to that 
of impetigo contagiosa. If the crust has rested on an ulcerated and sup- 
purating base it becomes more and more dry as the inflammation sub- 
sides. Frequently the different layers of crust become superimposed so 
that a mass of dried detritus, several millimeters thick and of charac- 
teristic "oyster shell" appearance results. Finally the crust may be 
detached "en masse" leaving a smooth, supple, white and hairless sur- 
face. The duration of inflammatory reaction may vary within the widest 
limits. Reactions of the first and second degree may apparently subside 
in from one to four weeks. A moderately severe reaction of the third 
degree requires a period of from six to eight weeks for complete recovery. 
If a severe reaction of the fourth degree has been produced, six or eight 
months or even a longer time may elapse before healing occurs. In 
some cases, if the reaction has been of considerable severity, attacks of 
dermatitis (so-called secondary or deferred reactions) may occur at 
intervals for several years, even after complete healing has apparently 
taken place. 

Fortunately a tendency to the development of epithelioma on the scar 
tissue resulting from severe radium reactions has not been observed. 
Telangiectasia frequently supervenes on the radium scar in the course 
of eight or ten months after healing has occurred. 

In the treatment of inflammatory skin reactions the writer has found 
the following application of some benefit in relieving the subjective 
symptoms: Zinci oxidi, 5; bismuthi subnitratis, 5; adipis lanae hyd., 12; 
ol. olivae, 60; aq. calcis, 60. Irritating applications should be avoided. In 
fact, in many cases it is best to make no local applications, but to expose 
the inflamed area to the air and allow nothing, not even gauze dressing, 
to come in contact with it. 



106 RADIUM THERAPY 

When radium is applied to the mucous membrane in sufficient doses 
an appearance is produced at the end of the latent period not unlike 
that caused by the application of nitrate of silver. The irradiated area 
becomes at first white and later yellowish white. .At the height of a 
reaction of moderate degree, a more or less dense, yellowish white, ad- 
herent membrane covers the treated area, which is surrounded by a 
narrow red zone of inflammation. This membrane gradually becomes 
exfoliated and is replaced by epithelium which grows in from the edges. 
A smooth and supple scar is usually left which is whiter than the normal 
mucous membrane. Some months later, telangiectasia may occur. 

Secondary or deferred reactions have not received the attention that 
their importance warrants. They may appear several months or even 
several years after the primary reaction has healed. They usually come 
on suddenly, i.e., they develop quite fully in the course of a few days. 
In some cases of epithelioma of the mucous membranes it may be difficult 
to determine whether a deferred reaction or a recurrence of the growth 
is present. The mucous membrane, if affected by a secondary reaction, 
becomes grayish white and in a few days is covered with an adherent 
membrane. A condition practically identical with that observed during 
the primary reaction develops. Secondary reactions may persist for 
weeks or months. Sooner or later, however, healing occurs in almost all 
cases. 

In a patient with a pelvic periostea! sarcoma that was treated with 
very large doses, a severe primary reaction of the skin of the abdomen 
developed which persisted for nearly eight months. Two years later, 
upon the site of the former area of reaction, a secondary reaction de- 
veloped spontaneously. This reaction which took the form of a super- 
ficial ulceration accompanied by the formation of a pultaceous adherent 
mass of necrotic tissue, required three months for healing. 

In the therapeutic application of radium, severe reactions should be 
avoided when possible. In the treatment of certain dermatological con- 
ditions, however, conservative use may be made of the destructive action 
of radium. In producing reactions intentionally for cosmetic purposes, 
we always employ the glazed plaques. In tissues that have been sub- 
jected to previous treatment such as by x-rays, cauterization, etc., a radium 
reaction is likely to be atypical and healing may be deferred for months. 
Such tissues should be treated with the greatest caution and not more 
than one-fourth of the normal dose should be given. 

Areas that have been treated with radium may be sensitive to tem- 
perature changes long after healing has occurred. Many patients com- 
plain also of a peculiar sensation as if ants were crawling on the skin. 
All of these symptoms usually disappear in the course of a few months 
but they may in exceptional instances last for years. 



THE RADIUM REACTION 107 

2. INTRATUMORAL RADIATION 
Local Reaction Due to Intratumoral Radiations 

In certain cases, as we shall describe in a subsequent chapter, radium 
salts or radium emanation may be introduced directly into the substance 
of tumors "intratumoral radiation." Under these circumstances the 
radioactive material is usually enclosed in metal or glass containers 
i.e., needles or ampoules. The changes in the tissues caused by the in- 
sertion of minute glass emanation ampoules have been investigated by 
Halsey J. Bagg. A resume of some of the results of these studies may 
be conveniently given at this point. 

A series of emanation ampoules or tubes was buried in normal rat 
tissue of different kinds skin, muscle, brain, testes, etc. Another series 
of tubes was buried in the Flexner-Jobling rat carcinoma. Still another 
series of tubes was imbedded in human carcinoma. Suitable control 
experiments, undertaken to prove that the glass itself was not responsible 
for the effects, were made by imbedding nonactive emanation tubes in 
living tissue. Among the conclusions arrived at by Bagg were the follow- 
ing: In rat carcinoma, definite histologic changes were noted two days 
after the tubes were buried. Definite radium effects, such as complete 
necrosis around the tubes and changes in the adjacent outlying cells, 
were noted seven days after the tubes were inserted. Complete recovery 
in the case of a transplanted rat carcinoma two cm. in diameter was 
noted, about forty-two days after the insertion of three tubes contain- 
ing 3 me. each, placed 1 cm. apart and about 5 mm. below the surface. 

Lethal effects on normal tumor cells were produced by relatively small 
doses of emanation, less than one me. per tube being a satisfactory dose. 

An area of tissue about one cm. in diameter was effectively radiated 
by each tube. 

Histologically, the main effect was the production of an area of necrosis 
which was surrounded by a pronounced leucocytic infiltration. The area 
of effectively radiated tissue did not increase in direct proportion to 
the amount of emanation in the tube. When relatively strong tubes 
were used, the tissues in close proximity were radiated for a longer time 
than was necessary to produce lethal effects in these cells. The rays 
did not penetrate effectively, however, to a much greater distance than 
the 1 cm. zone, probably because the easily absorbable beta rays were 
responsible for the main effects. While the gamma ray effects from 
relatively strong tubes are undoubtedly greater than those from the 
weaker tubes, it was difficult to determine this point because of the 
prompt reduction in size of the treated tumors. Bagg suggests that 
human tumor tissue may be treated most effectively by imbedding tubes 
of 0.5 inc. strength 1 cm. apart evenly throughout the mass. 



108 RADIUM THERAPY 

Biologic Hypersensitiveness 

There is little doubt that some individuals are more sensitive to radia- 
tions than others. In certain individuals, prolonged exposures with a 
considerable quantity of heavily screened radium will cause marked 
.constitutional effects such as -nausea and depression. In others, a similar 
exposure produces little or no constitutional effect. Certain types of 
skin are apparently quite radiosensitive and may react severely to an 
exposure that will cause little or no effect in other types. We recognize 
only a few of the conditions that render one skin more radiosensitive 
than another. Among these conditions are (1) a lack of the normal 
quantity of pigment indicated by the fair color of the skin; (2) absence 
of the normal seborrheic oiliness. These factors seem to render the 
skin more radiosensitive. Certain parts of the integument in the same 
individual are also more radiosensitive than others. In general, the 
mucous membrane is more sensitive than the integument. Marked idio- 
syncrasies, however, are relatively rare but should always be thought of 
in the beginning of a course of radiations. 



CHAPTER XII 

THERAPEUTIC APPARATUS 

In the treatment of disease, radium may be applied in the form of 
(a) radium salts, (b) radium emanation, or (c) active deposit. 
The therapeutic effects of radiations from apparatus containing 
radium salts, radium emanation, or active deposit are identical. 

A. APPARATUS CONTAINING RADIUM SALTS 

Radium salts may be placed for therapeutic use in (1) tubes, (2) 
needles, (3) flat plates or plaques. 

1. Radium Tubes. Radium tubes are made of capillary glass and are 
filled usually with from 5 to 50 mg. of radium element in the form of 
sulphate. This is closely packed so that the salt does not move about in 
the tube. The length of the tubes varies from 1 to 2 cm. and the diameter 





A. B. c. D. E. 

Fig. 19. Apparatus for the application of radium. 

A, Silver tube containing 15.21 mg. radium element. Length of tube 16 mm., outside diameter 
2 mm., wall thickness ^o mm. B, Brass screen, wall thickness 1 mm., to contain tube A. C, Round 
glazed applicator, l / 2 strength, 1 cm. in diameter. D, Square glazed applicator, % strength, 2 by 2 
cm. E, "Toile" wrapped in rubber dam, ^o strength, 3 by 4 cm. 

from 1.5 to 3 millimeters. For convenience and safety in handling, the 
capillary glass tubes are usually inserted into silver tubes, just large 
enough to contain them. The silver tube may have a small screw cap to 
retain the glass tube and may be hermetically sealed. The wall thick- 
ness of the silver tube is usually % mm. but it may be of any desired 
thickness or the tube may be made of platinum or any other material. 

Over these tubes may be slipped screens of different thicknesses in 
order to filter out varying portions of the beta and gamma rays. 

2. Radium Needles, instead of the ordinary tubes, may be used and 
introduced directly into the tumor tissue. In this type of apparatus the 
radium sulphate is packed directly into a hollow needle which is fitted 
with a fine screw cap containing the eye of the needle. The cap is soldered 

109 



110 RADIUM THERAPY 

on so that the radium may be completely protected. As much as 12, or 
more, mg. of radium element may be packed into a needle smaller than 
an ordinary round surgical needle. Needles are usually made of steel, plati- 
num or sonxe strong noncorrosive alloy. The wall thickness of steel 
needles is usually %o mm., .the length 2.7 em. and the outside diameter 
1.75 mm. While platinum is nearly 3 times as dense as steel, and a plati- 
num needle will furnish about 3' times as much metal screening as if 
steel of the same thickness were used, the softness of even "hard" 
iridioplatinum renders this metal less useful. Speaking very generally, 
steel needles having a wall thickness of % of a millimeter and con- 
taining 10 or 12 mg. of radium element should not be left in the tissues 
over eight to twelve hours. The total amo\mt of radium element con- 
tained in the needles should not be over 50 or 60 mg. unless the physician 
has had the experience with the method and the cases are carefully 
selected. 

When radium emanation is available, its use is to be recommended 
instead of radium sulphate on account of certain mechanical advantages 
and the absence of the danger of losing the radium. As homogeneity 
of action on all the tumor cells is the ideal to be achieved, it is prefer- 
able to use several needles of weaker strength implanted in different 
parts of the growth rather than one powerful needle. 

3. Plat Plates, or Plaques, on Which the Radium Salt is Spread. The 
plaques may be composed of linen, rubber or metal. Flexible applicators 
that may be bent and thus adapted to the convexities and concavities of 
the skin surface may be made of the former two materials. Linen ap- 
plicators are known as "toiles. " The best type of metal applicator is 
made of silver, the radium salt being spread uniformly over a glazed 
surface which forms the face of the applicator. Lead free glass must 
be used. Plaques of this type are known as glazed radium applicators. 
These have practically replaced the older varnish applicators. The 
glazed surface applicators may be made of any desired shape but the 
surface must be flat. Attention must be paid to the degree of concen- 
tration of "spread radium" as it is. evident that different effects are 
produced by variations of this factor. 

Expressed in terms of radium element, which is the common standard 
in this country, "full strength," "half strength" and "quarter strength" 
applicators contain, respectively, 5.00 mg., 2.5 mg., and 1.25 mg. of 
radium element to the square cm. The strength of each applicator is 
always approximate. 

A convenient type of applicator is a square plaque 2x2 cm., and of 
"half strength," i.e., containing 10 mg. of radium element. Other 
plaques may be smaller or larger, round or oval, and contain less, or more, 
radium. Screens of any desired thickness may be placed over the face 
of the plaque just as when tubes are used. Lead or silver screens having 



THERAPEUTIC APPARATUS 111 

a thickness of % , %o and 1 mm - are convenient. Varied proportions of 
the beta rays may thus be filtered out in order to prevent, when thought 
advisable, too much action on the superficial layers of the skin. The 
plaques have the great advantage over the usual capillary glass tubes 
enclosed in silver of permitting a greater utilization of the beta rays. 
This is desirable in some types of angioma, epithelioma, etc. The plaques 
also emit a more uniform radiation on account of their plane surface. 
They are most useful in certain skin disorders, notably angiomata, in 
which the cosmetic result is important. The disadvantage of the plaques 
lies in their relatively large size which practically limits their use to 
the skin surface. 

When using plaques with metal screens, it is customary to place first 
over the face of the plaque the desired metal screen. Over the screen 
10 or 12 thicknesses of thin paper are then placed in order to absorb 
the secondary rays. In some cases one or more mm. of paper or other 
nonmetallic material may be used. The whole apparatus is then wrapped 
in rubber dam and applied to the lesion with adhesive tape, or a bandage. 

B. APPARATUS CONTAINING RADIUM EMANATION 

We have already said that both radium and radium emanation emit 
only alpha rays which do not escape from the tube containing them. The 
real source of the penetrating rays is the decay products, radium B and 
radium C, and especially the latter. 

When radium salts are confined in a tube the only function of radium 
itself and its next decay product, radium emanation, is to produce radium 
B and radium C as fast as these latter decay. It is evident then, that if 
we can separate the radium emanation from the solid radium and confine 
it in a glass tube, radium B and C will be produced by disintegration of 
the emanation and will themselves constitute the source of penetrating 
beta and gamma rays. In other words, the capillary glass tube in .which 
the emanation is confined may be used to radiate the tissues exactly as 
if it contained radium itself. Inasmuch, however, as radium emanation 
decays quite rapidly, falling to % its original amount in 3.85 days, the 
radiations from this source are not constant as is the case when radium 
itself is used. 

Objection to the use of radium emanation alone as a source of thera- 
peutic radiations has been made on the ground that the relatively rapid 
loss of activity impairs its value. This objection can easily be met by 
remembering that few treatments exceed 24 hours in duration and during 
this time only 16 per cent of the initial activity of the emanation is lost. 
For the production and collection of radium emanation for therapeutic 
use at least 1 gram, or more, of radium element is desirable from a prac- 
tical point of view. The salt used is radium chloride which is dissolved 
in water to which a small quantity of hydi-ochloric acid has been added. 



112 RADIUM THERAPY 

The extraction, purification, and compression into a small bulk of the 
radium emanation from this solution is a highly technical and compli- 
cated procedure requiring special apparatus. For the description of the 
process the reader is referred to a previous chapter. 

The advantages of radium emanation tubes over tubes containing 
radium salts are numerous ; among them may be mentioned the follow- 
ing: (1) The minute size of the emanation tubes. It is easily possible 
to make an emanation tube less than % or even y l(M the size of a 
tube of similar activity containing radium sulphate. (2) The greater 
flexibility of the armamentarium, since tubes or applicators of any size, 
shape or strength may be made. (3) The obviation of danger of loss of 
the radium since the radium itself is not actually used in the therapeutic 
applications. On the other hand, for certain surface applications and es- 
pecially in treating many skin diseases radium plaques are preferable 
to the emanation apparatus on account of their greater convenience, 
constant dosage and at close range their more uniform radiation. 

Apparatus designed for the practical application of radium emanation 
consists of: 

(1) Capillary glass tubes, in which the emanation is confined. These 
tubes vary in length from 3 to 20 mm., the outside diameter being from 
0.3 to 0.6 mm. They may easily be made of any desired strength. When 
intended for external radiations, they may contain ordinarily from 5 to 
50 me. each. Emanation tubes of less strength may be grouped together 
on pads so that the effective utilization of the weakest tubes is possible. 
When intended for external radiations, silver tubes are slipped over the 
emanation tubes as soon as the latter are sealed off from the emanation 
machine. These silver tubes are open at both ends. They are 16 mm. 
long, 3 mm. in diameter and have a wall thickness of 0.5 mm. Enclosed 
in the silver tubes before the active deposit has formed, the emanation 
tubes may be conveniently handled in this manner with less danger to 
the operator. The emanation tubes are retained in the silver tubes by 
a paraffin plug at each end of the latter. The tubes are then set aside 
for three and one-half hours, at the end of which time the strength of 
each tube is measured. The silver tubes are distinguished from each 
other by means of a coating of enamel, of different colors or combina- 
tion of colors, an ingenious method devised bj" Failla. A record is kept 
of the number of millicuries contained in each enameled tube so that its 
strength may be calculated from day to day. 

Glass emanation tubes are sometimes used without filters. They may 
be laid on the surface of a growth or may be used for insertion into tumor 
tissue. They are often called "bare tubes" or ampoules to indicate the 
fact that they are used in this manner. The "bare tubes" used for 
insertion into tumor tissue are ordinarily about 3 mm. in length and 
have a diameter of about 0.3 mm. They usually contain from 0.5 to 3 



THERAPEUTIC APPARATUS 



113 



me. of emanation. They may be made by cutting up longer emanation 
tubes by means of a minute gas flame. As the pressure of the emanation 
in the tube is less than atmospheric pressure,- no emanation is lost by 
this procedure. Failla has devised, an ingenious machine by means of 
which a glass tube may be cut into shorter lengths with great rapidity. 
The method of using the bare emanation tubes by inserting them into 
the tumor tissue is described in a subsequent chapter. We have devised 
an instrument for the convenient insertion of ampoules (Pig. 36). 
(2) Special steel needles, devised by Joly and Stevenson, in which the 



1 I 



A. 



B. 



C. 



D. 



E. 



F. 



Fig. 20. Apparatus for the application of radium emanation. 



A, Capillary glass emanation tube, length 7 mm., outside diameter ^lo mm. B, Knameled silver 
tube, length 1.6 cm., wall thickness fyio mm. to contain glass emanation tube A. C, Brass screen, 
length 2]/2 cm., wall thickness .f>2 mm. to contain silver tube B. D, Brass screen, length 3 cm., 
wall thickness 1.8 mm. to contain silver tube B. E, Hollow steel needle with screw cap, length 
17 mm., wall thickness Vio mm. to contain emanation tube A. Into a similar needle may be 
packed about 12 mg. radium sulphate, the cap being then hermetically sealed on. F, Hollow steel 
needle with plunger to contain glass emanation tube A after removal of plunger. The needle may 
then be inserted into the tumor for the required number of hours. From this needle may also be 
ejected by means of the plunger a similar but more minute capillary glass emanation tube which 
may be allowed to remain in the substance of a growth. The author's instrument for the con- 
venient insertion of glass ampoules is shown in Fig. 36. 

capillary glass emanation tubes may be placed. The steel needle, con- 
taining the emanation tube, may be inserted into the substance of 
tumors. These steel needles have a wall thickness of 0.3 to 0.4 mm. and 
a length of from 1 to 2 cm. The needle containing the glass emanation 



114 RADIUM THERAPY 

tube is withdrawn from the tissues after the required length of time has 
elapsed. Instead of steel, the needles may be made of platinum or any 
other desired material. In estimating the time of exposure, due regard 
must be paid to the amount of screening power possessed by the wall of 
the needle. This method of using needles has been replaced in large 
measure by the method previously described in which bare emanation 
tubes are inserted and left to decay in the tumor tissue. In some cases, 
however, the use of metal needles is desirable. 



C. APPARATUS FOR USING THE RADIOACTIVE DEPOSIT 

The field of usefulness for the active deposit is relatively small at the 
present time. The active deposit may be utilized, however, in several 
ways. These are (1) the deposit may be allowed to collect on a small 
piece of metal such as lead foil. (2) The deposit may be collected on a 
wire attached to the negative pole of a battery. Radioactive wires may 
be utilized by insertion into the tissues. (3) A solution of active deposit 
may be used. 

1. The Active Deposit Collected on Metal 

We have already stated that when radium emanation is separated from 
the radium and confined in a tube, a thin coating or film of "active de- 
posit" forms on the walls of the tube and that the tube itself may then 
be used as a source of radiation, the function of the emanation being 
simply to keep up the supply of "active deposit." We may even go a 
step further. Once the active deposit has settled on the walls of the 
tube, the emanation itself may be taken away and the active deposit 
alone may be used as a source of radiations. Under these circumstances, 
however, the tube is short lived as the emanation is lacking ta replenish 
the active deposit as fast as it decays. 

If a small piece of metal such as lead foil is enclosed for three to four 
hours in a container with the emanation, the metal becomes coated with 
"active deposit" and may be removed from the container and used alone 
as a source of radiations. Radioactive lead foil has been used principally 
for the treatment of vernal conjunctivitis. 

2. Radioactive Wires 

By a suitable arrangement, a platinum wire may be attached to the 
negative pole of a battery and inserted into a glass bulb into which the 
emanation may be introduced. The radium A that is formed from the 
emanation has a positive charge. It goes, therefore, as Rutherford first 
observed, to the negative electrode and is deposited there. There is thus 
formed "radioactive deposit" on the wire, the maximum amount being 
obtained after about three hours. The radiation from the wire consists 



THERAPEUTIC APPARATUS 115 

of alpha, beta and gamma rays. Just as in the case of the piece of metal 
enclosed in the emanation chamber and previously referred to, the "ac- 
tivity" of the wire decays rapidly. 

As shown by Lyster and Russ, an "active wire" may be of value when 
introduced directly into the tissues. Under these conditions, the radia- 
tions do not suffer any loss by absorption in the apparatus such as 
happens when the ordinary radium emanation container is used. As will 
be seen by referring to the following table, however, the radioactivity of 
the active deposit falls to less than half value in one hour. The short life 
of the active deposit thus curtails its usefulness. 

TABLE XIII 
(After Cohvoll and Russ.) 



RATE 


OF DECAY OF 


RADIOACTIVE DEPOSIT 


ALPHA 

TIME 


KAYS 
ACTIVITY 


GAMMA RAYS 
TIME ACTIVITY 


minutes 


100 


minutes 100 


10 " 


53 


10 " 96.6 


20 " 


46 


20 " 88.4 


30 " 


40 


30 " 


40 " 


35 


40 ' ' 66.9 


50 " 


30 


50 " 


60 " 


26 


60 " 38.5 


1 hr. 30 min. 14 


1 hr. 30 min. 25.3 


2 hr. 00 " 


7.2 


2 hr. 00 " 12.9 


3 hr. 00 " 


1.8 


3 hr. 00 " 3.1 



3. Solution of Active Deposit 

The active deposit may be dissolved in water or allowed to collect 
in a closed chamber on some soluble substance such as common salt 
which may then be dissolved. The solution may then be injected, sub- 
cutaneously or intravenously. The method of preparing a solution of 
active deposit has been described in a previous chapter. 



CHAPTER XIII 
DOSAGE 

A scientific and perfected method of dosage in radium therapy would 
demand that the rays coming from each apparatus be carefully measured 
and directed in accordance with our knowledge of the radiation neces- 
sary to destroy each normal and diseased cell complex. These ideal 
conditions for treatment cannot be completely fulfilled. 

In the first place we are dealing with the living organism and even 
if the rays could be measured for each applicator and directed properly 
the intensity of radiation necessary to produce certain results will vary 
to some extent with the individual tissue or tumor that is treated. 
Within certain limits, however, the proper measuring of the dose of rays is 
of the highest importance and is the foundation of a scientific therapy. The 
number of possible arrangements of apparatus containing radium is so 
great that we must limit ourselves to a discussion of a few types of ap- 
plicators that are adaptable to a number of conditions. We shall give, 
however, the results of certain mathematical calculations that are of 
value in enabling us to estimate the intensity of the radiations from 
different types of applicators at different distances. 

In considering the subject of dosage we must distinguish between 
(a) surface radiations, i.e., radiations that are delivered by placing the 
appai'atus at various distances from the surface of the skin or mucous 
membranes, and (b) intratumoral radiations, i.e., radiations that are 
derived from the actual introduction of the radioactive material into 
the substance of tumors. 

SURFACE RADIATIONS 

Neglecting for the moment the radiosensitiveness of the tissues, the 
therapeutic effect of radiations depends upon their quality, their intensity 
and the duration of the exposure. The quality of the radiations depends 
upon the filtration. The intensity of the radiations at a given point 
depends upon: 

1. The quantity of radioactive material. 

2. The filtration. 

3. The shape of the source, i.e., the method of distribution of the 
radium on the apparatus. 

4. The distance from the source. 

5. Absorption in the apparatus and in the tissues. 

6. The secondary radiations in the tissues. 

A marked variation of any one of these factors naturally alters 

116 



DOSAGE 117 

the effect of the radiation. We may now consider the effect of each 
factor. 

(1) The Quantity of Radium or Radium Emanation in the Apparatus 

It is evident that, other things being equal, the larger the quantity of 
radioactive material the more intense is the radiation. Speaking very 
generally the quantity of radium used naturally depends upon the pur- 
pose of the radiation, i.e., whether the lesion requires a mild or intensive 
dosage and whether superficial or deep effects are desired. The quantity 
used varies therefore from a few milligrams which may be suitable for 
superficial cosmetic disorders of the skin to one gram or more which may 
be necessary for influencing deeply seated or extensive malignant tumors. 
Tt has already been stated that experience has shown that tubes and 
plaques containing from 5 to 50 milligrams of radium element or tubes 
containing the same number of millicuries of emanation are the most 
convenient and useful. Almost any combination of apparatus to aug- 
ment the amount of radium for a single case may be employed. Com- 
binations of apparatus to increase the quantity of radium and therefore 
the dose are made in accordance with certain mathematical calculations 
and as the result of experience in dealing with special kinds of lesions. 

It must be especially emphasized that while there is probably an opti- 
mum dose and method of treatment, equally good results may be achieved 
in many cases by very different methods. The various factors mentioned 
above that enter into the effect of the radiation may all differ with dif- 
ferent operators and yet the final result may be equally good. Wickham 
long ago insisted upon the fact that we cannot be too dogmatic, or use a 
too "cut and dried" method in matters pertaining to radium therapy. 
In children, the dose should not be more than one-half and in the case of 
very young children not over one-fourth of the normal dose for adults. 

(2) The Filtration 

We have discussed in a previous chapter the use of metallic and non- 
metallic screens to filter out or absorb types of radiations that are some- 
times undesirable before they reach the skin. In routine practice, the 
metal screens over the radium vary in thickness from 0.1 mm. to 2 mm. 
while the nonmetallic material used, in addition, may vary from 1 mm. 
to 1 or more cm. 

In general, when superficial effects are desired, little or no metal 
screening may be used from a theoretical point of view, as the first centi- 
meter of tissue absorbs practically all the beta rays. Although under 
these circumstances, both beta and gamma rays take effect, the quantity 
of beta rays greatly exceeds that of gamma rays while their absorption 
takes place readily; therefore their action greatly preponderates in short 
unscreened exposures. Great care must be observed, however, in using a 
preponderance of beta rays on the skin, as painful burns may be easily 



118 RADIUM THERAPY 

produced. It is seldom wise to use varnish or glazed apparatus or bare 
emanation tubes without a certain amount of metal screening unless the 
operator has had experience with the method. 

When deep effects are desired, all of the beta rays and some of the 
softer gamma rays should be absorbed by a screen of brass 2 mm. thick 
or by its equivalent of another metal. Only the hard gamma rays are 
thus effective in penetrating the screens and affecting the tissues. 

The reason for the use of thick metal screens, in the treatment of 
deeply situated tissues is thus very evident. If an unscreened radium prep- 
aration is used, the greater part of the radiation, consisting of beta rays, 
will be absorbed by the superficial layers of tissue. As a result of this 
absorption, the superficial layers may receive an amount of rays sufficient 
to destroy them while the deeper tissues will receive relatively little 
radiation. On the other hand if screening of sufficient thickness, such as 
may be furnished by two millimeters of brass, is used, the superficial and 
deep layers of tissue may receive approximately the same amount of 
radiation. As many types of tumor cells are more sensitive to the rays 
than normal cells, the purpose of the radiation, i.e., the destruction of 
tumor cells and the preservation of the normal cells may be accomplished. 

TABLE XIV 

This table shows the ionizing effect due to beta and gamma rays in air. At the 
same distance (1 cm.) if absorption is not considered, the ionization due to beta rays 
may be assumed, according to Eve "s experiments, to be thirty-four times that due to 
gamma rays. We may also accept Eve's values for the coefficients of absorption, i.e., 
for beta rays .012; for gamma rays, a value so small as to be negligible. 

The table illustrates the effect of a filter of sufficient thickness to absorb all but 
gamma rays in causing a diminution of the total intensity. 



DISTANCE IN 
CENTIMETERS 




EFFECT 




BETA RAY 


GAMMA RAY 


TOTAL 


1 


3360 


100 


3460 


2 


830 


25 


855 


3 


365 


11 


376 


4 


203 


7 


210 


5 


128 


4 


132 


6 


88 


3 


91 


7 


64 


2 


66 


8 


48 


2 


50 


9 


38 


1 


39 


10 


30 


1 


31 



Let us now consider the effect of 

(3) The Shape of the Source and 
(4) The Distance of the Source from the Surface 

From a theoretic point of view, the radium preparation may be dis- 
tributed on an applicator of almost any desired shape or size. Thus, 



DOSAGE 119 

radium emanation may be concentrated at one or more points or lines; 
radium salts may have a linear distribution, as in the case of tubes, or 
they may be spread uniformly over plates of various shapes and sizes. 
Practically, we limit ourselves to the use of tubes (i.e., a linear distribu- 
tion) containing either radium emanation or salts, and to the use of 
round, square or rectangular plaques of various sizes containing radium 
salts. 

It may be shown by mathematical calculation that the difference be- 
tween the effect due to a linear distribution (i.e., a tube several milli- 
meters long) and that due to a point is not more than a fraction of 1 per 
cent at a distance of several centimeters. The orientation of the tube at 
these distances is also unimportant. 

We are concerned chiefly, therefore, with the effect of tubes and of 
plaques which may be used singly or in combination. We may now con- 
sider the variation in intensity of the radiations at different distances 
when the source is 

(a) A single point, or a line several mm. long, i.e., a single tube. 

(b) A number of points or lines, i.e., several tubes. 

(c) A plane surface such as may be formed by one or more plaques or 
by laying a number of tubes side by side. 

(a) Single Tubes 

Considering each tube as a point source, the variation of the concentra- 
tion of the rays with distance is in accordance with the law of inverse 
squares, i.e., the intensity of the rays varies inversely as the square of 
the distance from the source, any effects of absorption being, for the 
moment, neglected. 

Let us assume that we have a source of gamma rays (filtered to absorb 
beta rays) so small that it may be considered as a point. Let this source 
be situated in a medium such as air which does not appreciably absorb 
the gamma rays. We may consider the point as a source of radiant 
energy which is emitted equally in all directions. 

If we assume that a sphere of unit radius is drawn about the point 
source as a center, all of the radiation will go through the surface of this 
sphere. As there is nothing to distinguish one portion of the spherical 
surface from another, we can assume that the energy passing through a 
unit area of such a surface is a measure of the intensity at that distance 
from the point. 

Now suppose the unit area is moved out to a distance of two centimeters. 
It is now part of the surface of a sphere of area 4ir(2) 2 instead of 
4 IT (I), 2 i.e., of a surface with four times the area of the first sphere. 
The energy that passed through the spherical surface of radius 1, must 
now pass through the spherical surface of radius 2, but it will be spread 
over four times the area over which it was previously distributed. Hence 



120 RADIUM THERAPY 

the amount of energy passing through the unit area, which we have taken 
as a measure of the intensity, is just one-fourth, at a distance of 2 cm. 
from the source, of the intensity at a distance of 1 cm. from the source. 
Similarly, at a distance of 3 cm., it is % of the intensity at 1 cm. ; at 
4 cm., % arid so on. The intensity due to a point source varies inversely 
therefore as the square of the distance. Consequently, if the source is a 
single tube, a variation in the distance of the source from the surface of 
even a few millimeters is sufficient to cause an appreciable difference in 
effect. From the standpoint of homogeneity of radiation, it is frequently 
desirable to place the radium tube at a distance of a few millimeters 
from the surface. For example, neglecting absorption for the moment, 
a layer of tissue, 5 mm. thick, placed 1 mm. distant from the radium tube 
emitting only gamma rays would receive on the far side, which is 6 mm. 
distant, % 6 , i.e., (% 2 ) of the dose received on the near side, which is only 
1 mm. distant. If the same layer of tissue were placed 5 mm. away from 
the radium, it would receive on the far side, which is 10 mm. distant, only 
% (i.e. 5 2 /10 2 ) of the dose received on the near side, which is 5 mm. dis- 
tant. It is evident, therefore, that by placing the radium tube at a cer- 
tain distance from the skin, the different layers of tissue will receive 
more uniform radiation. In actual practice, this principle, whenever 
practicable, may be taken advantage of and several millimeters to one or 
more centimeters of gauze, rubber or wood may be interposed between 
the metallic screen over the radium tube and the skin, in order to give the 
desired distance. This material thus serves the double purpose of absorb- 
ing the secondary rays from the apparatus and also of retaining the 
radium tube at the proper distance. In order to compensate for the fall- 
ing off in intensity of the rays due to the increased distance of the 
radium, proper increase in either the quantity of radium or the duration 
of the exposure or both of these factors must be made. 

When the radium tube is introduced into a small cavity such as the 
interior of the uterus, it 'is, of course, seldom possible to keep the tube 
more than a few millimeters distant from the tissues. Under these cir- 
cumstances, the tissue nearest the tube receives a dose that is frequently 
excessive but in this particular situation no ill effects are ordinarily ob- 
served. On the skin, however, an unnecessary and undesirable reaction 
would be produced if the radium tube is in too close apposition to it. As 
has been stated before, when very superficial effects are desired, the 
radium tube may be placed in relatively close contact with the tissue. 
Great care must be exercised under these circumstances, however, not to 
prolong the duration of the exposure beyond the proper limits, as a pain- 
ful burn may be easily produced. As we have seen, when deeper effects 
are desired, the radium tube may advantageously be placed at least a 
few millimeters away from the lesion or several tubes may be used simul- 
taneously at a distance of several millimeters or centimeters, so as to 



DOSAGE 121 

cover the area occupied by the lesion. The latter arrangement, which is 
ordinarily the better one, will be considered in a subsequent section. 

It may be found by experiment that fifty millicuries, contained in a 
point or minute tube, screened to absorb all but gamma rays will pro- 
duce, at a distance of 1 cm., an erythema of the skin in twelve hours, 
i.e., 600 me. centimeter hours. (50 x 12.) 

Let us assume the permissible skin dose to be 600 me. centimeter hours. 
"We can now find, at least theoretically, the smallest distance from the 
skin at which, for example, a fifty millicurie tube can be left for an hour. 
This is easily done as follows, if we consider the tube as a point source : 

The intensity at any point at a distance r from the source is ~ "We 

wish this intensity, when multiplied by the time in hours (1 in this case) 
to be equal to 600. 

Hence = 600 r 2 = y i2 r = %V3 = .29 cm. 

r 2 

or approximately 3 mm. Actually the tube can be placed closer than 
this, since a tube is not a true point source. The intensity at .29 cm. 
away is not 600 but is given by 

2-^ tan* ' " being ec l ua l to 
~Tf~ ~zf zero in this case. 

where M is number of millicuries in the tube, I its length, / the distance 
away. Take M == 50, I = .7, / = .29. We get for the intensity at .29 cm., 

100 - 1 .7 

tan . , or 433. 



.7(.29) .58' 

This is about two-thirds of that permissible. Hence to approximate to 
the possible distance, try .29 V% = -236 cm. The intensity at that dis- 
tance is 

100 - 1 .7 

tan . =592. 



.7 (.236) .472 

Hence .235 cm. is as near to the skin as one may leave a 50 millicurie 
tube for an hour. If we accept as approximate the rule that for the 
same value of distance times the time, with the same intensity, the effect 
is the same, this will also be the minimum permissible time to leave a 
25 me. tube for two hours, a 100 me. tube for one-half hour, etc., since 
25 x 2 == 100 x Y 2 . The above rule holds, however, only within certain 
limits as we shall show later on. 

(b) Several Tubes 

Let us now consider two 50 me. point sources. Let us try to give 
three points on the skin the same amount of radiation. Let us take one 



122 



RADIUM THERAPY 



X 



X ^ ' 

k X S ' 

\ X S ' 



\/ 



xl 



D C 

Fig. 21. Diagram showing two radium tubes affecting three different points on skin. 

point directly below each tube, and the third point halfway between 
them. Let A and B be the two tubes, D, E, and C the points on the skin. 
(Fig. 21.) The intensities at D and E will, from symmetry, be the same. 
Let us assume the intensity at D and also at E to be 600. Then the in- 

50 50 

tensity at C due to A is -r^. That at C due to B is - - . Now AC = BC 



AC 



BC 2 



if the midpoint of DE is C. Hence the total intensity at C is 
100 



2 x 50 
AC 2 



AC 2 ' 



Let 



= T. DE = X 



Then A C == A D X D C = T 2 +_ 

4 



100 



2? 1 

= 600 or T 2 + = 

X' 46 



T' -I 

50 50 

The intensity at D due to A is A n2 or . The intensity at D due to 



AD 2 



B is 



50 



50 



50 



. . The sum of these two intensities is to 



BD 

be 600. 



BE f DE 



50 



50 



= 600 or 



= 12 



"We have therefore two equations. 



X* 

+ _ = 1/6 

4 



I" 



= 12 



We can solve these for X 2 and Y 2 and hence get the desired distances AD 
and DE. We find for AD, the distance from the skin, .333 cm. and for 
AB, the distance apart of the point sources, .471 cm. 

On the other hand, if we use tubes instead of point sources, we find that 



DOSAGE 123 

with the distances as given, the intensity at J> and E amounts to 482. 
Hence we must approximate as before by decreasing the distances in the 
ratio V%- By several such approximations (we need here to correct the 



ratio -~^ - as well as V AD and \/AB together) we arrive at the values. 

\/AB 
Distance from skin = .289 cm.; distance apart = .440 cm. 

The same procedure can be followed for points and tubes at the cor- 
ners of an equilateral triangle and also at the corners of a square. The 
results are given in Table XV. 

TABLE XV 
THEORETIC MINIMUM PERMISSIBLE DISTANCE FROM SKIN FOR 50 MC. FOR ONE HOUR 

POINT SOURCES TUBES 7 MM. LONG 

DISTANCE FROM DISTANCE DISTANCE FROM DISTANCE 

THE SKIN APART SKIN APART 



Single 


tube 


.289 


cm. 


.0 


.235 


cm. 


.0 




Two 


tubes 


.333 


1 1 


.471 cm. 


.289 


1 1 


.440 


cm. 


Three 


" 


.353 


1 1 


.612 " 


.312 


1 1 


.307 


1 1 


Four 


1 1 


.375 


1 1 


.619 " 


.332 


a 


.595 


it 



If we wish to change the amount of radium, we must change either 
the time or the distance. If the distance be kept constant, the time 
should be changed in such a way that the numerical value of the product 
obtained by multiplying the number of millicuries by the time in hours 
is kept the same. In general two arrangements of point sources (or of 
tubes at a distance of more than a few centimeters) are similar in effect 

(Amount of radiating substance) (Time) 
when we have the same value for - .,. , 

(Distance) 2 

for each distance, i.e., for the distance apart of the tubes and also the 
distances from the skin. Thus if we increase the time from one hour to 
six, we must, for point sources, increase the distance each in the ratio 
V6 etc. 

TABLE XVI 

THEORETIC MINIMUM PERMISSIBLE DISTANCE FROM SKIN FOR 50 MC. FOR Six HOURS 

Assuming the maximum permissible (lose as 50 me. at 1 cm. for 12 hours, the minimum 

permissible distances for 50 me. for 6 hours will be 

POINT SOURCES TUBES 

DISTANCE FROM DISTANCE DISTANCE DISTANCE 

SKIN APART FROM SKIN APART 



Single source 


7.10 mm. 




6.79 mm. 




Two sources 


8.16 mm. 


11.53 mm. 


7.92 " 


11.56 mm. 


Three " 


8.64 " 


14.99 " 


8.47 " 


14.96 " 


Four " 


9.18 " 


15.18 " 


9.01 " 


15.19 " 



For tube sources, this method gives only approximate results, due to 
the departure from the inverse square law. It must be especially empha- 



124 RADIUM THERAPY 

sized, however, that biologically the method of calculation outlined above 
does not hold true for all intensities and times. The actual biologic 
effects can only be determined by experience. For small variations of 
intensity and time the above method is approximately correct. The 
effect due to a large intensity for a short time is not the same, however, 
as that due to a small intensity for the correspondingly longer time. We 
shall refer to this point again in our discussion of the duration of the 
exposure. 

Prom the foregoing, it may be stated that, in general, two equal sources 
or tubes may be placed with their centers approximately twice as far 
apart as their distance from the skin. This arrangement provides an 
approximately uniform field of radiation at the skin sui'face. The fore- 
going rule does not hold, however, in the case of large extended sources 
as we shall show later on. Three equal sources or tubes may be placed 
at the corners of an equilateral triangle. 

Four equal sources or tubes may be arranged at the corners of a 
square, if we wish to make the intensity beneath the center of the square 
equal to that under each of the four corners. 

In the case of the equilateral triangle and the square (3 tubes and 
4 tubes respectively) the same general rule holds as in the case of two 
tubes, i.e., the sides of the triangle and the sides of the square may be 
approximately twice as long as the distance of the tubes from the skin. 

(c) Plaques. Tubes Laid Side by Side 

It is evident that as the number of tubes is increased the effect approaches 
very closely to that produced by a plaque, i.e., by a uniform distribution 
of the radioactive material on a plane surface. At a distance of a few 
millimeters, the plaque source has a slight advantage over the multiple 
tube source in that the former produces an approximately uniform field 
of radiation. This uniformity of effect is of considerable importance in 
the treatment of cosmetic skin disorders, such as angiomata. At a dis- 
tance of several centimeters, both types of apparatus have an almost 
identical effect. 

We may now give some illustrations of the relative effects of a few dif- 
ferent types of applicators. For convenience, the gamma ray intensity 
derived from a point source containing one mg. of radium element at a 
distance of one centimeter, is taken as the unit in all of the following 
calculations. 

In calculating Table XVII each tube was considered as a point. The 
calculation was also made for 25 tubes considering each tube as a 
line; the result was 9.941, a difference from 9.946 of % per cent. 

The intensity decreases as the number of tubes increases, approaching 
the value for a uniform distribution which may be estimated from the 
above table as approximately 9.8, i.e., a difference of only about 2 per 



DOSAGE 



125 



TABLE XVII 

EFFECT or DIFFERENT NUMBERS OF TUBES CONTAINING A TOTAL QUANTITY OF 500 MG. 

DISTRIBUTED OVER A PLANE SURFACE 10 x 10 CM. DISTANCE FROM PLANE 

OF TUBES TO POINT ON Axis Is ASSUMED TO BE 6 CM. ABSORPTION 

IN THE APPARATUS Is NOT CONSIDERED 



NUMBER OF 
TUBES 


GAMMA KAY INTENSITY AT A 
6 CM. FROM THE PLANE 


POINT ON THE AXIS, 
OF THE TUBES 


1 


13.88 




4 


10.31 




16 


9.99 




25 


9.95 




100 


9.89 





cent from the value for twenty-five tubes. The advantage in increasing 
the number of tubes (i.e., sources) beyond 15 is not immediately appar- 
ent for a distance of 6 or more cm. from the skin. 

Tables XVIII and XIX illustrate the difference in effect of a plaque 
and a point source respectively at various distances. As we have already 

TABLE XVIII 

INTENSITY OF GAMMA RADIATION DUE TO A CIRCULAR PLATE 4 CM. IN DIAMETER AND 
A POINT SOURCE, RESPECTIVELY. EACH TYPE OF SOURCE Is ASSUMED TO CON- 
TAIN 50 MG. OF RADIUM ELEMENT. THE INTENSITY Is CALCULATED AT 

A POINT ON THE AXIS OF THE PLATE, I.E., ON A LINE PER- 
PENDICULAR TO ITS CENTER. ABSORPTION IN THE 
APPARATUS Is NOT CONSIDERED. 



DISTANCE IN CM. 

OF THE SOURCE FROM 

THE SURFACE 



CIRCULAR PLATE 4 CM. 
IN DIAMETER, CONTAINING 

50 MG. RADIUM ELEMENT. 
(ABOUT 4 MG. PER SQ. CM.) 



POINT SOURCE 

CONTAINING 50 MG. 

RADIUM ELEMENT 



.1 


cm. 


74.8 


5000 


.2 


1 1 


57.7 


1250 


.3 


1 1 


47.7 


555 


.4 


it 


40.7 


313 


.5 


1 1 


35.4 


200 


.6 


1 1 


31.1 


139 


.7 


n 


27.7 


102 


..8 


1 1 


25.4 


78 


.9 


1 1 


22.3 


62 


1.0 


1 1 


20.1 


50 


1.2 


t ( 


16.6 


34.7 


1.5 


tt 


12.8 


22.2 


1.6 


1 1 


11.8 


19.6 


2.0 


ii 


8.67 


12.5 


2.5 


tt 


6.17 


8.00 


4.0 


tt 


2.79 


3.13 


6.0 


1 1 


1.32 


1.39 


8.0 


< t 


.76 


.78 


10.0 


1 1 


.49 


.50 



126 RADIUM THERAPY 

shown, the plaque source and the multiple tube source are practically 
equivalent, at least at a distance of several centimeters, in the production 
of a homogeneous field of radiation at the surface. 

TABLE XIX 

INTENSITY OF GAMMA RADIATION DUE TO A CIRCULAR PLATE 10 CM. IN DIAMETER AND 
A POINT SOURCE, RESPECTIVELY. EACH TYPE OF SOURCE CONTAINS 

500 MG. RADIUM ELEMENT 

THE INTENSITY is CALCULATED AT A POINT ON THE Axis OF THE PLATE. ABSORPTION 
IN THE APPARATUS Is NOT CONSIDERED 

DISTANCE IN CM. OF CIRCULAR PLATE 10 CM. POINT SOURCE 

THE SOURCE FROM IN DIAMETER CONTAINING CONTAINING 500 MG. 

THE SURFACE 500 MG. RADIUM ELEMENT RADIUM ELEMENT 
(ABOUT 6.36 MG. PER SQ. CM.) 



1 


cm. 


65.2 


500 


2 


4 t 


39.6 


125 


3 


t t 


26.6 


55.6 


4 


t t 


18.8 


31.3 


5 


(( 


13.9 


20 


7 


t t 


8.24 


10.2 


10 


I I 


4.46 


5.0 


15 


t I 


2.11 


2.22 


20 





1.21 


1.25 


25 


Cl 


.784 


.800 



Tables XVIII and XIX show that so far as the axis and direct radiation 
are concerned, there is little difference in the effect of the two types of 
sources at a distance of more than 7 cm. Closer than this the intensity due 
to the point source becomes much the greater. Hence if the skin is closer 
than 6 cm. an extended source (i.e., either plaques or a number of tubes) 
may be used to greater advantage than a point source for deep treatments. 
If the skin is nearer than 1 cm., as in superficial treatments, the plaque 
source is particularly advantageous in comparison with a point source. 

The advantage of the extended or distributed source lies in the fact 
that it can be put nearer to the skin than the point source, and, while 
producing the same effect on the skin itself, it gives a greater effect at 
a point below the surface. Thus, if 20 were the limiting dose for the 
skin in the above example, the point source must be at least 5 cm. away, 
while the extended source can be put within less than 4 cm. of the skin. 
In the latter case, the intensity 5 cm. below the skin surface would be 5 
for the point, 5.5 for the distributed material, i.e., 10 per cent higher for 
the latter. For a distance of 3 cm. below the skin surface, the advantage 
is less than 4 per cent; for 10 cm., about 10 per cent. There are, in addi- 
tion, certain technical reasons on account of which a distributed or 
widely extended source is more convenient of application than a point 
source. Thus it is more practical to arrange on an applicator, that has, 



DOSAGE 127 

e.g., an area of 100 square cm., 10 tubes or plaques each containing 
50 mg., than a single powerful tube, containing 500 nig. 

It is frequently of interest to know the theoretic variation of intensity 
for plaques of different sizes. 

In general, for a surface distribution, if one reduces every dimension in 
the same ratio, keeping the surface density (amount per sq. cm.) con- 
stant, the intensity at any given point can be found for the new distribu- 
tion from the intensity of the corresponding point, respectively, in the 
old distribution by multiplying the given distances by the "ratio of 
reduction." Thus, for a circular disk of radius 5 cm., using 500 mg., the 
field at a distance of 1 cm. is the same as for a circular disk of radius 
2 cm. (5 x .4) using 80 mg. (500 x (.4) 2 ) at a distance of 4 mm. (1 x .4) ; 
that for a distance of 2 cm. is the same as for the second case at 8 mm. and 
so on. While from a physical standpoint the intensity may be calculated 
as outlined above, the biologic effect may not be the same for plaques of 
different sizes. 

Table XX shows the variation in gamma ray intensity at different 
distances due to a square plate, on which 12 tubes are symmetrically 
arranged, and to a point source, respectively. 

From a practical point of view, the more superficial the situation of 
the lesion, other things being equal, the closer to the skin the radium may 
be placed, and vice versa, the deeper the situation of the lesion, the 
farther away from the surface of the skin the radium should be placed. 

In employing superficial radiations, the overlying skin or mucous mem- 
brane frequently but not necessarily becomes markedly inflamed or even de- 
stroyed. Inflammatory reaction should be avoided, as a rule, when possible. 
When employing deep radiations, it is usually desired to preserve the over- 
lying skin or mucous membrane. Hence, only a slight amount of surface 

TABLE XX 

GAMMA BAY INTENSITIES DUE TO A SINGLE 6x6 CM. PLATE, CONTAINING 200 MO. IN 
12 TUBES. ABSORPTION IN THE APPARATUS Is NOT CONSIDERED. 



DISTANCE 


FROM AXIS 


DISTANCE 
12 TUBES 


FROM PLATEz=6 CM. 
POINT SOURCE 


DISTANCE FROM 
12 TUBES 


PLATE=10 CM. 
POINT SOURCE 





cm. 


4.845 


5.556 


1 


.898 


2.000 




2 


1 1 


4.503 


5.000 


1 


.833 


1.923 




4 


1 1 


3.670 


3.846 


1 


.665 


1.724 




5 


1 1 


3.202 


3.279 


1 


.557 


1.600 




6 


1 1 


2.775 


2.778 


1 


.441 


1.471 




8 


1 1 


2.022 


2.000 


1 


.208 


1.220 




10 


it 


1.493 


1.471 




.998 


1.000 




12 


1 1 


1.128 


1.111 




.821 


.820 




14 


i ( 


.875 


.862 




.679 


.676 




16 


i ( 


.693 


.685 




.566 


.562 




18 


il 


.562 


.556 




.475 


.472 




20 


ft 


.463 


.459 




.403 


.400 





128 



RADIUM THERAPY 



TABLE XXI 
GAMMA KAY INTENSITIES DUE TO Two SUCH PLATES, OR POINTS, IDENTICAL WITH 

THOSE IN THE PREVIOUS TABLE. DISTANCE PROM SOURCE TO SURFACING CM. 
The term ' ' center line ' ' is used in considering the effect of two applicators arranged 
so that the planes containing the tubes are at the same distance from the surface but 
separated by an interval of space. The center line is the line perpendicular to the 
plane of the tubes and passing through the midpoint of the line between the centers 
of the surfaces of the applicators on which the tubes are arranged. 
Absorption in the apparatus is not considered. 



DISTANCE FROM 


DISTANCE APART 


DISTANCE APART 


DISTANCE APART 


CENTER LINE 


OF PLATES = 


OF PLATES = 


OF PLATES == 







CM. 


4 


CM. 


8 


CM. 




PLATES 


POINTS 


PLATES 


POINTS 


PLATES 


POINTS 


1 cm. 


8.173 


8.846 


6.445 


6.624 


4.797 


4.778 


3 " 


7.620 


8.334 


6.525 


7.000 


5.163 


5.317 


5 " 


6.525 


7.000 


6.338 


7.027 


5.631 


6.111 


7 " 


5.163 


5.317 


5.631 


6.111 


5.720 


6.418 


9 " 


3.903 


3.889 


4.545 


4.708 


5.196 


5.685 


11 " 


2.897 


2.862 


3.468 


3.463 


4.232 


4.402 


13 " 


2.186 


2.156 


2.584 


2.556 


3.238 


3.237 


15 " 


1.690 


1.667 


1.956 


1.950 






17 " 


1.338 


1.321 











TABLE XXII 

GAMMA RAY INTENSITIES DUE TO Two 6x6 CM. PLATES EACH CONTAINING 200 MG. 
IN 12 TUBES. ABSORPTION IN THE APPARATUS Is NOT CONSIDERED. DIS- 
TANCE FROM SOURCE TO SURFACED CM. 



DISTANCE PKOM 


DISTANCE APART 


DISTANCE APART 


DISTANCE APART 


CENTER LINE 


OF PLATES = 


OF PLATES = 


OF PLATES = 




2 CM. 


6 CM. 


10 CM. 




PLATES POINTS 


PLATES POINTS 


PLATES POINTS 


cm. 


7.340 7.692 


5.550 5.556 


4.044 4.000 


2 " 


7.278 7.778 


5.692 5.846 


4.268 4.249 


4 " 


6.867 7.556 


5.996 6.471 


4.798 4.957 


6 " 


5.996 6.471 


5.973 6.667 


5.378 5.862 


8 " 


4.798 4.951 


5.378 5.862 


5.538 5.241 


10 " 


3.650 3.640 


4.363 4.531 


5.065 5.556 


12 " 


2.715 2.685 


3.337 3.334 


4.133 4.305 


14 " 


2.055 2.027 


2.485 2.459 




16 " 


1.591 1.570 







inflammation is ordinarily produced and in most cases it may be avoided al- 
together. 

For certain of the most superficial effects, the radium may be placed 
practically in apposition with the skin or mucous membranes, especially, as 
we have shown, when the source of the radiations is a plane surface. For 
somewhat deeper effects the distance of the radium from the surface may 
be from 2 mm. to 1 cm. ; in other cases requiring still deeper effects, from 
1 to 6 cm. ; for the deepest effects, from 6 to 10 or more cm. As the distance 



DOSAGE 



129 



of the source from the surface increases, the quantity of radium necessary 
for certain effects must be increased. "While the diminution of intensity 
due to distance and absorption may be partly compensated for by in- 
creasing the duration of the exposure, massive deep effects cannot be pro- 

TABLE XXIII. 
METHODS OP CALCULATING ABSORPTION IN THE APPARATUS 

Absorption coefficient = .05. 

By one method, i. e., treating the absorption of the radiation from each point sepa- 
rately, one gets for the intensity due to 500 mg. in 25 tubes, at a point on the axis 6 cm., 
distant from the plane of the tubes, G.32. By a second method, i. e., using the average 
distance, 6.28. 

Sample calculation. 



NO. TUBES 


EFFECT DUE TO EACH 


TOTAL EFFECT 




FIRST METHOD 




1 


-(-! + . 3) 
.555e , =.372 


.372 


2 


.SOOe .330 


.660 


2 


.385e IS" .243 


.486 


2 


.SOOe .330 


.660 


4 


.454 e i" .295 


1.180 


4 

2 


-(.i+V~) 

.357e u- .222 

-d+ W) 

.384e '" .242 


.888 
.484 


4 


.357e ! .222 


.888 


4 


.294e .176 
SECOND METHOD 

d d 


.704 


6 . 322 
nd 


1 


6 6 


6 


4 


2V~10 6.3246 


25.298 


4 


2V~13~ 7.2112 


28.845 


4 


2VTT C.C332 


26.553 


8 


2V TT 7.4834 


59.868 


4 


2VT? 8.2462 

-.45906 
9.941e =6.281 


32.985 


25)179.528 


20)7.1812 


.35906 
.1 


.45906 



The difference between the results of the two above methods is 2/3 per cent. Ordi- 
narily it would be much less as in these calculations a small distance has been used. 



130 RADIUM THERAPY 

duced without using relatively large quantities of radium. Practical ex- 
perience has shown that in most cases demanding deep effects a minimum 
of 500 mg. is required, while in other cases not less than 1000 to 2000 mg. 
are necessary. 

In such cases, the minimum amount of metal screening is 2 mm. of brass 
or its equivalent of another metal, and the distance of the radium from 
the surface should not be less than 10 cm. 

5. Absorption 

(a) Absorption in the Apparatus. Let us now consider the effect of 
absorption in the apparatus in decreasing the intensity of the gamma 
radiations. For convenience, the gamma ray absorption in the apparatus 
has been calculated in Tables XXIII and XXIV for a medium of about 
the density of wood, which has an absorption coefficient of approxi- 
mately .05. There are two possible ways of calculating the effect of absorp- 
tion on the radiation due to a number of tubes, as shown in Table XXIII. 
By the first method, the absorption is calculated for each tube separately, 
and the resulting corrected values of intensity are added together. By the 
second method, the average of the thicknesses of absorbing material between 
the radium and the point affected is found first, and the sum of all the uncor- 
rected values is corrected by the amount of absorption which would occur if 
this average distance held for all ; this second method is only an approximate 
one, of course. In either case, whether the correction is made for each tube 
separate!}', or, using the average distance for all the tubes at once, we mul- 
tiply the uncorrected value by the exponential e-^d, where /* is the coefficient 
of absorption, d the thickness of absorbing material in question. As we 
have said before, /* is takeu as ^o = .05 in Tables XXIII and XXIV. The 
absorption factor due to filtration is taken as e- - 1 . 

TABLE XXIV 

GAMMA RAY INTENSITY DDE TO A CIRCULAR PLATE 10 CM. IN DIAMETER, CONTAINING 
500 MiM.KiKAMS RADIUM ELEMENT AT A POINT ON ITS Axis, 

CONSIDERING ABSORPTION 

This is compared with the intensity due to a point source containing the same 

quantity of radium. 



DISTANCE OP THE SOURCE 
FROM THE SURFACE 


INTENSITY DUE TO 
PLATE SOURCE 


INTENSITY DUE TO 
POINT SOURCE 




1 cm. 


57.6 


475.6 




2 " 


33.4 


113.1 




3 " 


21.5 


48.4 




4 " 


14.6 


25.6 




5 " 


10.3 


15.6 




7 " 


5.6 


7.2 




10 " 


2.6 


3.0 




15 " 


.99 


1.05 




20 " 


.44 


.46 




25 " 


.22 


.23 



DOSA<;K 



131 



The conclusions to be drawn from Table XXIV are (1) that absorption 
in the apparatus cuts down the intensity due to a distributed source 
more than it does that due to a point source ; this is, of course, self- 
evident in any case, since the distributed source is under the conditions 
taken (point source taken at center of disk, and effect on axis considered) 
on the average farther away than the point source. Thus the effect on 
the axis at a distance of 10 cm. differs by 11 per cent without consider- 
ing absorption, 13 per cent if absorption is considered, the advantage 
being with the point source in each case. (2) That if 20 still be the 
maximum skin dose possible, the point source can now be put about 4.5 
cm. from the skin, the extended source 3.2 cm. (previously 5 and 3.8) 
i.e., the superiority of the latter in this respect is increased. The in- 
tensity 5 cm. below the skin surface for the same skin dose of 20 is now 
15 per cent greater for the plaque source than for the point source and 
about the same (15 per cent) at a point 10 cm. below the skin surface. 

TABLE XXV 

GAMMA RAT INTENSITY DUE TO SINGLE 6x6 CM. PLATE CONTAINING 200 no., RADIUM 

ELEMENT IN 12 TUBES, EVENLY DISTRIBUTED ON THE SURFACE. ABSORPTION 

IN THE APPARATUS Is CALCULATED BY THE APPROXIMATE METHOD 





PLATE 


SOURCE 






PLATE SOUECE 








APPROX- 


POINT 




APPEOX- 


POINT 




EXACT 








EXACT 








METHOD 


IMATE 


SOURCE 


IMATE 
METHOD 


SOURCE 






METHOD 




METHOD 




C CM. AWAY 








10 CM. AWAY 






AND ON AXIS 


3.180 


3.178 


3.724 


AND ON AXIS 


1.028 


1.028 


1.097 


2 cm. from axis 


2.914 


2.912 


3.298 


2 cm. from axis 


.985 


.983 


1.045 


A I t It It 


2.295 


2.276 


2.426 


4 tt tt 1 1 


.872 .870 


.910 


5 " " " 


1.960 


1.940 


2.008 


5 " " " .801 


.797 


.828 


g it 


1.639 


1.613 


1.644 


6 " " " .725 


.720 


.743 


g 1 1 1 1 1 1 


1.119 


1.099 


1.098 


8 " " " .576 


.571 


.582 


10 " " " 


.763 


.748 


.743 


10 " " " .446 


.442 


.446 


12 " " " 


.528 


.5] 8 


.514 


12 " " " .342 


.338 


.340 


24 tt it it 


.374 


.368 


.364 


14 " " " .262 


.258 


.259 


16 " " " 


.271 


.266 


.264 


16 " " " .201 


.199 


.198 


18 '< " " 


.199 


.198 


.195 


18 " " " .155 


.153 


.153 


20 ' ' " ' ' 


.150 


.148 


.146 


20 " " " .120 .119 


.118 



The advantage of a distributed source over a point source at the 
same distance from the point being treated is evidently not more than 
3 per cent, at any point, and really the point seems to be the better for 
this case as near the axis it gives a value higher by 15 per cent for 6 
cm. distance. The whole advantage of the distributed source lies in this 
latter fact, however, since this means that the point must be farther away 
in order that the intensity on the axis be such as not to burn the skin 
near by. In other words, for the same intensity on the axis, the intensity 
6, 8 or 10 cm. off the axis is 15 or 20 per cent greater for the greater 



132 



RADIUM THERAPY 



number of tubes. The field is more uniform, 
the advantage does not appear so great. 



For the 10 cm. distance, 



TABLE XXVI 

GAMMA RAT INTENSITIES DUE TO Two 6x6 CM. PLATES, EACH CONTAINING 200 MO. 
IN 12 TUBES AT A DISTANCE OF 6 CM. FROM THE COMMON PLANE 



DISTANCE TROM 




DISTANCE APART 




CENTER LINE 




OF PLATES 






CM. 


4 CM. 


8 CM. 


1 cm. 


5.209 


3.934 


2.758 


3 " 


4.819 


4.033 


3.058 


5 " 


4.033 


3.943 


3.442 


7 " 


3.058 


3.442 


3.554 


9 " 


2.167 


2.669 


3.185 


11 " 


1.493 


1.910 


2.494 


13 " 


1.034 


1.318 


1.789 


15 " 


.727 


.896 




17 " 


.524 








2 CM. 


6 CM. 


10 CM. 


cm. 


4.590 


3.278 


2.238 


2 " 


4.553 


3.414 


2.402 


4 " 


4.299 


3.677 


2.823 


6 " 


3.677 


3.708 


3.288 


8 " 


2.823 


3.288 


3.451 


10 " 


2.013 


2.566 


3.113 


12 " 


1.390 


1.838 


2.445 


14 " 


0.962 


1.269 




16 " 


0.678 







Hence, absorption in the apparatus being considered, a nearly uniform 
field will be obtained for the primary rays at a distance of 6 cm. from 
the skin surface when the radioactive plates are a little less than 4 cm. 
apart. 

TABLE XXVII 

GAMMA RAY INTENSITIES DUE TO Two 6x6 CM. PLATES EACH CONTAINING 200 MG. 
IN 12 TUBES AT A DISTANCE or 10 CM. FROM THE COMMON PLANE OF THE TUBES 



DISTANCE FKOM 
THE CENTER LINE 


DISTANCE APART 
OF PLATES 
CM. 4 CM. 8 CM. 


1 cm. 


1.857 


1.597 


1.301 


3 " 


1.753 


1.561 


1,315 


5 " 


1.561 


1.471 


1.323 


7 " 


1.315 


1.323 


1.286 


9 " 


1.063 


1.130 


1.186 


11 " 


.834 


.926 


1.027 


13 " 


.644 


.724 


.861 


15 " 


.493 


.561 




17 " 


.378 







DOSAGE 133 

TABLE XXVII CONTINUED. 

DISTANCE FROM DISTANCE APART 

THE CENTER LINE OP PLATES 

2 CM. 6 CM. 10 CM. 






cm. 


1.744 


1.450 


1.152 


2 


1 1 


1.710 


1.448 


1.168 


4 


t < 


1.604 


1.428 


1.210 


6 


< t 


1.428 


1.366 


1.243 


8 


1 1 


1.210 


1.243 


1.229 


10 


1 1 


.983 


1.073 


1.140 


12 


14 


.777 


.880 


.992 


14 


1 1 


.598 


.696 




16 


tt 


.458 







Hence, considering absorption in the apparatus, a nearly uniform field 
will be obtained for the primary rays at a distance of 10 cm. from the 
skin, when the radioactive plates are about 6 cm. apart. 

(b) Absorption in the Tissues. We may now discuss the effect of 
absorption in the tissues in decreasing the intensity of the radiations 
below the skin surface. In order to estimate the effect of absorption 
we may compare (1) the superficial dose, i.e., the intensity of the radia- 
tions at a given point on the surface of the skin and (2) the deep dose, 
i.e., the intensity of the radiations at a given point at different depths in 
the tissues. 

Let us assume that 500 mg. of radium element screened with 2 mm. of 
lead and contained in 25 point sources is arranged uniformly on a plate 
(plane surface) 10x10 cm. and is placed so that the radium is 6 cm. 
distant from the surface of the skin. Let us also assume an absorption co- 
efficient of .01 between the plate and the skin surface. The intensity 
at the surface of the skin on a line perpendicular to the center of the 
plate is then 7.19. 

Under the same conditions, assuming an absorption coefficient for the 
tissues of .05, the intensity at a distance of 6 cm. below the surface (12 
cm. from the plate) will be 1.65; 10 cm. below the surface (16 cm. from 
the plate) it will be .72; 12 cm. below the surface (18 cm. from the plate) 
it will be .57. 

Under identical conditions, but assuming that the radium is placed 
at a distance of 10 cm. from the skin, the superficial dose (i.e., the in- 
tensity at a point on the surface) will be 2.299 while the deep dose (i.e., 
the intensity at a point 10 cm. below the surface or 20 cm. from the 
plate) will be .50. 

From the above, it may be seen that, with the source 6 cm. from the 
surface, the ratio between the superficial and deep dose at a point 10 
cm. below the surface is about 1 to 10; with the source 10 cm. from the 
surface, 1 to 6. The ratio of the superficial doses in the two cases is 7 
to 3 ; the ratio of the deep doses about 7 to 5. From the standpoint of 



134 



RADIUM THERAPY 



Curves for eikct Jue 1o fwo6^6^m p/ofe>, 

Lath 2Q try in 12. tuh& 
Distance vi point horn common [Ion. 10 uv 
Disfoace opai Tot phtei mc/icafed torcmh 
curve 




( 7 8 7 /p // 

22. Graph illustrating Table XXVII. 



/.? 



IV 



equalizing the deep dose and the superficial dose, this comparison shows 
the advantage of placing the source at a considerable distance from the 
surface. Of course, the method of treatment from the greater distance 
has the disadvantage of requiring a larger quantity of radium or a 
longer exposure. It is evident that it is impossible also to put the source 
at a distance sufficiently great to make the superficial dose and the deep 
dose from primary gamma rays equal because of the absorption in the 
tissues. The decrease in intensity with distance from the source is also 
very marked. These difficulties may be minimized or overcome by using 
several portals of entry. 



DOSAGE 135 

Multiple Portals of Entry 

The intensity permissible at the surface, as we have already said, can- 
not l>e pushed down into the depths of the body unless more than one 
portal of entry be used. In order to deliver, with one portal of entry, 
an intensity beneath the surface approximating that at the surface, the 
rays should be made as nearly parallel as possible, i.e., the plate must 
be placed at a considerable distance from the skin. Under these cir- 
cumstances, the resulting intensity at every point in the tissues is rela- 
tively low; consequently either a large amount of radium or a treat- 
ment of long duration must be used. Moreover, the absorption in the 
tissue, though somewhat modified by the secondary effects, is bound to 
diminish the intensity below the surface to a certain extent. For strictly 
parallel rays, the diminution amounts to from %(> to ^o of the total 
intensity per centimeter; the same, or slightly more, for rays not strictly 
parallel, (divergent or convergent beams). For the latter type of rays, 
the diminution in intensity due to the inverse square law must be taken 
into account; and in addition, in any case, the augmentation due to 
secondary rays produced in the tissues must be considered. 

In order to determine the number of portals of entry necessary in a 
given case, one should know, if possible, the ratio between the suscepti- 
bilities of the parts that one does not wish to injure and of those that one 
wishes to destroy. It is then necessary to determine at what points the 
portals of entry can be placed; i.e., one must consider the contour of the 
skin surface as related to the position of the region to be treated. The 
only remaining requisite theoretically necessary for a complete determi- 
nation of the portals of entry is a knowledge of the intensity due to the 
radioactive source used at given distances, above or below the skin 
surface. 

For certain very special conditions, one can obtain the desired relations 
quite readily, but in the general case it is, of course, a very hard if not 
impossible task to find the best possible arrangement, although ordinarily 
one can get a usable solution and therefore one sufficient for the purpose. 

Let us take, for example, a very special case. Suppose a tumor situated 
at a point 10 cm. below the skin is to be radiated and that we wish to 
treat it with radium placed at a distance of 10 cm. above the surface. 
To make the problem as easy as possible, we may also assume the skin 
surface to be a circle, having a radius of 10 cm. about the point P, which 
is to be treated. (Fig. 23.) It is necessary to determine the ratio of the 
field at S on the surface of the skin, to that at P, when a certain quantity 
of radium is placed at A, 10 cm. from 8 on the line P 8 produced. If 
absorption be neglected and the radium be taken as a point source, the in- 
tensity at S is, from the inverse square law, - "Or^ - where M is the 

A S 100 



136 



RADIUM THERAPY 



number of millicuries of radium emanation used. 
M M 



The intensity at P is 



similarly 



i.e., just % of that at S. 



A P 2 400 ' 

Hence, at first sight, in order to make the intensity at P equal to that 
at 8, one would say that it is necessary to have four portals of entry, situ- 
ated at A, B, C, and D, the effects of which would all combine at P making 
the intensity at point P equal to that at point 8. We find, however, four 
portals are insufficient since B, C, and D contribute not alone to the effect 
at P but also to that at 8. Let us then try five portals. This number 
proves to be insufficient, and so on up to nine or more portals of entry. 



D 




B 



Fig. 23. Diagram illustrating multiple portals of entry. 

It should be theoretically possible, by sufficiently increasing the number 
of portals to obtain an intensity at P which would be greater in relation 
to that at 8 than the ratio of the carcinoma dose to the skin dose. Actually 
the number of portals can be made fewer by using portals outside one 
plane, and by suitable screening. 

Let us suppose that all radiations are screened off except, for each 
portal, a beam just sufficient to radiate the tissue to be destroyed (as- 
suming no sideways scattering). Then the four portals required by 



DOSAGE 137 

theory will be enough, provided they are placed so that the overlapping 
of beams occurs almost entirely in the diseased tissue, i.e., the portals 
should not be diametrically opposite as in Fig. 23. It is then possible 
to place the portals much nearer together. They must be sufficiently 
far apart, however, so that the four beams do not overlap nearer the 
portals than the tumor at P, or even that three beams do not overlap 
except in the immediate vicinity of the tumor. 

Let us now place an applicator containing 1000 inc., arranged on a 
plate (10 x 10 cm.) at a distance of 10 cm. from the skin. Let us assume 
that the maximum skin dose is obtained by applying it for eighteen 
hours, i.e., 18000 me. 10 cm. . hours (1000x18). Actual experiments 
have proved this latter assumption to he nearly correct. The maximum 
skin dose is thus found Tinder the conditions stated to be 180 me. cm. 

h U - 



Assuming the ratio of 1.15 of skin dose to carcinoma dose, as deter- 
mined by Kroenig and Friedrich to be correct, the carcinoma dose that 
it is necessary to deliver 10 cm. below the surface at a point which we 
will assume to be the site of the tumor, is 156 me. cm. hours. This dose 
can be delivered theoretically with four portals of entry, by giving at 
each portal a radiation that is slightly less than the maximum skin dose. 

The above result is easily calculated from the following considerations. 
According to the inverse square law, the intensity at a distance of 20 
cm. is Y 4 of that at 10 cm.; hence in order to make the intensity mul- 
tiplied by the time product at a distance of 20 cm. the same as that at 
10 cm., we must use four different sites of application. The sum of the 
effects at each portal on the skin will then be equal to the total effect 
on the tumor. 

The above calculation assumes that there is no absorption in the tis- 
sues. If we assume an absorption coefficient of .05, the effect due to each 
portal will be decreased in the deep dose by e'- r> ; hence, since the sur- 
face dose is unaffected, the number of portals of entry must be increased 
by e- 5 i.e., 4 e-~' or in other words, about 6 portals will be the number 
required. 

It is possible, however, that the effect of "scattering" the primary 
beams, i.e., the effect due to secondary radiations, nearly cancels the 
effect of absorption. 

Deep Dose Produced with X-Rays Compared with that Produced with 

Gamma Rays 

With x-rays, the problem of delivering the deep dose is even more 
difficult in some particulars than with gamma rays, because of the in- 
ferior penetrating power of the former. Hence, whatever can be ac- 
complished with x-rays can also be done with gamma rays providing the 
amount of radium necessary to produce the required intensities is avail- 



138 RADIUM THERAPY 

able. If intensities at the skin surface comparable with those producible 
with x-rays can be produced with gamma rays, the intensities in the 
depths of the tissues will be far greater when radium is the source of 
the radiations. 

It is the product of the coefficient of absorption and the intensity that 
really matters, however. Radium is equal or even superior to x-rays in 
the treatment of certain lesions involving the surface layers, because 
of the convenience of its applications and the closeness with which it 
may be brought to the points to be influenced. This nearness of applica- 
tion results in a more sharply bounded region being affected. There 
is also less penetration to points where radiation effects are not desired. 

X-rays possess an advantage over radium in the fact that a parallel 
beam is more easily obtainable with the former. 

TABLE XXVIII 

RELATIVE INTENSITIES AND EFFECTS DUE TO PARALLEL BEAMS OF X-RAYS AND GAMMA 

BAYS RESPECTIVELY 

It is assumed that the effects of the absorption of equal quantities of both agents are 

equal. 
Assume that the absorption coefficient for x-rays = 0.13; for gamma rays=0.033. 



DISTANCE 


X-RAYS 
INTENSITY 


EFFECT 


GAMMA 
INTENSITY 


RAYS 
EFFECT 





1 


.13 


1 


.033 


1 


.88 


.11 


.97 


.032 


2 


.77 


.10 


.93 


.031 


3 


.68 


.088 


.90 


.030 


4 


.59 


.077 


.87 


.029 


5 


.52 


.068 


.84 


.028 


6 


.46 


.060 


.82 


.027 


7 


.40 


.052 


.79 


.026 


8 


.35 


.0 (0 


.77 


.026 


9 


.31 


.040 


.74 


.025 


10 


.27 


.035 


.72 


.024 


11 


.24 


.031 


.70 


.02.1 


12 


.21 


.027 


.67 


.022 


13 


.18 


.024 


.65 


.022 


14 


J6 


.021 


.63 


.021 


15 


.14 


.018 


.61 


.020 


20 


.07 


.009 


.52 


.017 


25 


.04 


.005 


.44 


.015 



(1) Hence, for the same intensity at the surface, the intensity at any 
point below the surface is greater for gamma rays; the effect, however, 
is greater for x-rays down to 14 cm. depth. (2) For the same effect at 
the surface, however, the intensity and effects at any point below the 
surface are much greater for gamma rays than for x-rays. 

The first of the above statements merely has to do with the relative 
strengths of each source to be used. The second is of importance as re- 
gards the number of sources (i.e., of portals of entry) necessary, and the 



DOSAGE 139 

possibility of increasing the dose at points below the skin to a greater 
value than at the skin. 

It is the ratio of the deep dose to the surface dose that determines the 
number of portals of entry necessary. 

In order to make the dose at a depth of 10 cm., equal to that at the 
surface, at least four portals of entry are needed for the type of x-rays 
considered, while two are more than sufficient for the gamma rays. At 
a depth of 15 cm., eight portals of entry for x-rays, and still only two 
for gamma rays are necessary. Two portals will still suffice for gamma 
rays at a depth of 20 cm., while fifteen are needed for x-rays. 

It must be emphasized that the above comparison assumes that the 
beams from both types of sources are parallel. 

6. Secondary Radiations 

Let us now consider the effect of the secondary radiations in the 
tissues in augmenting the intensity of the radiations below the skin 
surface. 

It was formerly believed that the relative intensity of the rays in the 
depths of the tissues, as compared with the surface intensity, depended 
upon two main factors, viz., the diminution of the intensity with distance 
and the amount of absorption that the rays undergo in the apparatus 
and in the tissues. More recently it has been shown that in all mathe- 
matical calculations of the deep intensity, the secondary radiations re- 
sulting from the impingement of the primary radiations upon the tissues 
must be taken into account. Gudzent comes to the conclusion, in a con- 
sideration of this topic, that the simple absorption laws for radium rays 
as applied to ordinary matter cannot be applied to living tissue on ac- 
count of the impossibility of estimating the secondary radiations in the 
latter. This author states, "it is not correct, therefore, to compare the 
absorption of the rays in water with the absorption in the tissues. The 
amount of energy that is effective biologically is always greater than can 
be expected according to the simple laws of absorption. According 
to the calculations of Glocker, with the hardest x-rays that can be 
technically produced, the estimated or calculated dose may be increased 
by the secondary radiations in the tissues at a depth of 7 cm. by 43 per 
cent, and at a depth of 14 cm., by 77 per cent. With the more penetrating 
radium rays, the percentage will be still higher. In calculations that 
do not consider the secondary radiations, wrong conclusions will be 
reached. The deep dose, on account of the reasons just stated, cannot 
therefore, be estimated by mathematical calculations." 

Kroenig and Friedrich state, however, that the secondary radiations, 
produced by the impingement of primary x-rays on water approximate 
those produced in the tissues. Our own experiments described in Chap- 
ter VII lead us to believe that the secondary radiations in tissues may 
augment the effect of the primary gamma rays by as much as 70 per cent. 



140 RADIUM THERAPY 

If this be true, it lessens materially the diminution of intensity due to 
absorption. 

The Duration of the Exposure 

Surface exposures may last from a few minutes to twenty-four or more 
hours. The shortest exposures are given as a rule with unscreened radium. 
Under such circumstances, beta and gamma rays take effect. The longest 
exposures are given as a rule with heavily screened radium, the gamma 
rays only being effective. Examples of the length of therapeutic ex- 
posures are given in a subsequent section. 

The term "milligram hours" or "millicurie hours" was introduced by 
Dawson Turner to express the duration of the exposure. By these terms, 
we designate a number which is obtained by multiplying the number of 
mg. of radium element or of millicuries of emanation by the number of 
hours of exposure. We may neglect for the moment the decay of the 
emanation. Thus, 10 mg. or 10 inc. or emanation, employed for ten 
hours, would be expressed as "100 milligram" or "millicurie hours." 
These terms are not altogether satisfactory because of their relative in- 
accuracy and inadequacy. Thus the terms are without great significance, 
when expressing surface radiations, unless the other known factors that 
enter into the dose, i.e., the screening, the shape of the source and 
especially the distance are also stated. A marked variation of any one 
of this latter group of factors alters the significance of the number of 
milligram or millicurie hours of exposure. For example, at a distance of 
1 cm., 100 mg., concentrated at a point and applied for 10 hours will give 
'a very different effect from the same quantity concentrated on 100 sq. cm. 
and applied for the same length of time. The same number of mg. hours 
of exposure, i.e., 1000 may be said to have been given in both instances, 
however. 

Another element of inaccuracy consists in the fact that the quantity 
multiplied by the time is relatively accurate only within certain limits. 
Thus, at identical distances, 100 mg., contained in a minute capillary 
tube, applied for one hour, and one milligram contained in a similar 
tube and applied for 100 hours, will give different effects and yet the 
number of mg. hours of exposure i.e., 100 may be said to have been 
given in both cases. The biologic changes in the tissues during the 
longer exposure are probably responsible for the difference in the ob- 
served effect. 

This brings up the question of whether the biologic action is the same 
if one employs a large intensity for a short time or a smaller intensity 
for a longer time. According to Kroenig and Friedrich's experiments 
with x-rays, if the ratio of intensities employed is equal to 1 to 5 the 
degree of a biologic action for the same dose is independent of the in- 
tensity. For ratios greater than 1 to 5 the degree of the biologic action 
for the same calculated dose is greater for the greater intensity. Accord- 



DOSAGE 141 

ing to these authors, therefore, if we assume this statement to hold for 
radium, it may be roughly estimated that 20 mg. applied for ten hours 
would give approximately the same biologic effect as 100 mg. applied 
for two hours, provided the other conditions of the application are iden- 
tical. In both cases, 200 mg. hours would be the calculated dose. On the 
other hand, 20 mg. applied for ten hours would give a less intense effect 
than 200 mg. applied for one hour, although in both cases the dose may be 
stated to be 200 mg. hours. Practical experience has shown that the biolog- 
ical effect is not the same for large variations of the time and intensity. 
It should be possible, however, to determine more accurately the biologic 
effect of variations of these two factors by a sufficient number of experi- 
ments. "The physiological effect of the radiation must depend largely 
but not entirely upon the total ionization produced during the treat- 
ment per unit volume of tumor, which is substantially a measure of the 
energy absorbed. It is evident then that the intensity of radiation at the 
point we want to affect and the time of exposure are equally important. 
But we can produce the same total ionization by a small intensity of 
radiation and a long exposure or vice versa and the question is whether 
it makes any difference physiologically which method we use. 

"For small variations, it makes no appreciable difference if the time of 
exposure is increased in the same proportion that the intensity of radia- 
tion is decreased or vice versa. But if we increase the intensity 100 times 
and decrease the time 100 times we cannot expect to obtain the same 
result as before. Apparently then there is an optimum intensity of radia- 
tion coupled with a definite time of exposure but, unfortunately, the 
relation between the two varies with the nature of the tumor, etc., and 
cannot be determined except by experience." (Failla.) 

In spite of their limitations and relative inaccuracies we believe that 
the expressions "milligram" and "millicurie hours" serve a useful 
purpose and should not be discontinued. When these terms are used, 
however, the other factors already mentioned that are of importance in 
estimating the dose should also be stated. As the third factor of most 
importance is usually the distance of the source from the surface, I 
would suggest that in the use of the terms "milligram" and "millicurie 
hours," the distance in centimeters be stated. Thus, one may say, 100 
milligram-centimeter-hours or 100 milligram-10 centimeter-hours, the 
first expression meaning that at a distance of one centimeter and the 
second that at a distance of 10 cm., 100 mg. hours were given. 

Millicurie Hours 

While the number of "milligram hours" may be easily found by mul- 
tiplying the number of mg. used by the number of hours of exposure, 
the problem is not so simple when one wishes to compute the number 
of "millicurie hours," on account of the decay of the emanation, which 



142 RADIUM THERAPY 

loses approximately 16 per cent of its activity each twenty-four hours. 
It is of importance, therefore, to determine the amount of emanation 
with which it is necessary to start a given interval (treatment) in order to 
have a given mean value during that interval. This is shown in Table XXIX. 

TABLE XXIX 



TIME OF APPLICATION 
IN HOURS 


VALUE, I.K., NUMBER OP MILLICURIES 
NECESSARY TO START WITH IN ORDER 
TO HAVE MEAN VALUE OF 100 


1 


100.4 


2 


100.75 


3 


101.1 


4 


101.5 


5 


101.9 


6 


102.3 


7 


102.65 


8 


103.0 


9 


103.4 


10 


103.8 


11 


104.2 


12 


104.55 


13 


104.95 


14 


105.3 


15 


105.7 


16 


106.1 


17 


106.5 


18 


106.9 


19 


107.3 


20 


107.7 


21 


108.1 


22 


108.5 


23 


108.9 


24 


109.3 


30 


111.6 


36 


114.2 


42 


116.5 


48 


119.1 



In most cases it is sufficient to take the reciprocal of the value which 
the strength will take at the middle of the period of application. Thus 
for 48 hours to take 

100 100 

i.e., 



value present 24 hours later ' e - ; 

or, approximately, -= = 6/5 x 100 = 120 

O/D 

This holds more accurately for a shorter period, less accurately for a 
longer one. 

We may now give a few illustrations of dosage. 



DOSAGE 143 

1. Superficial Radiations 

Radium Salts in Plaques. For many skin diseases, % strength appli- 
cators may be used. It is convenient to have four applicators which may 
be laid side by side to form an area of 16 square centimeters. The total 
quantity of radium element in the four applicators is thus 20 mg. With 
this type of apparatus, a caustic dose may be easily and even inad- 
vertently given if no screen is used and the time of application unduly 
prolonged. For the most superficial effects, one may give an exposure, 
if the apparatus is unscreened except for the rubber dam in which it is 
wrapped, of from three to five minutes. Such exposxires should not be 
repeated more than.two or three times in the course of a week. 

Such treatments are adapted to superficial skin diseases. 

For skin disorders that are somewhat infiltrated and require deeper 
effects, the apparatus may be screened with 0.1 mm. of lead and an ex- 
posure of from one to four hours in several periods may be given. 

For the production of still deeper effects, the apparatus may be 
screened with a layer of lead 1 mm. thick and an exposure of six 
or more hours in several periods may be given. In all the above ex- 
posures, the apparatus may be applied in close contact with the skin. 
If the screening is 2 mm. of brass and the distance from the skin is in- 
creased to 1 cm., an exposure of forty-five hours in three periods may be 
given. 

Radium Salts or Emanation in Tubes. For superficial effects, 50 
mg. or me. may be concentrated on an area of from 4 to 6 square cm. 
The screening may consist of a layer of silver .5 mm. thick plus a layer of 
rubber 2 mm. thick. An exposure of from three to four hours may be 
given, when small areas such as from 4 to 6 square cm. are treated. 

For the production of somewhat deeper effects, the screening may be 
increased to 1 mm. of silver plus 1 cm. of rubber or wood. An exposure 
of twelve hours or more may be given when small areas such as 4 to 6 cm. 
are treated. 

2. Deep Radiations 

For deep effects, plaques or tubes containing radium salts or tubes 
of radium emanation may be used. For influencing deeply seated tumors, 
exposures lasting from ten to thirty or more hours in periods of ten or 
more hours each are suitable. 

The radium plaques or tubes may be arranged side by side on a plane 
surface having, e.g., an area of 100 square cm. 

The routine screening in these treatments is 2 mm. of brass or its 
equivalent of another metal. The radium is placed at a distance of from 
6 to 10 or more cm. from the skin surface. The use of not less than 
500 mg. or me. is necessary in most cases; in other cases not less than 
1000 mg. or me. should be employed. If 500 mg. or me. are used, a 



144 



RADIUM THKRAPY 



total exposure of 25 hours at a distance of 6 cm. may he given in two or 
more periods. At a distance of 10 cm., a total exposure of 36 hours may 
he given in two or more periods. With 1000 ing. or me. under the same 
conditions, 12% hours may he given at a distance of 6 cm. ; 18 hours 
at a distance of 10 cm. If emanation is used, duo allowance must he 
made for its decay. The exposures may ho given in two or more periods. 



INTRATUMORAL RADIATIONS 

In some cases, as has heen said before, the radioactive material may 
be inserted directly into the tumor tissue. Radium salts in 'metal needles 
may be used for this purpose or radium emanation contained in metal 
needles or glass ampoules may he employed. I usually prefer radium 
emanation in glass ampoules. 

At the present time, the exact dosage employed in metal needles is 
largely a matter of experience and judgment on the part of the oper- 
ator. Speaking very generally, 5 steel needles having a wall thickness 
of 0.4 mm. and each containing as much as 10 me. of emanation may he 

TABLE XXX 

SUGGESTING DOSES (.T ANEW AY) THAT MAY BE USED WHEN BARE EMANATION AMPOULES 

ARE INSERTED INTO TUMORS 

FOB CIRCULAR AND APPROXIMATELY OVAL TUMORS OP THE SAME LONG DIAMETER 



DIAMETER 


DEEP INKII.TK 


ATION 


SURFACE 


ABXA 


DOSAGE 


1 


cm. 










.7 


7 


sq. 


cm. 


5 me. 


V 


(4 cm. 










1.7 




* t 


1 1 


8 ' 


< 


2 


cm. 


3.14 " 


t i 


10 ' 


' 


2% cm. 


Not more 


than 


1% cm. 


4.8 




t t 


1 1 


15 ' 


( 


3 


cm. 


Between 


1 


and 


2 cm. 


6.5 




t I 


t 1 


17.5 


me. 


4 


cm. 


Between 


1 


and 


2 cm. 


12.5 




1 t 


" 


20 


" 


5 


cm. 


Between 


1 


and 


2% cm. 


19.3 




( t 


< ( 


22.5 


t I 


6 


cm. 


Between 


1 


and 


3 cm. 


28.2 


7 


It 


t i 


25 


t t 



FOR SPHERICAL TUMORS THERE IS LITTLE DIFFERENCE 



DIAMETER 


AREA OP PLANE 
OF DIAMETER 


NO. OF CUBIC 
CEN-TIMETERS 


DOSAGE 


1 cm. 


.77 


sq. cm. 


.52 c.c. 


5 me. 


1% cm. 


7.7 


1 1 ti 


1.70 " 


8 " 


2 cm. 


3.14 


it 1 1 


4.18 " 


10 " 


2% cm. 


7.8 


1 1 n 


8.19 " 


15 " 


3 cm. 


6.5 


n 1 1 


14.08 " 


20 " 


4 cm. 


12.5 


1 1 1 1 


33.44 " 


22 " 


5 cm. 


19.3 


it tt 


65.29 " 


25 " 


6 cm. 


28.27 


1 1 ft 


112.86 " 


30 " 


7 cm. 


38.48 


1 1 1 1 


251.52 " 


35 " 


8 cm. 


50.26 


it it 




40 " 



DOSAGE 145 

left in the tissues six -hours. In all eases needles should not be inserted 
nearer to each other than 1 to 2 cm. Prior to Bag'g's experiments, which 
have already been referred to, the dose used in the insertion of the glass 
emanation ampoules was larger than we now employ. This aiithor's 
experiments have shown the advisability of using relatively small doses. 

In dealing with smaller growths, it is sometimes advisable to increase 
the dose suggested by Bagg. We frequently employ in treating the 
smaller growths 5 me. of emanation per c.c. of tumor tissue. This amount 
of emanation may be contained in several ampoules. "When treating the 
larger growths, 0.5 inc. per c.c. of tissue may be sufficient, when the 
total amount of emanation equals from 25 to SO me. When the latter 
quantity of emanation is used, a larger amount of '.'cross firing" from 
the different tubes naturally takes place than when smaller quantities 
of emanation are employed. 

Methods of Decreasing and Increasing the Radiosensibility of Tissues. 
The question naturally arises whether it may be possible especially in 
deep therapy to make the skin more insensitive and the tumor more 
sensitive to the radiations. Schwarz has demonstrated that the radio- 
sensibility of the skin is dependent to some extent on its plethora. In 
order to create an anemia of the skin and thus render it less sensitive, 
this author used compression of the surface by thin wooden plates and 
showed that the skin was able to stand without injury doses of radium 
that otherwise injured it. H. E. Schmidt and others have confirmed this 
observation. Reicher and Lenz have suggested that a diluted adrenalin 
solution be injected into the skin hi order to render it anemic. Chris- 
toph Mueller-Immenstadt has used high frequency currents for the 
same purpose. He states that this procedure not only desensitizes the 
skin, but renders the underlying tumor more sensitive because of the 
coincident plethora produced in the tumor. This observation has not 
yet been confirmed. Several authors have endeavored to sensitize 
tumors by means of injections of different chemicals, such as eosin, etc. 
Werner injected lecithin and cholin into tumors for the same purpose. 
The injection of the various substances just named has not led, however, 
to any practical results. Gauss and Lemcke, Mueller-Immenstadt 
and others have suggested that by injecting into tumors substances of 
high atomic weight, such as electrocuprol, cuprose, etc., the formation 
of secondary rays in the tissues might be increased. Halberstaedter 
and Goldstuecker radiated trypanosomes which had been immersed in 
colloidal metal solutions and showed that they had become more sensitive 
to radiations than the controls which were immersed in salt solution. 

It is hoped that future researches may widen the scope of these ex- 
periments. Up to the present time, however, the attempts at desensitizing 
the skin and sensitizing the tumor have not proved of any utility in 
actual practice. 



CHAPTER XIV 

THE TECHNIC OF RADIATION 

It is manifestly impossible to give a complete description of all of 
the methods of applying the apparatus for the various objects of radia- 
tion. We may, therefore, limit ourselves mainly to a discussion of the 
different principles involved. 

It is important that the operator shoiild have the requisite knowledge 
of the amount of radium in the apparatus, the quantity and quality of 
the rays passing through the screens, and the effect on the skin at the 
given distance. 

There must also be a clear understanding of the object of the radiation. 
The kind of tissue that is to be treated or destroyed together with its 
situation and extent must be known as far as possible. 



(a) SURFACE RADIATIONS 
1. Superficial Radiations 

The lesion to be treated, if superficial and on the skin, may be gently 
cleansed if necessary and the rubber, wood, gauze or other material of 




Fig. 24. This photograph shows the method of handling radium. A radium tube is being inserted 

into a screen. 

the thickness required in order to keep the radium at the proper dis- 
tance may then be applied and held in place by adhesive tape or a 
bandage. 

The radium plaques or tubes, singly or in combination, may then be 
laid upon the material covering the lesion and held in position in the 
same way. 

Protection from the discharges from a moist lesion is always assured 
for the apparatus by wrapping it in a finger cot or dental rubber dam. 

146 



TIIK TKCHNIC OF RADIATION 



147 



In the treatment of a lesion of the mucous membranes, the tubes may 
be attached to a wire or other carrier, covered with the desired thickness 
of rubber or gauze and then, after being encased in a finger cot, applied 
directly to the lesion. In order to protect the normal tissues adjacent to 
a lesion on the skin, one may use a sheet of lead 2 to 4 mm. thick in 
which an aperture is cut to fit the lesion. This lead absorbs 8 to 15 
per cent of the gamma rays and while it does not, of course, protect 
the normal tissue completely, it affords a relative amount of protection 
that is ordinarily sufficient. It must be remembered that if the radium 




Fig. 25. Forceps 30 cm. long for handling radium tubes. 

tube is held at a distance of several millimeters from the lesion by the 
lead protector, this distance must be taken into consideration in estimat- 
ing the dosage. In accordance 'with the law of inverse squares, the in- 
tensity of the rays from a single tube diminishes very rapidly as the 
distance of the tube from the lesion increases. 

For the relative protection of the eyeball in epithelioma of the eyelid, 
wo use a specially constructed gold screen, made after the model of 
an artificial eye. It is always desirable if possible to protect hairy 
regions, such as the eyebrow, from the action of the rays. 

For applications to the different natural cavities of the body, various 
methods may be used to suit the requirements of the case. 



Fig. 26. Three pronged forceps 30 cm. long for handling radium tubes. 

In the vagina or uterus, gauze packing suffices as well as anything for 
holding the tubes in position. Heavily screened tubes placed against 
the cervix will not ordinarily injure the healthy adjacent vaginal mucous 
membrane if sufficient packing is used to separate the walls of the vagina to 
the fullest extent. "Distance" in addition to the screens on the radium 
protects the healthy tissue sufficiently. 

In the nose, mouth, esophagus, rectum and bladder, the tubes may be 
attached to a pliable silver wire which can be bent to the required angle 
and fastened to the adjacent skin. In addition to the wire it is always 
advisable to have the radium tube anchored by a long silk thread which is 



148 



RADIUM THERAPY 





THE TKCHXIC OF RADIATION 



149 



also fastened to the neighboring skin by adhesive tape. This procedure 
is a precautionary measure in case the wire should break. 

For the protection of the rectal wall opposite to a circumscribed car- 
cinoma of the organ, we insert a finger cot which may be distended with 
air by a catheter. In this case, also, distance protects the healthy, bal- 
looned out, mucosa. 

For some years, especially in mouth cases, we have made use of the 
dental modeling compound suggested by Janeway. This material can be 
fashioned to suit the outline of any growth that is accessible and the 
tubes may be laid in little troughs in the compound. By this device, 



Fig. 28. Screen holders. These instruments are of two different sizes and enable the 
technician to grasp the cylindrical screens containing the emanation tubes. One end of a screen 
is shown inserted into the holder. A similar holder (not shown in the photograph) grasps the 
other end of the screen. The technician may thus screw the two parts of the screen together, 
without allowing the fingers to come in contact with the radium tubes. 

the tubes may be held in position without much discomfort to the pa- 
tient for the required length of time. 

The amount of radium to be used in superficial treatments naturally 
varies with the purpose of the radiation. 

For example, if a tumor is very small and superficially situated on 
the skin, a plaque of radium containing as small a quantity as 10 mg. 
may sometimes be used. The beta rays from such a plaque may be uti- 
lized by employing little or no screening. The plaque may be placed in 
direct contact with the lesion or at a distance of a few millimeters from it. 



Fig. 29. Same apparatus as in Fig. 28 but of smaller size. . 

When dealing with larger superficial growths on the skin 200 or more 
milligrams may be required. The radium may be contained in plaques 
or tubes that are screened with 1 mm. of silver or its equivalent and may 
be separated from the lesion by 1 cm. of rubber or wood. 

For epithelioma of the mucous membranes, it is seldom Avise to use 
less than 200 milligrams of radium element or me. of emanation. 

In using the technic suggested above, more or less local inflammatory 
and even destructive action may be produced by the radium, although 
certain lesions may retrogress without macroscopic evidences of in- 
flammation. 

The biologic effect of the radiation naturally depends on the technical 



150 



RADIUM THERAPY 



conditions of the application, i.e., the quantity of radium, the shape of 
the applicator, the screening, the distance and the duration of the ex- 
posure. 

The frequency of repetition of superficial treatments depends, of 
course, on the dose employed. Exposures may be given daily or on 
alternate days or twice weekly, etc., depending on all the circumstances. 










Fig. 30. Flat silver screens with caps, devised for holding from 2 to 6 enamel emanation 
tubes. These screens are 2 cm. long, 4 to 16 mm. wide (outside dimensions), and vary in wall 
thickness from 0.5 mm. to 1.5 mm. 

2. Deep Radiations 

In postmortem examinations of cancer of the cervix which had been 
treated by placing radium in or against the cervix, Bumm found that 
cancer cells were destroyed up to a distance of 2% to 3 cm. from the 
radium tube. At a distance of 4 cm., vigorous carcinomatous cells in 
groups as large as peas or cherries were found in the parametrium. Be- 
yond 5 cm., cancerous lymph glands were found that were not 
affected. As a result of these observations, Bumm's dictum that radium 
has an effective area of influence of not more than from 2 to 3 cm., was 
widely accepted. 

According to the earlier observations of Wickham and Degrais, radium 
rays may penetrate effectively to a depth of at least 9 cm. 

Kroenig has recently stated that it is possible to radiate successfully 
a carcinoma of the cervix uteri through the abdominal wall, i.e., the 



THE TECHNIC OF RADIATION 



151 



rays penetrate effectively to a depth of at least 10 cm. Kelly and Burn- 
ham and many others have successfully radiated mediastinal and ab- 
dominal tumors. In such cases it may be estimated that the rays pene- 
trate to a depth of at least 10 cm. 

Kroenig and Gauss have stated that the rays from 500 mg. of radium 
element that is distributed on a plate apparatus placed at a distance of 
6 cm. from the skin may penetrate effectively to a depth of from 14 to 
16 cm. It is evident that Bumin's dictum, that radium rays will not pene- 
trate effectively into the tissues to a distance of more than from 2 to 3 cm., 
must be given up. Under certain conditions, such as existed in Bumin's 
cases, his conclusions were undoubtedly correct. For example, in the 
treatment of cancer of the cervix uteri, even though the quantity of 
radium be very large and the duration of the treatment prolonged, the 



Fig. 31. Tandem gold screens for holding one or more enamel emanation tubes. These 
screens have a universal thread so that a radioactive rod of any desired length may be made. The 
proximal end of the apparatus is attached to a long flexible silver wire. Length of each screen 2 
cm., outside diameter 4 mm., wall thickness 0.8 mm. 



Fig. 32. Platinum screen for containing a glass emanation tube. A long silver wire is 
screwed into the end of the screen so as to facilitate its introduction into small cavities. Length 
of platinum screen 2 cm., outside diameter 2 mm., wall thickness 0.5 mm. 



Fig. 33. Screen for inserting radium tubes into the esophagus. The bulb on the distal end 
may carry a silk thread for guiding the instrument. A "screw-nut" slides on the wire so that 
the distance from the applicator to the patient's teeth may be easily maintained. 

effective raying of distant cancerous masses by means of a tube placed 
within the cervix may be practically impossible. Long before cancer cells 
situated near the walls of the bony pelvis, (i.e., about 6 cm. distant from 
the tube) would be seriously affected, an enormous overdose would be 
given and a dangerously destructive action might be produced on the 
tissues adjacent to the tube. 

On the other hand, if a quantity of radium sufficient to give an ade- 
quate intensity is properly distributed on a plane surface of sufficient 
size and is placed at a sufficient distance from the lesion, the depth to 
which the rays will effectively penetrate without untoward effects may 
be enormously increased. There is abundant evidence that indicates, 
as has been shown in the previous chapter, that by this method of pro- 



152 



RADIUM THERAPY 



cedure it is possible to radiate any part of the body with an intensity 
of rays powerful enough to destroy malignant cells, however deeply 
situated. By using different portals of entry, almost any part of the 
body may be brought, for purposes of radiation, within a distance of from 
10 to 14 cm. from the surface of the skin. The limitations of radium 
therapy, therefore, are not 'those imposed by the inability of the rays 
to penetrate with an adequate intensity to a sufficient depth, but rather 
by the fact that serious injury to normal structures may be caused by 
the delivery of too large a dose of deep rays. It must be especially 




- 



Fig. 34. Radium pad composed of "squares" of soft wood. The interinr uf die package is 
stuffed with cotton. Dimensions of pad IQxlO'xlO cm. Fifteen screens containing radium emana- 
tion tubes are held in position on the pad by adhesive plaster. This type of apparatus is used for 
deep gamma radiation of large tumors. 

emphasized that, for adequate deep effects, a considerable quantity of 
radioactive material must be used preferably not less than from 500 to 
1000 or more milligrams of radium element or millicuries of emanation. 
In some cases, 2000 nig. or me. are desirable. While the relatively slight 
intensity from smaller quantities, such as :500 milligrams, can be to some 
extent compensated for by prolonging the exposure, practical experience 
has shown that in most cases the best effects are obtainable only by using 
the larger quantities for a shorter time. 



THK TKCHNIC OF RADIATION 



153 



For the treatment of deeply seated tumors or other pathologic tissues, 
when the overlying skin or mucous membrane is to be preserved, pads or 
packages of various sizes are used in order to give the desired distance. 
These pads are made up in advance to suit the individual case by using 
a number of small square blocks, made of soft wood, balsa wood, cork 
or hard rubber. A suitable size for these blocks is 2x2x1 cm. The 
blocks may be fastened together by adhesive tape to form various sized 




IMR. 35. The upper photograph shows the needle holder devised by Dr. O. T. Freer. A metal 
needle containing a glass emanation tube is shown in the end of the holder. After insertion into 
the tumor tissue, the needle may he withdrawn when the required exposure has heen given. The 
lower photograph shows the instrument devised by Dr. Freer to facilitate the withdrawal of metal 
needles from tumor tissue. The silk ligature attached to the needle may he engaged in the groove 
on the end of the instrument. Traction on the needle may then be easily nuide without damage to 
the tissues. 

packages. On account of the joints formed by the tape, even the larger 
pads have a certain degree of flexibility. On these packages or pads the 
tubes are placed in parallel rows or in accordance with any desired ar- 
rangement. The tubes may be held in place by strips of adhesive tape. 




Fig. 36. Author's instrument, constructed on the plan of an ordinary syringe, for burying 
emanation ampoules. The obturator, sliding in the lumen of the needle, enables one to eject the 
ampoule intu tin- tumor tissue. 

The size of these large packages varies in accordance with the lesion 
to be treated. We frequently use packages having the dimensions of 
6x6x6 cm. or 10x10x10 cm. (See Fig. 34.) In order to reduce the 
weight of the larger wooden packages and to minimize the amount of gamma 
ray absorption in the applicator, we fill the center of each package with 
cotton, the small wooden blocks forming merely the outside or shell of the 
package. In applying the packages carrying the radium, the so-called "cross 



154 



RADIUM THEHAl'Y 



fire" method suggested by Wickham should be utilized to the utmost. 
In accordance with this principle, subcutaneous tumors are attacked 
from as many different angles or sides as possible, in order to deliver 
the greatest possible volume of rays to the deeper parts of the growth 
and at the same time spare the overlying skin. -The periphery of a tumor 
is always attacked first. As we have pointed out in the previous chapter, 




Fig. 37. Heavy cast-iron movable shield for the protection of the operator. 

in order to produce a uniform field of radiation at the skin surface, the 
radium packages in which the radium is 6 cm. from the skin should be 
4 cm. apart; if the radium is 10 cm. from the skin the packages should 
be 6 cm. apart. Otherwise some sort of a shield should be used in order 
not to give an overdose to a single skin area. 

If large and deeply seated tumors, such as may occur in the neck, 



THE TECHNIC OF RADIATION 155 

breast, abdomen, pelvis, etc., are present, there should be used for the 
radiations not less than 500 to 2000 or more milligrams or millicuries. 
The radium should be placed at a considerable distance, e.g., ten or more 
centimeters from the skin. The tubes or plaques may be evenly arranged 
according to the desired method of distribution on one side of the Avooden 
package just described. The opposite side of the package is placed on 
the skin. All of the requirements of proper distribution of the radium, 
its distance from the skin, etc., may thus be fulfilled. In addition, every 
area of skin from which the tumor can be attacked should be homo- 
geneously radiated as we have just described. 

F>y this method of procedure, a deep gamma ray effect is produced, 
but there is little or no local inflammation of tissue next to the applicator, 
if the duration of the exposure is correct. 

Employing 1000 mg. distributed over an area of 100 sq. cm. and placed 
at a distance of 10 cm. from the surface, the safe limit of skin toleration 
is about 18 hours. If 2000 mg. are used, 9 hours may be given. This 
exposure may be divided into two or more periods. . An interval of several 
days should elapse between each period. 

It must be emphasized that the above dosage cannot be repeated with 
impunity because of the deep effects on normal tissue. A second course 
of treatment, given six weeks later, should not consist of over 5000 me. 
or mg. hours. These doses were suggested by Janeway and Failla and 
they accord in a general way witli my own practice. 

In using adhesive plaster to bind the radium packages to the skin, 
it must be remembered that the epidermis that has been rayed heavily 
is unusually sensitive. Superficial excoriations may easily occur and 
may become a source of great annoyance to the patient. Great care should 
be employed therefore in applying and removing sticking plaster in 
such areas. 

(b) "INTRATUMORAL" RADIATION 

(1) The insertion of radium salts or radium emanation in metal 
needles into the tissues. 

In the use of metal needles the following precautions should be ob- 
served: (1) An aseptic technic is necessary inasmuch as screened radium 
does not have a marked antiseptic effect. (2) Several needles of moderate 
strength should, if possible, be used, rather than one strong needle, in 
order that an even distribution of the rays may be produced in the entire 
growth. (3) It is important that a certain quantity of healthy tissue 
should surround the growth in order that repair may be accomplished. 
(4) The quantity of radium embedded in a growth depends upon the size 
of the tumor and the thickness of the needle wall and to some extent upon 
the situation of the growth. Encapsulated organs, such as the tonsil and 



156 RADIUM THERAPY 

the prostate, are especially suitable for needling. The needles should 
not be inserted into normal tissue. 

(2) The insertion of bare glass ampoules containing radium emanation 
into the tissues. 

The method of treating tumors by the insertion of bare glass emanation 
tubes or ampoules is one of considerable promise. Indeed it is not too 
much to say that this method has almost revolutionized the treatment of 
certain localized tumors. The method appears to have been suggested 
first by Duane. It has been employed extensively by Janeway and his 
coworkers at the Memorial Hospital in New York, by Kelly and his as- 
sociates in Baltimore, by the writer and many others. 

The glass emanation ampoules that are used are ordinarily about tln-ee 
millimeters long and 0.3 mm. in diameter. They may be inserted into the 
tumor in proper cases and allowed to remain in situ. Over !)() per cent 
of the activity is lost in two weeks and they decay practically to zero 
in about forty days. Each tube during the entire time of decay gives a 
dose that may be expressed in millicurie hours by multiplying 132, i.e., 
5% days, by the number of millicuries originally in the tube. AVe assume 
in the foregoing calculation that the tube has not been broken during 
the insertion and that it remains in the tissues until its complete or 
nearly complete decay. It is advisable to combine in some cases the 
insertion of the emanation ampoules with powerful surface gamma ray 
radiations. 

In the introduction of the ampoules, the following technic suggested 
by Failla may be used: The glass emanation ampoules may be boiled 
and inserted into the sharp end of a sterile needle which admits a plunger 
at the other end. It is convenient to have at hand a number of needles, 
each of which is loaded in this manner. After insertion into the tumor 
tissue, the needle should be withdrawn a few millimeters just before 
the plunger ejects the ampoule so that the danger of breaking the am- 
poule by forcing it against the tissue is obviated. One may also withdraw 
the needle simultaneously with the pushing in of the plunger. The 
ampoule thus rests in the minute cavity formed by the sharp end of the 
needle. I have devised a small instrument, which has been previously 
mentioned, for the insertion of the ampoules. (Fig. 36.) 

While theoretically some slight danger of inducing metastasis or trans- 
planting tumor cells may be incurred by this method, I am of the 
opinion that this danger is negligible if the technic is correct. 

The following suggestions may be observed in the insertion of tire- 
ampoules: Aseptic precautions must be used; each ampoule should not 
contain more than three millicuries of emanation; the ampoules should 
be inserted about one cm. apart; care should be taken not to implant 
them near large vessels, nerve trunks, bones or thin-walled viscera; if 



THE TECHNIC OP RADIATION 157 

possible to avoid it, the ampoules should not be inserted into healthy 
tissues. 

A zone of necrosis forms around each ampoule a week or more after its 
insertion. Healing occurs in from four to eight weeks and in favorable 
cases a smooth cicatrix is left. 

The quantity or dose of radium emanation to be used in intratnmoral 
radiation is considered in the Chapter on Dosage. 

It must be especially emphasized that the effects of radiation re- 
sulting from the introduction of radioactive substances into tumors are 
strictly localized. The method is evidently not suited for the treatment 
of large, deeply situated lesions. Such lesions must usually be attacked 
by the method of deep gamma ray radiation that has already been de- 
scribed. 

In some cases, the two methods, intratnmoral radiation and deep 
gamma radiation, may be advantageously combined. 



CHAPTER XV 

RADIUM IN GENERAL SURGERY 
A. MALIGNANT TUMORS 

Carcinomata exhibit different degrees of radiosensibility. Adler has 
tried to determine whether this difference in sensibility depends on the 
histologic structure of the tumor. According to this author's investiga- 
tions, rapidly growing carcinomata of the primary glandular type are 
almost refractory to radium while with the sclerotic types developing 
more slowly excellent results are frequently obtained. Bumm and 
Schaefer on the other hand have found that the so-called medullary car- 
cinomata, in which the supporting stroma is scanty, are more easily 
influenced by radium than the sclerotic types. According to these 
authors no carcinoma has been observed that can resist radium. Kroenig 
and Friedrich also state they have found that every carcinoma can 
be influenced by radium if it is applied in the correct technical manner. 
They point out, however, that a difference in effect is to be observed in 
noncachectic and cachectic individuals. The former class of patients 
usually responds well, while in the latter class, heavy radiations may be 
ineffective or even dangerous. On this account these authors would 
exclude markedly cachectic individuals from treatment by radiations. 
In this view they are supported by Gudzent. Klein has shown that in 
the tissues surrounding carcinoma there is a so-called battle zone con- 
sisting histologically of advancing carcinoma cells opposed by leuco- 
cytes and connective tissue cells. In cachectic individuals, this zone is 
scarcely to be found, although the carcinoma may be advancing rapidly. 

From the clinical point of view, practically all observers agree that 
carcinoma in individuals who are in a relatively robust condition is much 
more susceptible to radiations than carcinoma occurring in the cachectic. 
We have seldom seen even good temporary results in those who exhibit 
considerable cachexia. 

Summing up the different views, we may conclude, in spite of some 
opinions to the contrary, that all accessible carcinoma is probably more 
susceptible to proper doses of radiation than most normal tissues. There 
is little doubt, however, that earcinojnata of different and even of the same 
pathologic types exhibit considerable variation in their response to ra- 
dium. Whether this depends altogether upon some difference in the 
radiosensibility of the tumor cells, it is impossible at present to decide. 
The writer believes that the radiosusceptibility of the growth is the 
most important factor. Other factors, however, in all probability are 
also at work in determining the response of the tumor to radiations. 

158 



RADIUM IN GENERAL SURGERY 159 

(a) Operable Malignant Tumors 

Janeway has raised the question of the advisability of treating pri- 
marily with radium certain eases of cancer of the mucous membranes 
even though they may be operable. Gudzent states that it is justifiable 
to treat with radium selected cases of operable carcinoma provided the 
necessary surgical experience and an adequate knowledge of the technic 
of the application of radium can be combined. In cancer of the cervix 
uteri, even though it is operable, Bumm, Doederlein and Kroenig have 
abandoned operation in favor of radium therapy. Nearly all radium 
therapeutists are in accord, however, that with the exception of certain 
selected cases of epithelioma of the skin, and mucous membranes, oper- 
able growths should be operated upon. 

We have already mentioned that a certain type of malignant tumor in 
mice frequently cannot be successfully transplanted after radium treat- 
ment. The most rational procedure, therefore, even in dealing with 
clearly operable malignant disease is first to treat the growth and the 
lymphatics draining the involved area with radium. Immediately after- 
ward, operative removal of the tumor should be carried out. A few 
weeks later, postoperative prophylactic radiations should be given. 



(b) Inoperable Malignant Tumors 

In inoperable cases of malignant disease, treatment with radium has 
been followed in numerous cases by a clinical recovery that has some- 
times been maintained for a number of years. Radium, therefore, gives 
promise at least of a certain amount of relief even in those cases in which 
surgical procedures are inadvisable. It is of the utmost importance to 
bear in mind, however, that the inoperable cases submitted to radium 
fall into two categories: (1) Those in which it seems best to make a 
strong effort to bring about a clinical recovery. (2) Those in which only 
palliative treatment is advisable. Failure to recognize the latter class 
of cases will result in disappointment and even may cause great harm. 
Indeed, it is better to omit treatment altogether rather than to attempt 
the impossible and cause additional suffering from radium effects. 

The whole principle of the disappearance of carcinoma or other malig- 
nant growths under the influence of radium rays is based on the fact that 
the tumor cells are more susceptible to the rays than the normal tissues. 
According to many different authors, certain types of carcinoma cells are 
four to seven times as sensitive as most normal cells. According to 
Friedrich and Krocnig's experiments with x-rays, the radiosensitiveness 
of breast carcinoma to the middle epidermal cellular layer is in the 
ratio of 170 to 150, i.e., 1.15 to 1. In other words, a dose of x-rays 
that will not destroy the epidermis will cause the resolution of breast 
carcinoma. Certain cases of squamous cell carcinoma are probably only 



160 RADIUM THERAPY 

slightly more radiosensitive than the middle epidermal layer. Radia- 
tion that falls short of destroying normal tissues will often cause necrosis 
and disappearance of the tumor itself. One strives, therefore, to produce 
with radium a change in the growth that will not at the same time be 
accompanied by serious injury to the healthy tissue. This is best accom- 
plished by giving maximum doses at the outset. Subsequent doses 
should always be of less intensity. 

Some authors believe that a single intensive dose is best in dealing 
with malignant growths. This procedure seems to me, however, to be 
practical in only a few cases and sometimes is not without danger to the 
patient. Ordinarily, several intensive doses at suitable intervals are in 
my opinion to be preferred. 

In many inoperable cases that come under radium treatment, metas- 
tasis lias already taken place. In such cases, palliation is all that ca7i 
ordinarily be hoped for, although the primary growth can occasionally 
be healed by radium. 

We may now refer to the radium treatment of malignant disease oc- 
curring in different situations in the body. 

THE TREATMENT OF CARCINOMATA 

For convenience of description we may group together carcinomata 
affecting the different organs. 

1. Epithelioma of the Skin 

The problem of treatment of epithelioma of the skin depends to a 
great extent upon the type of growth that is present. 

(a) Squamous-cell Epithelioma 

If the case is considered operable by the surgeon and the adjacent 
glands are palpable, the draining lymphatic glands and gnnvth may be 
excised "en bloc." If the glands are not palpable, operation may be 
limited to the growth and radiation given to the glands. There is little 
doubt, however, that even in distinctly operable cases, preoperative 
radium treatment will be of advantage. At the time of operation, emana- 
tion ampoules may be buried in the operation field. After operation, 
prophylactic radiations should also be given. Over dosage should be 
guarded against. With an early diagnosis, recovery should be brought 
about in at least 95 per cent of the cases. 

Inoperable cases of squamous-cell epithelioma may frequently be re- 
tarded in their progress for considerable periods of time and in some 
instances a clinical recovery may be brought about. The diagnosis of 
squamous-cell from basal-cell epithelioma is frequently impossible with- 
out a microscopic section and as it is often inadvisable to obtain this a 



RADIUM IN. GENKRAt:;SUR^E:RY 161 

few of the clinical points of difference may be indicated. (1) Its loca- 
tion. Epitheliomas of the lower lip, tongue, penis and extremities are 
usually of the squamous-cell type. One-half of the epitheliomas of the 
upper lip are also of this type. (2) A papillomatous aspect to the growth 
is indicative usually of squamous-cell cancer. (3) Rapidly growing epi- 
theliomata with metastases to the adjacent lymphatic glands are prac- 
tically always of the squamous-cell type. 

It must be emphasized, however, that there is no absolute rule holding 
in all cases that allows of a 'complete clinical differentiation. 

The technic of the radium treatment of squamous-cell epithelioma of 
the glabrous skin when it is for any reason inoperable naturally varies 
with the clinical type. 

For very small and superficial growths "one quarter" or "one half 
strength" glazed plaques may be used. Screened with 0.1 mm. of lead 
and applied in direct contact with the skin, a total exposure of six or 
more hours may be given in several periods of one to two hours each. 

In dealing with larger, deeply infiltrated and ulcerated growths, it is 
best to use only gamma rays. In some cases two hundred millicuries, 
screened with two millimeters of brass and arranged so that it is con- 
centrated in the proportion of 5 millicuries per square centimeter 
may be applied at a distance of 3 centimeters for thirty hours in periods 
of ten or more hours each. In six weeks, if there are evidences of the 
disease persisting, a similar course but of less intensity should be given 
provided signs of radium reaction are absent. Great care should be 
taken to avoid "burns" which may be very painful and prevent further 
treatment at a critical time. Some advise vigorous treatment with un- 
screened applicators for certain refractory types and even in ordinary 
eases. This procedure, however, causes considerable inflammatory re- 
action and if unsuccessful precludes for a time further treatment in most 
cases on account of the pain. We prefer, therefore, the former method 
in ordinary cases but in some cases we resort to the unscreened glazed 
applicators. In some cases bare emanation ampoules may be buried in 
the growth. For the prophylactic treatment of the adjacent lymphatic 
glands powerfid deep radiations are advisable. Four hundred millicuries 
(5 me. per square cm., 2 mm. screen, 6 cm. distance) may be applied for 
a total of thirty hours. 

(b) Basal-cell Epitheliomata 

In the treatment of basal-cell epitheliomata, radium, in our judgment is 
the most satisfactory agent we possess and sometimes succeeds when 
everything else fails. In spite of some statements to the contrary, we be- 
lieve that this type of epithelioma is one of the most amenable of all 
types of new growth to radium. Failure may, of course, occur in very 
extensive cases in which the loss of tissue is very great and repair is 



162 



RADIUM THERAPY 




Fig. 38. Epithclioma of right cheek. 



RADIUM IN GENERAL SURGERY 



163 




Fig. 39. Patient in Fig. 38 after radium treatment. 



164 



RADIUM THERAPY 




Fig. 40. Epithelioma of right side of nose. 



RADIUM IN; GENERAL SURGERY 



165 




Fig. 41. Patient .in Fig. 40 after radium treatment. 



166 



RADIUM THERAPY 




Fig. 42. Epithelioma of tip of nose. 



RADIUM IN GENERAL SUKGERV 



167 




Fig. 43. Patient in Fig. 42 after radium treatment. 



168 



' RADIUM : THERAPY 




Fig. 44. Epithelioma of left lower eyelid. 



RADIUM IN GENERAL SURGERY 



169 




Fig, 45. Patient in Fig. 44 after radium treatment. 



170 



KADHJM THKRAl'Y 




Fig. 46. Epithelioma of right inner canthus, eyelids and nose. 



RADIUM IN GENERAL SURGERY 



171 




Fig. 47. Patient in Fig. 46 after radium treatment. 



172 



KAD1UM THEKAI'Y 




Fig. 48. Epithelioma of left inner canthus, eyelids, nose, cheek and upper lip. 



RADIUM IN GENERAL, : SURGERY 



173 




Fig. 49. I'aticnt in Fig. 48 after radium treatment. 



174 



RADIUM THERAPY 




Fig. 50. Epithelioma of the right temple 



RADIUM IN GENKRAL SURGERY 



175 





31. Patient in Fig. 50, after radium treatment. 



176 



RADIUM THERAPY 




Fig. 52. Epithelioma of the left temple. 



RADIUM IN GENERAL SURGERY 



177 




Fig. 53. Patient in Fig. 52 after radium treatment. 



378 



RADIUM THERAPY 




Fig. 54. Kpithelioma of left malar region. Patient referred by Dr. Joseph Scheurich. 



RADIUM IN GENERAL SURGERY 



179 




Fig. 55. Patient in Fig. 54 after radium treatment. 



180 



RADIUM THERAPY 




Fig. 56. Epithelioma of forehead. 



RADIUM IN GENERAL SURGERY 



181 




Fig. 57. Patient in Fig- 56 after radium treatment. 



182 



KADIUM THERAPY 




Fig. 58. Epithelioma of right ear. 



RADIUM IN GENERAL SURGERY 



183 




Fig. 59. Patient in Fig. 58 after radium treatment. 



184 



RADIUM THERAPY 




Fig. 60. Epithelioma situated below right ear and involving ear lobe. 



RADIUM IN GENERAL SURGERY 



185 




Fig. 61. Patient in Fig. GO after radium treatment. 



186 



RADIUM THERAPY 




Fig. 62. Epithelioma of nose, left eyelid, cheek, and upper lip. 



RADIUM IN GENERAL SURGERY 



187 




Fig. 63. Patient in Fig. 62 after radium treatment. 



188 RADH'M TI1KKAPY 

almost impossible. In a few cases, there seems to be a laek of vital 
power in the cells to respond to treatment. Cases that have had various 
other kinds of treatment, such as. exposures to x-rays, extending over 
long periods, frequently do badly. The method of application in the 
basal-cell type of epithelioma is similar to that used for squamous-cell 
cancer. Treatment of less intensity is usually sufficient, however. 

When dealing with very small and superficial growths, one may use a 
quarter-strength applicator screened with VJ,, mm. of lead and in close 
contact with the skin for six or eight hours in several periods of one or 
two hours each. In treating larger, deep-lying growths, we follow the 
plan previously indicated for the more grave type of sqmnnous-cell epi- 
theliomata but shorter exposures are adequate, as a rule, to bring about 
resolution and healing. In certain cases, the use of b;irc emanation am- 
poules which jn-e inserted into the edges of the epithelioma is advisable. 

In the treatment of epithelioma supervening on sear tissue due to pre- 
vious exposure to x-rays, very cautious and light treatment should be 
given. Not over one-half the amount indicated above as suitable for 
ordinary cases should be used, ;is experience has shown that the previ- 
ously treated tissue breaks down very easily and the ulceration caused 
may heal with the greatest difficulty. The scar following radium treat- 
ment, even in extensive cases, is usually smooth and supple and very 
inconspicuous. Contractures seem never to occur, a point of the great- 
est importance in treating lesions about the eyelids. When ectropion has 
resulted from previous operations, it may sometimes be lessened by ra- 
dium treatment. I have treated with radium over one thousand cases 
of basal-cell epithelioma of various clinical types and failure to bring 
about recovery has been uncommon. 

(2) Epithelioma of the Nasal Mucosa 

Epithelioma in this situation :nay be treated by carrying the radium 
tubes attached to a long silver wire through the anterior nares into the 
nasal passage. The same technic may be employed for sarcoma and 
lymphosarcoma of the cavity of the nose and nasopharynx. One hundred 
millicuries contained in two tubes, arranged end to end, screened with 
one millimeter of silver and one or two millimeters of rubber may be 
used in periods of one to three hours each for a total exposure of 6 hours. 
In certain cases, bare emanation ampoules may be successfully buried 
in the epithelioma. 

(3) Epithelioma of the Lip 

Epithelioma of the lower lip comprises about one-half of the cases of 
epithelioma. It begins most frequently at the junction of the mucous 
membrane and the skin. It may begin, however, either on the cutaneous 
or mucous surface of the lip. It is usually of the squamous-celled type. 



RADIUM IN GENERAL SURGERY 189 

Speaking very generally if the lesion is less than a centimeter in diameter 
and is not deeply infiltrated, radium may be used alone with expectation 
of success in selected cases. Larger lesions should be treated by pre- 
operative radiation and excision. Postoperative radiation is always 
advisable. 

In the application of radium to the growth, the usual technic consists 
in the use of not less than 200 to 300 me. This may be screened with 
1 mm. of silver plus 2 mm. of rubber. One should radiate an area extend- 
ing several centimeters beyond the visible disease. Certain tumors should 
be attacked from the superior, the internal and the external aspect of 
the lip. Six hundred me. hours may be given to an area of 4 square 
centimeters. This technic produces sharp reaction. 

If the adjacent lymphatic glands are not palpably enlarged, they may 
be left undisturbed by the surgeon but should receive heavy prophylactic 
gamma-ray radiation. If the adjacent glands are palpably enlarged, 
conservative surgical removal may be undertaken in selected cases. The 
operation may be pi-eceded and followed by surface radiation. In some 
cases bare emanation ampoules may be buried in the operative field fol- 
lowing removal of the lymphatic structures or in the glandular masses 
in case they are not removed but merely surgically exposed. 

(4) Carcinoma of the Lingual, Buccal and Pharyngeal Mucous 

Membranes 

While epithelioma of these structures is frequently refractory to ra- 
dium, very good and even brilliant results may sometimes be obtained. 
The most notable advance in the treatment of cancer in these situations 
consists in the use of bare emanation ampoules which are inserted into 
the tumor in the manner previously described and allowed to decay in 
xilii. When surface applications are made, we would advise the use of 
not less than 200 millicuries. The radium should be screened with 1 milli- 
meter of silver and 2 millimeters of rubber. An exposure of five hours in 
divided doses may be given. For holding the radium in position we fre- 
quently utilize the dental composition material suggested by Janeway. 

At the present time, in suitable cases, we invariably bury bare emana- 
tion ampoules in growths of the accessible mucous membranes. 

Leukoplakia 

It must be remembered that patches of leukoplakia may disappear 
spontaneously if tobacco is discontinued. 

The radium treatment of leukoplakia, which is such a frequent pre- 
i-iirsor of epithelioma of the lingual, buccal and pharyngeal mucous mem- 
branes, is often successful. A caustic dose must often be employed in 
order to bring about the desired result, but at times deeper and less 
caustic radiations may be given. A method that we have frequently 



100 



RADIUM THERAPY 




Fig. 64. Epithelioma of lower lip. 



RADIUM IN GENERAL SURGERY 



191 




Fig. 65. Patient in Fig. 64 after radium treatment. 



192 



RADIUM THERAPY 




Fig. 66. Epithelioma of upper lip. 



RADIUM IN GENERAL SURGERY 



193 




Fig. 67. Patient in Fig. 66 after radium treatment. The insertion of false teeth gives the mouth a 

distorted appearance. 



194 



If \Dir.\l THKKAI'Y 




Fig. 68. Epithelioma supervening on leukoplakia of right cheek. 



RADIUM IN GENERAL SURGERY 



195 




Fig. 69. Patient in Fig. 68 after radium treatment. 



196 



RADIUM THERAPY 




Fig. 70. Carcinoma of the tongue in patient aged 65 years. Patient referred by Dr. 

Photograph taken July 7, 1921. 



P. Berg. 



RADIUM IN GENERAL SURGERY 



197 




Fjg. 71. Patient in previous figure after insertion of 19 millicuries of radium emanation con- 
tained in 15 bare glass ampoules. Photograph taken July 15, 1921. Six months later patient 
;i].prartd clinically well. 



198 RADIUM THERAPY 

used consists in the application of 80 millicnries concentrated in the 
ratio of 10 millicuries per square centimeter. This may be screened with 
1 millimeter of silver and 2 millimeters of rubber. A total exposure of 
eight hours in periods of one or two hours each may bo given. 

We may now refer particularly to carcinoma of the tongue and car- 
cinoma of the tonsil. 

(a) Carcinoma of the Tongue 

Cancer of this structure is always of the squamous-ccll type. It is the 
most likely of all cancers to invade the lymphatic glands early and 
widely. This in itself precludes successful treatment in many cases. In 
the most extensive cases, palliation only can be hoped for. Sometimes 
cases seem to yield quite satisfactorily to the insertion of radium, con- 
tained in metal needles, into the growth. I have reported a case treated 
in 1917 in this manner, who is well at the time of writing. In this case, 
60 milligrams were inserted into the growth for thirteen and one-half 
hours, and seven weeks later 72 milligrams for twelve hours. Hay ward 
Pinch has buried approximately 21 to 53 millicuries, contained in a plat- 
inum needle, in certain nodules for twenty-four hours. Sharp reaction 
follows this treatment and in some cases the nodule becomes replaced 
with scar tissue. The method of using bare emanation ampoules has 
practically replaced the use of metal needles. In some cases, surface 
applications may be advantageously combined with the method of 
burying bare glass emanation ampoules. The greatest care must be used 
not to give an overdose and produce sloughing. It must not be forgotten 
also that healing can only occur when a bed of healthy tissue capable 
of producing good granulations surrounds the growth. The regional 
lymph nodes may be treated in the manner already described. 

(b) Carcinoma of the Tonsil 

Cancer in this situation frequently yields to radium and sometimes 
displays a marked susceptibility. If metastases from a tonsillar growth 
are present in the neck these growths are also more than ordinarily sen- 
sitive to the rays. If the growth has extended to the tongue, the prog- 
nosis becomes the same as for cancer of that organ. 

We have successfully treated numerous cases of cancer of the tonsil. 
While formerly metal needles containing the radium were inserted in the 
growth, these have practically been given up in favor of the bare glass am- 
poules containing radium emanation. Radium may be applied to 
the surface of the tonsil by means of a wire holding a specially con- 
structed piece of dental modelling compound adjusted to the area to be 
treated. Two hundred millicuries screened with the equivalent of 2 
millimeters of brass and 2 millimeters of rubber may be applied for three 
hours in periods of one hour each. The intensity of the treatment to be 



RADIUM IN GENERAL SURGERY 199 

given naturally depends upon the extent of the disease. If the growth 
projects several millimeters above the level of the normal mucous mem- 
brane, larger doses will be tolerated as the tumor tissue acts as a filter 
and in addition, the distance of the radium from the normal tissue is 
obviously increased. Instead of surface applications, several bare emana- 
tion ampoules may be buried in the growth. Five-tenths to 1 me. or more of 
emanation to each cubic centimeter of tissue may be used. In suitable 
cases, the combination of these two methods seems to be superior to 
either method used alone. Overdosage must be carefully avoided. 

(5) Carcinoma of the Superior Maxilla 

Many cases respond favorably to radium treatment. The disease most 
often begins at the alveolar process of the jaw. Carious teeth are usually 
found in these cases and the disease may apparently have started around 
one of them. The antrum is usually invaded early by the growth. Metas- 
tasis occurs relatively late in the disease. In the application of radium, 
the antrum, if involved, should be opened, usually above the alveolar 
process. Indeed in any case it is not wise to allow the antrum cavity to 
remain closed. By means of long silver wires carrying the tubes, the 
radium may be brought into direct contact with the growth. In addition, 
heavy treatment may bo given externally over the cheek and within the 
cavity of the mouth so as to radiate the growth from all sides. In the 
technic of treatment, much depends upon the situation and extent of the 
disease. Within the cavity of the antrum, 200 millicuries screened with 
2 mm. of brass and 2 mm. of rubber may be applied for five hours. In 
the mouth, 200 me. with the same screening may be used for five hours. 
Externally, 250 me., screened with 2 mm. of brass and arranged on a pad 
covering 50 sq. cm., may be used for thirty-six hours at a distance of 
three centimeters in several periods of six to twelve hours each. G. B. 
New of the Mayo Clinic has used a combination of heat and radium in 
cancer of the jaw and cheeks. In cancer involving the antrum a solder- 
ing iron at a dull heat is carried into the antrum cavity and the growth 
is burned away. About two weeks later, when the slough has come away, 
radium is introduced into the antrum cavity. 

(6) Carcinoma of the Inferior Maxilla and Floor of the Mouth 

Cancer of the lower jaw usually begins on the alveolar process. Sooner 
or later, the floor of the mouth is "involved and indeed it is frequently 
impossible to determine in just what structure the growth originated. 
In some cases, the floor of the mouth is the primary seat of the disease. 
As a rule, metastatic involvement of the lymphatic glands of the neck 
occurs early. On this account 'cancer of the floor of the mouth is much 
more malignant than cancer of the superior maxilla or cancer of the 



200 



RADIUM THERAPY 




Fig. 72. Carcinoma of right superior maxilla involving antrum. I'hotograph taken January, 1915. 



HAD1UM IN GENERAL SURGERY 



201 




Fig. 73. Patient in Fig. 72 after radium treatment. Photograph taken April, 1915. 



202 RADIUM THERAPY 

huccal mucous membrane. When metastases to the neck are absent, 
radium treatment frequently produces a Clinical retrogression and even 
complete healing of the growth. If the lymphatic glands of the neck 
are involved, retardation of the disease is all that can ordinarily be hoped 
for, although the primary growth may disappear under treatnicnl. Two 
hundred millicuries screened with 1 millimeter of silver and 2 millimeters 
of rubber may be applied to the surface. A total exposure of four or 
more hours may lie given. Instead of surface applications, several bare 
ampoules may then be buried in the lesion ; 0.5 me. to 1 me. per cubic 
centimeter of tumor tissue may be used. The different areas of the 
neck likely to harbor metastases may receive prophylactic exposures. 
Five hundred millicuries screened with two millimeters of brass or its 
equivalent and concentrated on an applicator that has a superficial 
surface of 50 square centimeters may be used at a distance of 6 cen- 
timeters. A total exposure of twenty-five hours may be given in periods 
of ten or more hours each. If metastases are present, retardation of the 
growth may be brought about by the ordinary treatment for carcinoma- 
tons glands. 

(7) Carcinoma of Cervical Glands; Carcinoma of Thyroid Gland; 

Parotid Tumors 

For clinical convenience, carcinoma of the lymphatic glands of the 
neck, carcinoma of the thyroid gland, and tumors of the parotid gland 
may be considered together. 

(a) Carcinoma of the Cervical Lymphatic Glands 

These cases are usually secondary to carcinoma elsewhere. The pri- 
mary focus is most frequently in the labial, buccal, phafyngeal, lingual 
or laryngeal mucous membrane. The supraclavicular glands are fre- 
quently involved in mammary cancer. The primary focus from which 
carcinoma of the lymph nodes originates may even escape detection 
altogether. In most of the mouth cases, the neighboring lymphatic 
glands sooner or later become involved although this event may be de- 
layed for a considerable time. The treatment may be carried out by sur- 
face applications, by burying metal needles containing radium or radium 
emanation, or by burying bare emanation ampoules. Sometimes a com- 
bination of these methods is most desirable. Isolated and movable glands 
may be removed surgically prior to radium treatment. Following opera- 
tion, bare ampoules of radium emanation may be inserted in the operative 
field. If surface applications are used, 500 millicuries may be applied at a 
distance of 6 centimeters. Concentrated in the ratio of 5 to 10 millicuries 
per square centimeter and screened with the equivalent of 2 millimeters 
of brass, an exposure of twenty-five hours in several periods of ten or 
more hours each may be given. If metal needles are inserted, 5 to 75 



RADIUM IN GENERAL SURGERY 203 

millicuries in steel needles that have a wall thickness of 0.4 mm. may 
be buried for twelve or eight hours. If bare emanation ampoules are 
buried in inoperable masses, a dose of 0.5 to 1 me. or more per cubic centi- 
meter of tumor tissue may be given. Considerable judgment must be exer- 
eised in treating carcinomatous lymph glands. It must be remembered that 
the usual effect is retardation of the growth and that curative results can 
seldom be hoped for. Individual masses of glands that have some de- 
gree of mobility and are not too large may sometimes be removed by 
radium. Masses of glands that are fixed, poorly nourished and of large 
extent can seldom be successfully treated. Doses powerful enough to 
cause death of the cancer cells may produce under these conditions 
sloughing of large areas of normal tissue, which may add to the patient's 
discomfort and hasten his end. 

Douglas Quick has recently described the procedure used at the present 
time at the Memorial Hospital, New York, in dealing with cervical lymph 
nodes associated with intraoral cancer. 

In cases with no palpable nodes, surface radiations over the neck are 
employed, but excision of the lymphatic structures is not undertaken. 

In cases with palpable and operable nodes, surface radiations are fol- 
lowed by a neck dissection, preferably under local anesthesia. Following 
removal of the lymphatic structures, 5 to 15 me. of radium emanation in 
bare glass ampoules are embedded in the operative field. Following 
this procedure, surface radiations may be used on the opposite side of 
the neck. Too much radiation over the affected side may devitalize the 
tissues. If it is found that the disease, at the time of operation, has 
perforated the gland capsule, radical surgical removal is deemed unwise 
and the mass is infiltrated with bare emanation ampoules, the wound 
being then closed. The statistics of this author are encouraging. 

(b) Carcinoma of the Thyroid Gland 

Some cases of this disease are strikingly benefited. The technic of 
treatment should be wholly by external or surface radiations. Burying 
emanation needles in these tumors may result in an intractable fungating 
growth. Powerful deep radiations must be used. Six hundred milli- 
curies screened with the equivalent of 2 millimeters of brass and in the 
ratio of 5 to 10 millicuries per square centimeter may be applied at a 
distance of 6 centimeters. A total exposure of twenty hours in periods 
of ten or more hours each may be given. Metastasis to the bones or other 
organs may take place several years .after apparent recovery. 

(c) Parotid Tumors 

In carcinoma, endothelioma, and certain mixed parotid tumors, en- 
couraging results have been obtained. In tumors containing cartilage 
not so much effect is to be anticipated. The technic may consist of the 



204 RADIUM THERAPY 

application of 250 millicuries at a distance of 3 centimeters. Concen- 
trated in the ratio of 2.5 millicuries per square centimeter and screened 
with the equivalent of 2 millimeters of brass, a total exposure of thirty 
hours divided into periods of ten or fifteen hours each may he given. As 
in all other tumors, the teehnic varies with the apparent depth of the 
growth and the area that it covers. 

It is not advisable to introduce radium or emanation needles into the 
parotid gland. Hayward Pinch has called attention to the ill effects that 
are likely to follow this procedure. A severe reaction following the 
introduction of an emanation needle may result in the formation of a 
sinus which is kept open by the parotid secretion and from which an 
intractable ulceration may start. 

(8) Carcinoma of the Larynx 

In carcinoma of the upper larynx, or so-called extrinsic carcinoma, the 
results have been encouraging. In selected cases, one of the most effec- 
tive methods of radium application consists in the introduction of steel 
radium needles, each containing twelve milligrams of element or milli- 
curies of emanation directly into the growth. The needle introducer 
devised by Dr. 0. T. Freer is valuable for this procedure. The needles 
may be left in the tissues for from eight to twelve hours. In one case of 
carcinoma of the epiglottis, base of the tongue and left vallecula, treated 
by the writer in conjunction with Dr. Freer, complete recovery occurred. 
In this instance there has been no local recurrence for over four years, 
but a recurrence in the glands of the neck two years ago yielded to ra- 
dium. The patient is now clinically well. This case has been previoiisly 
reported by the writer. 

In intrinsic carcinoma of the larynx, radiation from the outside or 
inside of the larynx may be employed. Kelly and Burnam have referred 
to several cases treated by external radiations that have recovered and 
remained well for varying periods. Ordinarily, however, the combination 
of internal and external treatment is necessary for success. It is doubt- 
ful whether external radiations alone are sufficient to cause complete 
regression. G. B. New of the Mayo Clinic has treated intrinsic carcinoma 
of the larynx in the following manner: "Tracheotomy is first performed 
and after cocainization the radium is dropped directly into the larynx. 
The radium is held in place for from one to one and one-half hours at a 
time. While all patients are not benefited, very encouraging results 
and remarkable relief have been obtained. One man had an extensive 
carcinoma of the larynx obstructing the glottis so that it was necessary 
to do a tracheotomy; he was swallowing fluids only. In two months 
time he had gained forty-eight pounds in weight and could eat anything. 
He had a cork in the tracheotomy tube. The growth did not recur 



RADIUM IN GENERAL SURGERY 205 

locally but the patient died of chest metastases about fourteen months 
later. However, the treatment gave him a year of comfort." 

A method that promises to be even more effective than the one just 
described because it allows of accurate localization, consists in the appli- 
cation of the radium to the interior of the larynx by means of the special 
apparatus devised by Dr. 0. T. Freer. This apparatus is described in 
the chapter devoted to a consideration of the use of radium in laryn- 
gology. Screened with 1 millimeter of silver, 200 millicuries contained 
in 4 or 5 tubes may be used, in periods of twenty or more minutes each 
for two hours. During intralaryngeal treatments the throat must be kept 
free of saliva by an electric suction pump. 

(9) Carcinoma of the Esophagus 

In this all but hopeless disease the results of radium treatment in_a 
number of cases have been encouraging. Among those who have reported 
their results, some of which have been favorable, are Abbe, Exner, 
Einhorn, Finzi, Hayward Pinch, Janeway, Mills and Kimbrough and 
the writer. Abbe reported a case alive and well nine years after 
treatment. Mills and Kimbrough have seen favorable results. In the 
cases reported by the two last-named authors, the coincident use of the 
x-r;iys enabled them to localize more accurately the position of the 
bougie carrying the radium in the esophagus. In one case, Finzi ob- 
tained a clinical recovery that had been maintained for three years when 
the case was reported. In another case a clinical recovery was main- 
tained for four years when the patient died suddenly. Postmortem 
there was found carcinomatous involvement of a small intercostal branch 
of the aorta with resulting hemorrhage. 

In one of the writer's cases, treated in conjunction with Dr. John 
A. Cavanaugh, apparent recovery was maintained for about one year 
when the patient died suddenly of cerebral hemorrhage. 

Technic of Treatment of Carcinoma of Esophagus. Previous to under- 
taking treatment, careful localization of the growth is all important. 
Skiagraphs with and without a bismuth meal, direct esophagoscopy and 
measurements with bougies usually afford sufficient information. It is 
necessary that the lumen of the growth admit a bougie several milli- 
meters in diameter in order that the properly screened radium may pass 
completely within the stricture. In some cases, several days prior to the 
treatment, a silk thread may be swallowed by the patient. The bougie 
holding the radium may then be threaded upon the silk thread. This 
procedure will sometimes enable one in difficult cases to engage the 
apparatus in the lumen of the growth. The treatment may consist of the 
application of 100 to 150 me., screened with 1.5 mm. of silver. The bou- 
gie containing the radium emanation is passed into the strictured part 
of the esophagus and maintained in position for about eight hours. Prior 



206 RADIUM THERAPY 

to the treatment morphine and atropine may be given hypodermically. 
A special attendant should maintain the bougie in place. Several treat- 
ments may be given at intervals of 3 or 4 days until the patient has 
received about 1500 me. hours. 

Another technic adapted to certain cases and suggested by Janeway 
consists in the following procedure. A preliminary gastrostomy is per- 
formed. A silk thread is subsequently swallowed by the patient and the 
lower end is pulled out through the gastrostomy wound. A series of 
several radium tubes is Ihen attached to the oral end of the string and 
pulled through the stenosed tract by means of the lower end. The upper 
tube is of such size that it will not slip through the strictured part of the 
esophagus but will rest upon the upper end of the carcinoma. Janeway 
has used several tubes, containing 30 or 35 me. each, for from four to six 
hours. 

The immediate results of treatment are an improvement in swallowing 
due perhaps to the mechanical dilatation. About ten days later there 
may be increased dysphagia due to the onset of reaction. The hemor- 
rhage, odor and purulent discharge that may attend the passage and 
withdrawal of a bougie prior to treatment are no longer present. In 
a few weeks, as the reaction from the radium subsides, dysphagia is 
relieved and the patient may be able to swallow all kinds of food for a 
number of months. Greatly increased body weight and improvement in 
the general condition are usual accompaniments of the increased power 
of swallowing. 

(10) Carcinoma of the Stomach and Intestines 

In inoperable or recurrent- carcinoma of the stomach and intestines it 
is permissible to use radium in the hope of retarding the disease and 
relieving pain. Janeway has seen improvement follow a combination of 
posterior gastroenterostomy and radium treatment. After the above 
operation was performed, several radium tubes were pulled into place 
through the gastrostomy wound by means of a string previously swal- 
lowed. We have used a similar method for carcinoma of the sigmoid 
flexure of the colon. Inguinal colostomy was first performed. By means 
of a string passed through the distal portion of the bowel from the open- 
ing in the colon to the anus a string of tubes was pulled backward 
through the anus until they engaged within the lumen of the affected 
portion. 

Technic of Treatment of Carcinoma of Stomach and Intestine. Pal- 
liation is all that can be hoped for in these conditions. Symptomatic 
improvement has been noted following powerful, deep treatment to the 
abdominal wall. The condition demands the use of at least 500 me. This 
should be screened with 2 mm. of brass and placed at a distance of 6 to 
10 cm. The concentration may be in the ratio of 5 me. per square centi- 



RADIUM IN GENERAL SURGERY 207 

meter. At a distance of 6 cm. an exposure of twenty-five hours and at a 
distance of 10 cm. an exposure of thirty-six hours may be given in periods 
of ten or more hours each. 

(11) Carcinoma of the Rectum 

Considerable experience has been accumulated in the radium treatment 
of this disease. Rectal carcinoma varies a good deal in its response to 
radium. Adenocarcinoma of the annular, vascular type, situated in the 
upper half of the rectum, is probably more amenable than growths occu- 
pying only a portion of the rectal lumen and deeply infiltrating the rectal 
wall. Epidermoid carcinoma in close proximity to the anal region is less 
easily influenced than the other types. A number of cases of complete 
regression of the growth and apparent clinical cure persisting for vary- 
ing periods of time have been reported by different authors. The per- 
centage of clinical recoveries is not over 10 per cent. It must be remem- 
bered, however, that as a rule only cases in which surgical intervention is 
impossible are treated. Fully one-third of the cases are distinctly im- 
proved. In borderline cases, radium treatment may render operation 
possible. 

Technic of Treatment of Carcinoma of the Rectum. The method of 
treatment and the dosage vary. Applications to the surface of the car- 
cinoma may be made by introducing the tubes attached to a long silver 
wire into the rectum. In other cases, bare emanation ampoules may be 
buried in the growth. These methods may also be combined. 

Carcinoma involving a segment of the rectal wall is best adapted to 
the use of buried emanation ampoules. Carcinoma of the annular type 
may be treated by surface applications alone. In either condition, how- 
ever, the combined methods may be used. 

If tubes are inserted into the rectum they may ordinarily be applied 
by means of a long pliable silver wire which is bent over the buttock to 
the proper angle and secured with adhesive tape. In the case of an 
annular growth, the tubes must be carried into the lumen of the growth. 
In using tubes in the treatment of growths occupying only a portion of 
the lumen of the bowel, a lead plate several millimeters thick may be 
used over the tubes on the side opposite the growth in order to protect 
relatively the normal mucosa. In other cases, the normal rectal wall 
may be packed off by means of a rubber finger cot, to which a catheter 
is attached. The cot is distended with air after its insertion. In some 
cases, the application of the radium is made best by the aid of the proc- 
toscope. The quantity of radium employed varies with different operat- 
ors. Hayward Pinch has used 50 me. screened with 2 mm. of lead and 
2 mm. of rubber. An exposure of thirty hours in periods of six hours 
each has been given. The course of treatment was repeated in six weeks 
if thought necessary. With the above dosage, proctitis will be slight or 



208 RADIUM THERAPY 

absent. I favor, ordinarily, the use of a much larger quantity of radium. 
Many cases may be treated with 200 me. screened with 2 mm. of brass 
and 2 mm. of rubber for eight hours. The method of using even a larger 
quantity of radium for a relatively shorter time is preferable in many 
cases. If bare emanation ampoules are buried in the growth, the dose of 
0.5 to 1 or more me. of emanation per cubic centimeter of tumor tissue is ad- 
visable. When radium treatment for carcinoma of the rectum is contem- 
plated, a preliminary inguinal colostomy is advisable in many cases, 
although it is not always absolutely essential. 

(12) Carcinoma, of the Penis, Vulva and Urethra 

Carcinoma of the glans penis sometimes responds favorably to radium. 
Certain cases may be very refractory. We have treated 3 cases in which 
clinical recovery has occurred. In these cases, amputation of the penis 
had been previously refused. 

Technic of Treatment of Carcinoma of Penis, Vulva and Urethra. I 
have used in these cases either surface applications of radium or the in- 
sertion of bare emanation ampoules. Two hundred me. screened with 2 
mm. of brass may be applied at a distance of 1 cm. The concentration 
may be in the ratio of 10 me. per sq. cm. An exposure of four or five 
hours may be given. Great care should be taken not to produce severe 
reactions which may be extremely painful in this situation. If radium 
emanation in glass ampoules is inserted, the technic previously described 
may be employed. 

Cancer of the vulva may be treated by burying bare emanation am- 
poules or by surface applications. These two methods may also be com- 
bined. Unfortunately metastasis to the inguinal glands is usually an 
early complication of epithelioma of the vulva. The ultimate outcome is 
usually unfavorable although the local growth may be healed. 

Cancer of the female tirethra may be treated by the application of 
radium tubes to different parts of the growth or by burying bare emana- 
tion tubes in its substance. The tumor may be attacked from within the 
urethra or from the external aspect. The growth may also be reached 
by radiations from tubes placed along the anterior vaginal wall. Care 
must be taken not to overexpose the urethral mucous membrane. As it 
is impossible as a rule to introduce into the urethra a tube covered with 
sufficient rubber tubing to give an adequate distance of the radium from 
the growth, a burn of the urethral mucous membrane may be easily 
caused without producing marked retrogression of the growth. One 
hundred me. contained in two tubes arranged end to end, screened with 
0.5 mm. of platinum and 2 mm. of rubber may be introduced into the 
urethra for five hours in several periods of one or two hours each. The 
external aspect of the growth may be treated in a manner similar to 
that suggested for epithelioma of the skin. The labia should be widely 



RADIUM IN GENERAL SURGERY 



209 



separated with gauze during the treatments in order to avoid a burn 
of these structures. Through the anterior vaginal wall, the growth 
may be radiated with 200 me. The concentration of the emanation may 
be 10 me. per square centimeter and the screening 2 mm. of brass. 
The distance should be not less than 1 cm. An exposure of fifteen 
hours may be given divided into several periods. The radium may be 
held in the vagina by means of a long silver wire which may be bent 
to the required angle and fastened with adhesive tape to the anterior 
abdominal wall. In some cases bare radium emanation tubes may be 
buried in the growth. The dose of 0.5 to 1 me. per cubic centimeter of 
tumor tissue may be used. The different methods of treatment just de- 
scribed may often be advantageously combined. 

(13) Carcinoma of the Prostate Gland 

Benefit is frequently to be noted from radium treatment of this con- 
dition. 




Fig. 74. AdenoepttheKoraa of the prostate. 

The Technic of Treatment of Carcinoma of the Prostate. Formerly the 
radium contained in a hollow sound having a wall thickness of 1.5 mm. was 
introduced into the urethra and allowed to remain in contact with the 



210 



RADirM THERAPY 



growth. At the same time, another tube was introduced into the rectum in 
order to "cross fire" the carcinoma. While encouraging results have been 
obtained with this method, no plan seems to be so uniformly successful as 
that suggested by Barringer. The essence of this method consists in 
strong central radiation of the prostatic mass. 

This author uses 50 me. of radium emanation, contained in the distal 
1% inches of the lumen of a special gold or steel needle, four to six inches 
long. Sufficient screening is obtained by the thin wall of the needle. 
Under local anesthesia, the needle is introduced through the perineum 
and allowed to remain six hours in each prostatic lobe. If necessary, the 




Kig. 75. Same lesimi as in Fig. 74 after radium treatment. Young connective tissue, with newly 

formed vessels. 

needle, guided by a finger in the rectum, can be pushed into the seminal 
vesicles. In thirty cases treated by Barringer, marked retrogression of 
the growth followed in every case. 

Good results have been obtained by a similar method that I have out- 
lined. This consists in the use of eight or more steel needles each con- 
taining about twelve milligrams of radium element or millicuries of 
radium emanation. These are introduced into the prostate either through 
a perineal or supnipubic incision in such a manner as to radiate homogene- 



RADIUM IN GENERAL SURGERY 211 

rnisly the entire prostate. One of the writer's cases in which great im- 
provement followed has been reported by R. H. Herbst. The needle in- 
troducer illustrated in this report was devised by Dr. 0. T. Freer. In 
carcinoma of the prostate, the general method of needling is the one that 
promises to be of most value. The method of attack should be adapted 
to the situation of the growth. Hence, either the suprapubic or the 
perineal route or both routes may be chosen. The insertion of bare em- 
anation ampoules gives promise of good results. 

(14) Carcinoma of the Bladder 

Operable Cases. In dealing with operable cases of carcinoma of the 
bladder, postoperative radiation is advisable. 

Inoperable Cases. Inoperable carcinoma of the bladder may some- 
times be treated successfully with radium. Prior to the use of radium, 
fulguration is sometimes advisable in order to check the bleeding. The 
permanent cessation of hemorrhage and the disappearance of cystitis 
and all subjective symptoms may sometimes be observed as a result of 
radium treatment. Growths of considerable size may retrogress and 
ulcerated areas may become covered with healthy epithelium as shown 
by cystoscopy. 

Technic of Treatment of Carcinoma of the Bladder. Radium may be 
applied to bladder growths either by way of the urethra or through a 
suprapubic cystotomy wound. Accurate application to the growth is 
absolutely essential for success. It is worse than useless to apply radium 
blindly by means of an ordinary rubber catheter to the interior of the 
bladder. Special instruments have been devised by Barringer, Corbus, 
Kanavel, Young, and others for applying the radium through the urethra. 
Barringer has devised long applicators which may be used in the sheath 
of a Brown-Buerger operative cystoscope. Young has also devised spe- 
cial instruments for applying radium through the urethra. By means of 
these applicators, the radium may be held against the growth. Dr. A. 
B. Kanavel has devised a radium-containing capsule which is provided 
with a spring clip at one end. One or more capsules may be introduced 
through an operating cystoscope and attached, in suitable cases, by means 
of the clip to the surface of the bladder growth. With this device, treat- 
ments lasting for any number of hours may be given. The capsule may 
be removed by means of a silk thread which has been previously attached. 
The dosage in inoperable carcinoma of the bladder varies with the char- 
acter of the case and the tecluiic that is employed. 

Application through the Urethra. If the radium is applied via the ure- 
thra to the surface of the growth, 100 millicuries, screened with 1 milli- 
meter of silver may be used in periods of one hour each, several times a 
week, until an exposure of ten hours has been given. A better method 
((insists in the use of two hundred millicuries for five hours. Barringer 



212 RADIUM THERAPY 

has applied in some eases unscreened emanation to the surface of 
bladder growths via the urethra. The largest dose used by this author 
was 500 to 1000 millicuries for 650 millicurie hours. In some cases, 50 
millicuries contained in a steel needle was inserted into the growth for 
100 millicurie hours. In other cases, bare emanation ampoules were bur- 
ied in the growth. 

Application through a Suprapubic Cystotomy Wound. When accu- 
rate application through the urethra, for any reason, is impossible, supra- 
pubic cystotomy may be performed in order to render the growth acces- 
sible. Radium tubes may then be introduced through the cystotomy 
wound and held in position by sutures or by a long pliable silver wire 
which may be bent to the proper angle and fastened to the abdomen by 
adhesive strips. Using this technic from 100 to 200 millicuries screened 
with 2 millimeters of brass and 10 millimeters of rubber may be applied to 
the growth for from ten to twenty hours in periods of five to ten hours each. 
In some cases, radium emanation may be inserted into the growth. Five to 
eight steel needles having a wall thickness of 0.4 mm. and containing 60 to 
90 millicuries may be inserted for twelve or eight hours. In other cases 
bare emanation ampoules may be buried in the growth. In addition to the 
intravesical treatment, heavily screened radium may be applied to the 
perineum or inserted into the vagina or rectum in order to cross fire the 
growth. Care must be taken not to overexpose either of these cavities. 
In the treatment of carcinoma of the bladder it should be remembered 
that growths that are superficial may sometimes be successfully treated 
via the iirethral canal. For larger and deeply infiltrating growths, how- 
ever, the use of large quantities of heavily screened radium at a certain dis- 
tance from the tumor is imperative. Such cases usually demand that the 
bladder be opened suprapubically in order to render the tumor accessible. 
In still other cases, in which the age of the patient or other factors render it 
inadvisable to open the bladder, palliative treatment may be carried out 
from the skin surfaces by using large quantities of radium (500 to 1000 or 
more me.) heavily screened at a distance of 10 centimeters from the skin. 

One of our cases of inoperable carcinoma of the bladder, treated intra- 
vesically, which was referred by Dr. M. L. Harris, has been well for more 
than five years. 

(15) Carcinoma of the Breast 

Operable Cases. The policy of declining to treat operable cases of 
this disease solely with radium should be followed. Preoperative radia- 
tion of the breast and its lymphatics followed by operation seems the 
most logical procedure. Postoperative radiation of the operative field 
and the areas most likely to harbor metastatie deposits should be carried 
out. When at least 500 milligrams of radium are available, the thorough 
saturation of the whole chest wall and its draining lymphatics with deep 
penetrating rays is advisable. There are certain operable cases in which 



RADIUM IN GENERAL SURGERY 



213 




-" O ".',..' "* '. ''. 

;-<S^N';- ' K~ : -v 
*''' 




C": '" : . ** f] -'' 




. - . ., .;- >x -- . . _ . ; ;.-- ! :.,.. ' 



Fig. 76. Carcinoma of the breast after powerful radiation. The entire section is shown. 
Slightly enlarged (97 diameters). In this figure are seen, at B, glandular elements and the ex- 
cretory ducts, and, at C, the islets of neoplastic origin in the process of destruction. The can- 
cerous islets are situated at a greater distance from the source of the rays than the normal 
glands, and yet the former exhihit greater effects from the radiation. 

The normal glandular elements remain unchanged, while the neoplasm is reduced to a state 
of degeneration. This illustrates the difference in resistance of healthy and neoplastic tissue. 

A, Epidermis reduced to several hypertrophied cells. B, Normal glandular elements. C, Can- 
cerous islets in the process of degeneration. D, Connective tissue stroma of neoplasm. D', Meta- 
plastic connective tissue, uniting and taking the place of destroyed parenchyma. 



214 



RADIUM THERAPY 



the patient absolutely refuses to undergo operation. Some of these cases 
may be successfully treated with radium when the local conditions are 
favorable. When the breast is not too large and the adipose tissue is not 
excessive and the tumor itself is small and well localized, success is pos- 
sible insofar as the local growth is concerned. Unfortunately, metas- 
tasis to the regional lymphatics or to distant organs precludes recovery 
in most cases. 




Fig. 77. Portion of Fig. 76 at B. Knlargecl 800 diameters. 

A, Normal glandular cell. B, Supporting tissue. C, Lumen of excretory duct. D, Kpithclial 
tell bordering upon an excretory duct. 




Fig. 78. Portion of Fig. 76 at C, showing carcinomatous cells. Enlarged 800 diameters. The 
greater part of these cells are in process of degeneration although they have received less radia- 
tion than the cells in Fig. 41. 

A, Hypertrophied nucleus. B, Cell with pycnotic nucleus. CC ', Atrophied cell with nucleus 
absent (Karyolysis). D, Young fibroblast penetrating into a degenerated neoplastic islet. 

Inoperable Cases. In cases inoperable on account of the extent of the 
disease, only palliative treatment as a rule should be undertaken. In 
cases of the atrophic type, the progress of the disease may be retarded 
if the more accessible lymphatic glands alone have been invaded. In an 
inoperable case of this type recently under the writer's care, in which not 



RADIUM IN GENERAL SURGERY 



215 



only the whole breast but the axillary and supraclavicular glands were 
involved, complete disappearance of all palpable masses was brought 
about by radium, but metastasis to the spine occurred. In the more rap- 



:' '*' 



^ " m Ft%&' 

&;::>** ' .:> kl - 



. ... .v-^'SftV " -*ii 

. v ^%iti^ 




Fig. 79. Atypic cubical epithelioma of the breast, before radiation. Slightly enlarged (97 

diameters). 

A, Center of an epitheliomatous lobule. BB, Dense connective tissue forming the stroma. 
C, Excretory duct of the mammary gland. D, Group of glandular elements. 

idly growing type of carcinoma, response to radium treatment is likely 
to be poor, although pain may be relieved. 



216 



RADIUM THERAPY 



Technic of Treatment of Carcinoma of the Breast. Small cutaneous 
nodules or superficial ulcerations occurring on the chest wall may fre- 
quently be healed by surface radiation. The technic is the same as that 
for primary epithelioma of grave type involving the skin. Deeper nod- 
ules attached to the bone or cartilage of the chest wall may be treated 
effectively by surface applications or by the insertion into the nodule of 
a platinum emanation needle containing twenty-five millicuries for eight- 
een hours. (Hay ward Pinch.) In other cases, bare emanation ampoules 
may be inserted. 




it 
, & 
1 N- 


<T 

.ti 


, * 


1 - 


ffiS 








-(^ 



V.JJV 






' I ' ^ 

*r 

' S 







Fig. 80. A part of Fig. 79. Highly magnified (800 diameters). A, Cubic epitheliomatous 
cell of moderate size, with a single round nucleus am! homogeneous protoplasm. Note the ab- 
sence of connective tissue and the intracellular pseudoparasitic elements in the whole of this 
preparation which is taken from the center of a lobule. All these cells resemble one another. 

When large and deep tumor masses are present, radiations should be 
of a penetrating character. In some cases, 400 millicuries, screened with 
2 millimeters of brass and evenly disposed on a pad 9 x 12 cm., may be 
placed at a distance of 6 centimeters. A total exposure of thirty hours 
in periods of ten or more hours each may be given. 

In other cases demanding deep effects, 600 millicuries, screened with 
2 millimeters of brass may be placed at a distance of 10 centimeters and 



RADIUM IN GENERAL SURGERY 



217 



an exposure of thirty hours in periods of ten or more hours each may be 
given. Sometimes when pleural or peritoneal effusion has supervened in 
consequence of the involvement of the pleura or peritoneum by the 
growth, the fluid may be withdrawn and deep radiation immediately 
given. In some cases, the effusion has not reappeared. 

Douglas Quick has recently reported upon the method of burying bare 
emanation ampoules in the tiimor in cases of inoperable breast carci- 



* t 

: . %; . . .:/ 

,.;.-% . 



f v. 

r ... .. ' ?'' 

L - ..-.;. 

. - . **._ . 










. 

. 




B 
A 











, : 

' 






-,: 







Fig. 81. Same epithelioma as in Fig. 79, after radiation. Slightly enlarged (97 diameters). 
Section removed from tissue situated at depth of 2 cm. 16 days after radiation. The elements of 
the parenchyma are no longer grouped, as in Fig. 79, in lobular masses. These have become in- 
vaded and dislocated hy young, connective tissue stroma. The epitheliomatous cells are degenerated 
and swollen zones of cytolysis. The connective tissue stroma is renewed and is very rich in 
embryonic elements. 

AA, Epitheliomatous cells hypcrtrophied and degenerated. BB, Young connective tissue rich 
in new cells replacing the tumor elements, which have disappeared. C, Dense connective tissue, un- 
disturbed, forming the bed of the primary neoplasm. D t Clear zone of cytolysis. 



218 



RADIUM THERAPY 



noma coincidently with surface applications of x-rays. Of seventy-eight 
cases treated in this manner by Quick, seven showed complete regressions 
for periods of three months to more than two years. Twenty-one cases 
showed partial regressions. Twenty-four cases received temporary ben- 
efit only. Ten cases showed no improvement and nine cases could not be 
traced. Seven cases were treated during the four months just prior to 
the report and were not included in the statistics, although the initial 
response to the treatment was favorable. Russell Boggs has also re- 
ported favorable results from the insertion of steel needles containing 




. Fig. 82 A part of Fig. 81. Highly magnified <800 diameters). Note here the polymorphism 
of the tumor elements, their hypertrophic and malformed nuclear structures. The epitheliomatous 
nodules are infiltrated with a vascular connective tissue development in a state of paraembryonic 
metaplasia. Notice the presence, interspersed amongst the epitheliomatous cells, of large, star- 
shaped anastomosing connective tissue cells. 

A, Hypertrophied epitheliomatous cell with a giant nucleus. A'A', Cells with multiple nuclei. 
B, Capillaries, newly formed al the edge of the infiltration. CC, Pseudoparasitic Iwdies. DD', 
Pycnotic nuclei. E, Star-shaped connective tissue cell joined to its neighbors by protoplasmic elonga- 
tions. ^F, Young fibroblasts from the infiltration tissue. G, Monomiclear leucocytes interspci>rd 
in the infiltration tissue. //. Cell with vacuoles without nucleus in state of cytolysis. //', Cell de- 
prived of its nucleus (karyolysis). 

radium salts into breast carcinomata combined with the use of surface 
radiations with x-rays. 

In the report of the London Radium Institute for 1919, ninety-five cases 
of cancer of the breast were mentioned that had applied for treatment 
during the year. Seven cases were examined but not treated; no recent 



RADIUM IN GENERAL SURGERY 



219 



report had been received from 12 cases; 5 cases received prophylactic 
treatment; 50 cases were improved; 13 were not improved; 2 abandoned 
treatment ; 4 died and 2 were apparently cured. 
Between January, 1914, and January, 1921, the writer treated 90 cases 




Fig. 83. Carcinoma of left breast. This tumor measured 16x12 cm., and was elevated about 
5 cm. above the level of the skin. Photograph taken October, 1919. Patient referred by Dr. A. J. 
Auner. 

of breast carcinoma of different types. Eighty-five of these cases were 
primarily inoperable or inoperable recurrences. Five cases were treated 
that were operable so far as the disease was concerned, but inoperable 



220 



RADIUM THERAI'Y 



on account of other conditions. In 30 of the 85 inoperable cases just 
referred to, palliation only w;is attempted, the process being too far ad- 
vanced to permit of expectation of regression. Of the remaining 55 
cases of this group, 6 showed complete clinical regression, 29 were 
definitely improved, 10 were not improved to a marked extent and 10 
abandoned treatment. One of the earliest cases of clinical regression 




RADIUM IN GENERAL SURGERY 221 

that we obtained was mentioned by the writer in a previous article (Illi- 
nois Medical Journal, August, 1916). The patient referred to in the 
above report died later, probably from spinal metastasis, but her condi- 
tion was rendered comfortable and her life was apparently prolonged for 
about four years. 

Of the 5 operable cases that I have treated, 3 made a complete clinical 
regression that has been maintained for periods of from six months to 
two years. One case was refractory and one case abandoned treatment, 
after an initial marked improvement was noted in both instances. 

Improvement in the technic, such as the use of more massive doses of 
radium at a considerable distance from the skin combined with the 
implantation of bare emanation ampoules has led to better success 
in the last few years than was formerly thought possible. 

(16) Carcinoma of the Cervix Uteri 

Operable Cases. In the treatment of operable cases of cancer of the 
cervix, it was the general opinion until recently that hysterectomy with 
preoperative and postoperative radiations was the method of choice. 
Janeway and others have lately expressed the opinion that radium treat- 
ment alone, in certain cases of operable cancer of the cervix, is now 
justified. Some authors even state that operation in cancer of the cervix 
should be replaced by radium. We have already referred to the fact that 
Bumm, Doederlein and Kroenig have taken this position and have aban- 
doned operation in favor of radium treatment in all cases of cervical 
cancer. Schaefer, a coworker of Bumm, has reported the following 
results: Of 155 cases of cancer of the uterus treated with radium which 
were either operable or on the borderline of operability, recovery oc- 
curred in 83 (53.54 per cent). Seventy-four of these cases were operable. 
Of these, 48. (66. 21 per cent) were well after periods of one to three 
years. The foregoing results may be compared with the results of opera- 
tion in 203 cases reported by the same author. In this series 98 (48.27 
per cent) were well after periods of one to three years. Radiation seemed 
therefore to give results better than those obtained by operation. On the 
basis of these results, Schaefer has also abandoned operation for radia- 
tion in cervical cancer. 

Borderline Cases. In cases in which the surgeon is in doubt as to the 
advisability of operation, radium treatment is undoubtedly the prefer- 
able procedure. In these cases, long experience has shown that operative 
interference is not followed by good results. In some cases in this cate- 
gory and even in some cases that are strictly inoperable, radium treatment 
may render the case operable. It is probably best, however, not to at- 
tempt to remove the uterus when a clinical recovery has occurred under 
radium. 



222 



RADIUM THERAPY 




Fig. 85. Metatypic pavement cell epithelioma of the neck of the uterus, liefore treatment. ( Kn- 

larged 180 diameters.) 



c 



C-- 




Fig. 86. Same epithelioma as in Fig. 85. Fragment removed 10 days after the first application of 

radium. (Enlarged 380 diameters.) 

A, Cells that have not as yet undergone any changes. B, Cells influenced by the radiation 
and already showing signs of necrosis; (nucleus retracted in pycnosis the chromatic substance 
scattered in the cytoplasm). C, Cells hypertrophied in varying degrees with irregular, often mon- 
strously budded, nuclei. 



RADIUM IN GENERAL SURGERY 



223 



Inoperable Cases. "Uterine cancer continues to yield most gratifying 
results and the effect of radium treatment in inoperable cases is far in 
advance of those obtained by any other known medical or surgical meth- 
ods. " (Report of the London Radium Institute.) Certain authors are of 
the opinion that 25 per cent of inoperable uterine and vaginal cancer can 
be cured by radium. 

The clinical improvement of the majority of cases of carcinoma of the 
cervix under radium is striking. Cessation of the hemorrhage and foul 
discharge and relief from pain are very frequently obtained. Disappear- 
ance of fungating masses and healing of ulceration are often noted. In 




- -C 



Fig. 87. Same epithelioma as in Fig. 85. Section removed on the 29tli day after the first radia- 
tion. (Enlarged 180 diameters.) 

A, Group of hypertrophied epitheliomatous cells, degenerated, in process of disappearance 
(karyolysis, plasmolysis, cytolysis), imbedded in and infiltrated with: B, Embryonic and poly- 
nuclear cells. C, Remains of necrotic cells intermingled with polynuclear cells which disorganize and 
absorb them. U, Young connective tissue rich in embryonic cells, fibroblasts, plasma cells; the be- 
ginning of a cicatrization occupies the larger portion of the preparation. 

some cases, palliation only is to be expected. In a few cases, no improve- 
ment is obtained. 

The Technic of Treatment of Carcinoma of the Cervix. The technic of 
treatment naturally varies with different cases, and indeed almost every 
experienced worker with radium has, to some extent, an individual 
method. The difference in technic is quite remarkable and illustrates 
the toleration of the cervix uteri and adjacent tissues to radium treat- 
ment. It is noteworthy, however, that the enormous doses formerly rec- 



224 RADIUM THERAPY 

ommended by some Avriters have been attended not infrequently by 
untoward sequelae and particularly by rectovaginal and vesicovaginal 
fistulae. The present tendency is toward moderate dosage in or against 
the cervix. 

A review of the different methods as practiced by Bumm, Cheron-Duval, 
Clark, Begrais, Janeway, Kelly and Burnam, Hayward Pinch, Schmitz, 
Wickham and many others, seems to demonstrate clearly that moderate 
dosage brings about the local disappearance of the cancer quite as well as 
enormous doses and without the untoward effects that may attend the 
use of very large quantities of radium. We believe also that several 



B 



, V " ' " B 
B /. 

A - 



- -B 




-B 



Fig. 88. Same epithelioma as in Fig. 85. Fragment removed from the surface of the cicatrix 
of the neck of the uterus three months after first radiation. Dense connective tissue, rich in cellu- 
lar elements. 

A, Well developed, star-shaped connective tissue cells. B, Newly formed capillaries. 

treatments are often preferable to a single treatment, although the effect 
may not seem quite so brilliant. Whether a certain amount of curetting 
should precede radium treatment in order to remove fungating masses is 
debatable. We believe it is not advisable. We are opposed to prelim- 
inary cauterization undertaken for the same purpose. In the technic of 
treatment much depends upon the distribution of the radium with refer- 
ence to the growth. When the radium is not too concentrated per unit 
area, larger doses are naturally tolerated. 

We shall mention at this time the technic of only a few therapeutists. 

Burrows (Manchester and District Radium Institute) gives an exposure 



RADIUM IN GENERAL SURGERY 225 

of 3000 millicurie hours. He buries in the growth 5 to 7 platinum tubes 
(wall thickness % mm.) containing 120 millicuries and allows them to 
remain twenty-four hours. 

Hay ward Pinch (London Radium Institute) gives a total exposure of 
about 1600 millicurie hours. One tube of not less than 53.6 me. is intro- 
duced, if possible, into the cervical canal, and if this is impossible, into 
the posterior vaginal fornix. The screening is 2 mm. of lead plus 2 mm. 
of rubber. Several treatments are given the duration of the entire 
treatment being twenty-four to thirty hours. 

Janeway advises in average cases an exposure of 6000 millicurie hours. 
He used 300 millicuries in 3 tubes inside the uterus and 3 tubes contain- 
ing 200 millicuries over the cervix. The screening is the equivalent of 
3' millimeters of lead plus rubber. One treatment of twelve hours is 
given. More recently he has inserted, in addition, bare emanation tubes 
into the cervix. 

Schmitz gives a total exposure of 2000 to 2400 milligram hours in 
the cervix and later the same dose against the cervix. He uses fifty 
milligrams screened with 1.2 mm. of brass. 

My technic in average cases has consisted in giving an exposure of 
about 3000 millicurie hours. In suitable cases, 200 millicuries screened 
with 2 mm. of silver are introduced into the cervix for seven and 
one-half hours. Two subsequent exposures of fifteen hours each with 
50 millicuries screened with 2 mm. of silver plus 2 or more mm. of 
rubber against the cervix are then given at intervals of three or 
four days. It must be emphasized that there is no one technic adapted 
to all cases and that equally good results may doubtless be obtained in 
the same class of cases by different methods. In addition to the intra- 
uterine and intravaginal exposures, it is imperative to use powerful deep 
radiations over the abdomen and sacrosciatic notches. Three portals of 
entry may be mapped out on the abdomen. Five hundred to 1000 millicuries 
screened with 2 mm. of brass may be applied over each portal at a distance 
of 6 or 10 centimeters for twenty-five or eighteen hours in periods of ten or 
more hours each. The emanation may be arranged on a pad having a 
superficial area of 100 square centimeters. The splenic area should be 
carefully protected during the abdominal radiations. 

In carrying out intravaginal treatment, it is important to pack off well 
the posterior vaginal wall, as the rectum is especially sensitive to radium 
rays. Treatment may otherwise be followed by proctitis. 

When treatment is undertaken for -recurrences after extensive pelvic 
operations, the quantity of radium used in the vagina should be reduced 
by one-half and the time of exposure by one-fourth, otherwise the radium 
may cause at times a destructive and intractable reaction. Following 
in) r;i vaginal radium treatment, douches should be systematically given 
for at least six or eight weeks to prevent the formation of adhesions. A 



226 RADIUM THERAPY 

second series of treatments six or eight weeks after the first series may 
be advisable but these should always be of less intensity. Too powerful 
or too frequently repeated exposures may result in painful and destruc- 
tive reactions which may appear many months after the treatment is 
discontinued. 

From the standpoint of treatment, Dr. John (1. Clark draws a sharp 
distinction between cancer of the cervix and cancer of the fundus uteri. 
In the former condition, he advises the use of radium ; in the latter, he 
advocates hysterectomy even though the disease is advanced. Many 
authors advise the use of radium in all borderline and advanced cases 
of cancer of the uterus, irrespective of its location. 

Results of the Radium Treatment of Uterine Cancer. The literature 
of the subject has grown to such great proportions that we shall mention 
the results of only a few authors. Many additional references will be 
found in the bibliography. 

In the course of five years, IT. ('heron and Rubens-Duval treated 158 
cases of primary and recurrent inoperable uterine and vaginal caneer. 
In 155 cases there was improvement that was anatomically verified. In 
93 cases, the improvement was marked. The authors state that in 46 
cases there was probably a definite cure. In only 2 cases was the treat- 
ment without appreciable good effect. 

These authors have also reported a case that may be mentioned as show- 
ing the possibility of a complete anatomical cure of localized cancer with 
radium. The patient referred to suffered from inoperable cancer of the 
uterus and made an apparent recovery under radium. Fifteen months 
later the patient died of another disease and histological examinations of 
the various organs of the body showed no trace of cancer. 

Kelly and Burnani have reported a series of 213 cases of cancer of the 
uterus treated witli radium in which the results are thus summarized by 
the authors: "Out of 213 cases treated, 14 were operable and 199 
inoperable. 

"Operable cases: Of the 14 operable cases, 10 patients were operated 
on and treated prophylactically with radium. Of these, 2 have been well 
for more than three years, 1 for more than two years, 4 for more than 
one year, and 3 for more than six months. The number is too small from 
which to draw conclusions, and yet is suggestive when we consider that 
in 75 per cent of all cases with operation there is recurrence and that 
60 per cent of these recurrences take place within one year following 
the operation. 

"In four cases of the operable group, on account of some general con- 
traindication to operation, radium alone was used. All of this group are 
living and well ; two for over three years and two for over one year. 

"Inoperable cases: The total number of inoperable eases and inoper- 
able recurrent cases is 199, of which 53 patients have been clinically 
cured, 109 markedly improved and 37 not improved. 



RADIUM IN GENERAL SURGERY 227 

"Our series includes 35 of originally inoperable cancer of the cervix 
uteri or vagina in which the patients are clinically cured, in 2 cases for 
over four years, in 2 cases for over three years, in 4 cases for over one 
year, and in 10 cases for over six months. It also includes 18 cases of 
originally inoperable recurrent cancers in which the patients are now 
clinically cured ; in 1 case for over six years, in 1 case for over four years, 
in 11 cases for over two years, in 10 cases for over one year and in 5 
cases for over six months. Excluding the operable cases, in which we 
have both operated and used radium, there are 203 cases left; in 57 of 
these 203 cases the patients are 'clinically cured.' We will reserve the 
word cured for later reports, to apply to cases beyond the five year limit, 
which has been conventionally adopted by surgeons as a time limit for 
estimating the permanency of cures of malignant disease. Of the 57 
clinical cures, 1 has lasted for six years, 3 for over four years, 4 for over 
three years, 5 for ovor two years, 29 for over one year, and 15 for over 
six months." 

F. J. Taussig has recently collected the available literature dealing 
with five year radium cures of cervical cancer. Out of 1114 cases, oper- 
able and inoperable, reported by twelve authors in different countries. 
223 were said to be well after five years (about 20 per cent). Out of 415 
operable cases, 131 were well after five years (about 31 per cent). 

Between January, 1913, and January, 1921, the writer treated 138 
cases of carcinoma of the cervix. These cases may be divided into three 
groups. 

(a) Primary doubtfully operable, i.e., "borderline" 10 cases. 

(b) Primary inoperable 88 cases. 

(c) Inoperable recurrences after operation 40 cases. 

Of the 10 borderline cases forming the first group, we have reports 
from 6. Three of these are living after more than three years and 3 are 
dead. 

Of the 88 primary inoperable cases forming the second group, reports 
have been obtained from 45. Twenty-eight of these are living and 17 
are dead. Twelve of the living cases are well after more than three 
years. It may be stated, however, that in this group of inoperable cases 
there were 12 in whom palliation alone was attempted. 

Of the 40 inoperable recurrences forming the third group, we have 
reports from 20. Of these 8 are living and 12 are dead. 

Of a total of 138 doubtfully or wholly inoperable cases, 51 have been 
lost sight of. Eighty-seven have been traced, of whom 30 are living 
and 57 are dead. If we assume that none of the untraced cases is liv- 
ing the proportion of clinical recoveries for more than three years is 
slightly more than 21 per cent. 

In the majority of all of our cases, except those in which palliation only 
was attempted, local healing occurred under radium, and life was pro- 
longed and made bearable. 



228 



RADIUM THERAPY 



SARCOMATA 

When treated early and before dissemination to various parts of the 
body has occurred the results of radium treatment in sarcomata are on 
the whole beneficial. Unfortunately, the occurrence of metastasis may 
sooner or later render the prognosis unfavorable, but numerous cases 
have remained well for considerable periods of time. 

Different types of sarcomata exhibit marked variations in their radio- 
sensibility. Lymphosarcoma is particularly sensitive to treatment. It 
is one of the most gratifying of all growths in its response to radium. 
In this type of disease, large tumors which may affect the neck, medias- 
tinum, retroperitoneal lymph glands, etc., may disappear in the most 
surprising fashion. 




Fig. 89. Polymorphous sarcoma with predominance of fusiform cells. Before radiation (en- 
larged 400 diameters). The chromoplasm of the cells is quite abundant, forming a mesh-like net- 
work fiiled with hyaloplasm, with no elaboration of the collagen. 

A, Fusiform cell. B, Vessel lying in sarcomatous tissue and bordered by tumor elements. C t 
Cells in atypic karyokinesis. D.E., Tlasma cells. 

In a type of tumor usually referred to as sarcoma but classed by Jane- 
way and Ewing as "teratoid carcinoma of the testis and ovary" a remark- 
able susceptibility to radium is seen. Janeway has reported a number 
of cases successfully treated. 

In one of the writer's cases, referred by Dr. W. A. Stuhr, which was 
probably of the type just mentioned, a large mass was present in the 
right hypoehondrium. The tumor extended from the costal arch to the 
umbilicus and was apparently larger than a child's head. This growth 
had been preceded a year before by a sarcoma of the right testis which 
had been surgically removed. Complete disappearance of the abdominal 



RADIUM IN GENERAL SURGERY 



229 



tumor occurred within a few weeks under radium treatment. The patient 
is now in excellent health after more than three years. 

Melanosarcoma is not, as a rule, favorably affected by radium but in 
exceptional cases may yield completely. 

We may refer briefly to sarcomata occurring in different situations. 

(1) Sarcoma of the skin is usually amenable to radium treatment. 




Fig. 90. Same sarcoma as in pig. 89. Section of large nodule removed 15 days after powerful 
irradiations. Slightly enlarged (80 diameters). 

Zone A, Superficial part, in contact with the apparatus; zone of massive necrosis. 

Zone B, Showing cellular monstrosities and phagocytes. Sarcomatous elements scanty but 
quite bulky and in state of degeneration. Numerous leucocytes. 

Zone C, Showing stratum of least modifications nevertheless the sarcoma is modified. Hyper- 
trophied forms of cells of monstrous shapes. 

a. Monstrous degenerated cells, bb. Elongated sarcomatous elements having a resemblance to 
young fibrohlasts. cc, Multinuclcated plasma cells. /, Sarcomatous vessels. 



230 RADIUM THERAPY 

(2) Periosteal sarcoma is frequently benefited by radium. 

(3) Sarcomata of the tonsil and post nasal space are frequently amen- 
able to radium and very striking results arc sometimes obtained. I have 
treated in conjunction with Dr. (.). T. Freer three cases of sarcoma of the 
postnasal space in which recovery occurred. Two of these cases have 
remained well for more than three years. In one case, late glandular 
involvement proved fatal. 

(4) Sarcoma of the larynx may be treated in a similar manner to that 
.suggested for carcinoma. 



v 

X 




Fig. 91. Same sarcoma as in Fig. 89. After railiation. Highly magnified (400 diameters). 

This section shows a portion of zone II in Fig. 90 and illustrates tin- extraordinary volume, and 
the strange forms of the sarcoma elements under the influence <>f the radiation before they dis- 
appear by phagocytosis. The relative scarcity of neoplastic cells is plainly discernible. 

AA, Greatly hypertrophied sarcomatous cells with multiple or polylobular nuclei, with proto- 
plasm, acidophilous, invaded by polynuclear leucocytes. BB, Neutrophilc polymiclear leucocytes 
enclosed in the protoplasm of the degenerated sarcomatous cells. C, Fibrillar stroma infiltrated 
with, leucocytes. 

(5) Sarcoma of the orbital tissue recurring after operation is often 
benefited by radium. Unfortunately, metastasis to the neck or distant 
organs occurs sooner or later in most of the orbital cases. 

(6) Mediastinal sarcoma. Numerous instances of mediastiiial tumor 
have received great benefit from radium treatment. It is probable that 
many mediastiiial growths are lymphosarcornata and the excellent results 
sometimes noted after radium .treatment. may be explained by this Fact. 
Burnam has reported an interesting group of 8 cases oF mediastiiial 



KADIUM IN GENERAL SURGERY 



231 





232 



RADIUM THERAPY 



tumor treated with radium, in which the greatest improvement occurred 
in all but 1 case. 

The Technic of the Treatment of Sarcoma. The method of treatment 
varies greatly according to the situation and size of the tumor. In post- 
nasal cases, 100 me, or more, screened with 1 mm. of silver plus 1 mm. 
of rubber may be used. Contained in two tubes placed end to end, the 




Fig. 94. Sarcoma of left check in girl aged nineteen. Photograph taken May 17, 1921. Patient 

referred by Dr. O. T. Roberg. 

radium may be applied through the anterior iiares for six hours in sev- 
eral periods of two or three hours each. The treatments may be given 
every day or on alternate days. In tonsillar sarcoma, radium needles 
may be buried in the growth (60 mg. in 5 needles, %o mm. screen, 8 
hours), or bare emanation tubes may preferably be used. In orbital 
sarcoma, 100 me., screened with 2 mm. of brass may be inserted into the 
orbital cavity for six hours. This treatment should follow evisceration 



RADIUM IN GENERAL SURGERY 



233 



or exenteration either at the time of the operation or in the event of 
recurrence. In all types of deep sarcoma or when large masses exist, 
deep raying with large quantities of radium is the method to be chosen. 
Five hundred or 1000 inc., to each 100 square centimeters, screened with 
2 mm. of brass and placed at a distance of six or ten centimeters may 
be applied. At a distance of 6 cm., 12,500 me. hours and at a distance of 




Fig. 95. Patient in Fig. 94 after radium treatment. Photograph taken Oct. 20, 1921. Metas- 
tases to the skin of the right hreast, abdomen and thighs occurred later. These disappeared under 
radium. In December, 1921, patient appeared clinically well. In February, 1922, we learned 
that patient's health was failing. 

10 cm., 18,000 me. hours may be given. In mediastinal tumors, Kelly 
and Burnam have used more than a gram of radium at a distance of 
from 1% to 6 inches, for periods of four or more hours on each area. 

Pancoast has reported some encouraging results following the radium 
t refitment of brain tumors (sarcoma, glioma, endothelioma, pituitary 
tumors). 



234 



KADI I'M TllICKAPY 




big. 96: Tumors -of' eyelids.' Mii-n>sc<>|iH- xrtiun Allowed lymplioma (?). Photograph taken July, 
1920. I'atitMit referred by Dr. Wm. A. Fisher. 



RADIUM IN GENERAL SURGERY 



235 




Fig. 97. Patient in Kip:. 90 after radium treatment. Photograph taken September, 1920. 
Patient was well one and one-half years later. 



236 



RADIUM THERAPY 




Fig. 98. Sarcoma of bone. Recurrence after operation. Patient referred by Dr. A. B. Kanavel. 



RADIUM IN GENERAL SURGERY 



237 




Fig. 99. Patient in Fig. 98 after radium treatment. Improvement was only temporary. 



238 



RADIUM THERAPY 




Fig. 100. Lymphosarcoma of neck. Photograph taken July, 1919. Note scar of previous operation. 



RADIUM IN GENERAL SURGERY 



239 





.... 

fig. 101. Patient in Fig. 100 after radium treatment. Photograph taken in December, 1919. 
Later recurrences took place in throat, axillae, inguinal regions and abdomen which yielded for a 
time to further treatment. The patient had about a year of comfort as the result of the treatment. 



240 RADIUM THERAPY 

B. BENIGN TUMORS 

The treatment of keloids, nevi, etc., will he considered in the chapter 
devoted to Radium in Dermatology. 

The treatment of fihromyomata of the uterus will be considered in the 
chapter on Radium in Gynecology. 

C. CHRONIC INFECTIONS 
Tuberculosis 

Tuberculosis of the skin will be considered under Radium in Derma- 
tology. 

Tuberculous Adenitis 

In the early stages of tuberculosis of the lymphatic glands, radium 
treatment frequently causes a diminution in size of the glands and some- 
times brings about a clinical recovery. Moderately deep radiations 
should be given. Two hundred millicuries distributed in the ratio of 
]% me. per square cm. screened with 2 millimeters of brass and placed 
at a distance of 3 centimeters may be employed for thirty hours in peri- 
ods of ten or more hours each. 

Tuberculous Sinuses 

On numerous occasions we have introduced 25 to 50 milligrams con- 
tained in two or more tubes screened with one mm. of silver along the 
course of tuberculous sinuses leading to the bone. A total exposure of 
four to eight hours has been given. Improvement has sometimes fol- 
lowed. Other authors have reported the healing of such sinuses. 

In military surgery, Cameron has seen improvement follow the intro- 
duction of a radium tube containing 10 milligrams screened with one mil- 
limeter of silver into chronic sinuses for periods of ten to thirty minutes 
repeated several times at intervals of two to four days. 

Actinomycosis 

Actinomycosis has been treated with radium by Heyerdahl who has 
reported six cases. Four of these were clinically cured and two were 
improved. 



CHAPTER XVI 
RADIUM IN GYNECOLOGY 

A. MALIGNANT TUMORS 

The treatment of carcinoma of the uterus, the labia, the urethra, etc., 
has already been considered in the chapter on Radium in General Surgery. 

B. BENIGN TUMORS 
Fibromyoma of the Uterus 

Dr. Robert Abbe, of New York, was the pioneer in the use of radium 
in fibromyoma of the uterus. His first case was treated in 1905 by the 
introduction of radium into the interior of the uterus. In proper cases, 
radium treatment of uterine fibroids is now a routine procedure with 
those who have had experience with the method. Abbe, J. G. Clark, 
Degrais, Hayward Pinch, Kelly, Schmitz, Stacy, Wickham and many 
others have used radium extensively in this condition. Kelly has reported 
a series of 210 cases. Clark has observed more than 150 cases. I have 
treated over 60 cases. While there is general agreement as to the ben- 
eficial results of treatment, there are naturally some differences of opinion 
as to the class of cases in which radium is most suitable. With our pres- 
ent experience, we believe that one is justified in using radium in all 
cases of fibromyoma that are causing symptoms unless a positive contra- 
indication is present. Clark believes that fibroids in young women should 
be radiated with great caution on account of the possibility of bringing 
on an abrupt and serious menopause. lie ordinarily limits the use of 
radium therefore to cases occurring within the menopausal cycle. Kelly 
apparently docs not recognize an age limitation. Sixty-four of his cases 
were under forty and in twenty-eight of these, the tumor practically dis- 
appeared. The presence of acute or quiescent inflammatory conditions 
in the pelvis is a positive contraindication. Clark believes that when the 
tumor is larger than a three months' pregnancy, operation is to be pre- 
ferred. Dr. L. J. Stacy of the Mayo Clinic also believes that very large 
fibroids should be operated on and draws attention to the possibility of 
mistaken diagnosis and of unrecognized carcinoma of the fundus. Many 
authors do not regard the size of the tumor in itself as a contraindication 
to radium. The cervical, the submucous and the pedunculated varieties 
of fibromyoma are not suitable for radium treatment. Fibroids under- 
going degeneration should not be treated with radium. 

The chief positive indication for radium treatment is uterine hemor- 

241 



242 RADIUM THERAPY 

rhage due to the fibromyoma. Radium may be used, however, when 
hemorrhage is absent. The results of treatment are, in most cases, the 
cessation of the menorrhagia and metrorrhagia and the production of 
amenorrhea ; the reduction of the size of the fibroid, which may in some 
instances disappear. In some cases, the menses may reappear even after 
as long a period as two years. The application of radium entails no 
operative mortality. If radium fails, operation can be resorted to if 
thought advisable. 

Technic of Treatment of Uterine Fibroids. The technic of treatment 
naturally varies, depending upon the nature of the case and also upon the 
operator. Radium may be applied either by intrauterine applications, 
or externally by surface radiations over the abdomen when the size of 
the fibroid warrants the latter procedure. Good results may be obtained 
by moderate doses in the uterus. In cases in which radium is applied 
externally over the abdomen large doses are necessary. The intrauterine 
application of radium is to be preferred as a rule to its external applica- 
tion. Both procedures may be used coincidently in suitable cases. In 
some cases, when there is great objection to intrauterine application or 
when the pelvis is choked by the growth and intrauterine manipulation 
is impossible, radium may be introduced into the posterior fornix and at 
the same time powerful radiations may be used over the fundus uteri. 
The latter method has been used successfully by Hayward Pinch and 
others. External treatment alone may be successful. 

1. Intrauterine Radiations. By an intrauterine application of suffi- 
cient intensity the endometrium may be destroyed but ovarian activity 
may be preserved. In this respect the intrauterine application of radium 
appears to possess features of advantage over treatment with x-rays, as 
the symptoms of the menopause are frequently slight when radium is used 
in this manner and may be pronounced after x-ray treatment. The 
amenorrhea that is produced should last if possible until the fibroid has 
practically disappeared as the tumor may begin to grow again if men- 
struation returns. If this latter event happens, the treatment may be 
repeated if thought advisable. The production of amenorrhea requires 
ordinarily an application to the interior of the uterus of from 1000 to 
1500 millicurie hours. The quantity of radium used and, therefore, the 
length of the application vary with different operators. 

Dr. Howard Kelly has used 500 millicuries in the uterus for three hours. 
In the technic of the above author's treatment, the radium tube, screened 
to emit only gamma rays was screwed to the end of an ordinary uterine 
sound and introduced to the fundus uteri. The radium was allowed to 
remain not longer than one-half hour in one place, an average of six 
changes being made by turning once from right to left and then by with- 
drawing the sound one cm. at a time. 

Dr. J. G. Clark has used 50 milligrams enclosed in one or two tubes. 
An intrauterine exposure of from six to twenty-four hours has been 



RADIUM IN GYNECOLOGY 243 

given by this author, the shorter exposure being used in women under 
thirty-five and the longer, in women in the menopausal cycle. 

Hayward Pinch of the London Radium Institute has applied about 
50 millicuries screened with 2 millimeters of lead to the posterior fornix 
or to the interior of the uterus. The same quantity was used simultane- 
ously over the fundus. When the posterior fornix was the site of appli- 
cation, a total .exposure of thirty to sixty hours was given in the course 
of five to ten days. The series of treatments was repeated in six to eight 
weeks. If the interior of the uterus was treated, an exposure of from 
twenty-four to thirty hours Avas given. 

MY method consists frequently in the use of 100 millicuries properly 
distributed over the interior of the uterus. The screening is usually 
2 millimeters of brass or its equivalent of another metal plus 2 millimeters 
of rubber. With or without gas anesthesia, the cervix is dilated and 
curettage is performed in order to exclude malignancy and remove any 
polypi. The cavity of the uterus may be swabbed lightly with a 5 per 
cent solution of iodine. The radium tube or series of tubes, arranged so 
as to radiate the uterine cavity homogeneously, is then introduced and 
allowed to remain for from ten to fifteen hours. As a result of an intra- 
uterine treatment, there may be some nausea and vomiting and a feeling 
of depression in the ensuing twenty-four or forty-eight hours. There is 
usually no subsequent pain. Hemorrhage usually stops at once, but in 
some cases may diminish gradually and may persist to a slight degree 
for several weeks. 

FolloAving the treatment there may be a yellowish leucorrhea but this 
usually ceases within six weeks. The menopausal symptoms naturally 
vary with the age of the patient. In younger patients they may occa- 
sionally be quite severe, but in those within or past the menopausal cycle, 
sequelae of this kind are slight or absent. 

2. Surface Radiations. By employing surface radiations over the ab- 
domen a result similar to that obtained by intrauterine applications may 
be produced. Surface radiations are adapted to very large tumors. 

Employing this method, Kelly has used 1000 millicuries at a dis- 
tance of 10 centimeters from the skin. The emanation was distrib- 
uted at various points over the abdominal tumor and a total exposure 
of twenty-four hours was given. A satisfactory result may be ob- 
tained by using 500 millicnries, screened with 2 millimeters of brass. 
Distributed on a pad so that there may be a concentration of 5 milli- 
curies per square centimeter, 500 millicuries may be applied to different 
areas at a distance of 6 centimeters from the skin for twenty-five hours 
over each area in periods of ten or more hours each. At a distance of 
10 centimeters, 500 millicuries may be applied for thirty-six hours in 
several periods. The course of treatment should extend over one or two 
weeks and may be repeated in six or more weeks if thought desirable, 



244 RADIUM THERAPY 

although smaller doses should invariably be given in subsequent treat- 
ments. 

C. METRITIS AND ENDOMETRITIS 

In chronic metritis and endometritis recovery may often be brought 
about by the intrauterine application of radium. Several tubes, arranged 
tandem and containing a total of 50 millicuries, screened with the 
equivalent of one millimeter of lead and one millimeter of rubber, may 
be applied for from eight to ten hours. The treatment may be repeated 
in six weeks if necessary. Endometritis that has resisted all the ordinary 
measures and was formerly curable only by the removal of the uterus is 
sometimes completely relieved. 

D. METRORRHAGIA AND MENORRHAGIA NOT DUE TO 
CANCER OF FIBROID 

In metrorrhagia and menorrhagia due to causes other than cancer and 
fibroid, radium is sometimes of the greatest value. S. M. D. Clark has 
reported 50 cases of the above conditions benefited by radium. This 
author states that in "hemorrhage in young women" without definite 
etiology, in aggravated and intractable dysmenorrhea, and in "chronic 
metritis" with bleeding, radium has given promise of complete relief. 

E. MYOPATHIC HEMORRHAGE 

In myopathic bleeding from the uterus many authors have reported 
favorable results. In such cases, in which there is persistent uterine 
bleeding at the menopause without gross demonstrable cause, radium is 
very efficient. One hundred millicuries screened with one millimeter of 
silver and two millimeters of rubber may be applied to the uterine cavity 
for ten hours. 



CHAPTER XVII 
RADIUM IN DERMATOLOGY 

We have already referred to the fact that radium rays may produce 
either a "selective" or an "inflammatory" reaction in the skin. By 
some writers, the "selective reaction," a process by which pathologic 
tissues are altered without visible inflammatory changes, is held to be 
the more important. The ease, however, with which the actual destruc- 
tion of certain pathologic tissues can be produced leads us to place ra- 
dium in the front rank as a destructive agent. Within certain limits, 
radium is superior to the other common destructive agents used in der- 
matology, such as chemical caustics, the cautery, carbon dioxide snow 
or liquid air, electrolysis, etc. In actual dermatologic practice, one 
often combines the effect of the "selective" and the "inflammatory" 
reaction. The inflammatory reaction should be reduced to a minimum, 
however, and, if possible, avoided altogether in treating most dermatoses. 
Too free use of the inflammatory reaction, when the cosmetic appearance 
of the treated area is important, is undesirable on account of the possi- 
ble development, within the succeeding eight or ten months, of telangi- 
ectases. These are almost always the result of too large doses. 

Fortunately even a scar resulting from too strong doses of radium is 
almost always smooth, elastic and free from defects inherent in almost 
every other kind of destructive measure, except the telangiectasia men- 
tioned above. In favorable cases, the color of the previously irradiated 
skin area is almost like that of normal skin. A slight pigmentation may 
be present for a time, but this always disappears sooner or later. "From 
the histologic point of view, the action of radium on the integument, at 
least in therapeutic applications, can be shown to produce the same ef- 
fects whether the condition of the skin be normal or diseased. The ele- 
ments of the epidermis, whether physiologic or pathologic, are absorbed 
by degrees and disappear, while the overlying malpighian epithelium 
persists. The cells of the vascular connective tissue, whether normal or 
modified by inflammation or a carcinomatous process, have an alternat- 
ing evolution. In the first stage, they return to the state of embryonic 
connective tissue cells; in the second, they again arrive at maturity 
under the form of elongated fibroblasts, which are superimposed and fol- 
low the regular lines of stratification, again forming connective tissue 
bundles and elastic fibers." (Dominici and Barcat.) 

We may mention here the main groups of dermatoses in which radium 
offers a possibility of use: 

245 



246 RADIUM THERAPY 

A. Malignant tumors. 

B. Benign tumors. 

C. Chronic infections. 

D. Inflammatory and granulomatous infiltrations of uncertain nature. 

E. Hypertrophies. 

F. Neuroses. 

G. Disorders of the appendages of the skin: (a) Sebaceous glands; 
(b) hair and hair follicles. 

A. MALIGNANT TUMORS 

The treatment of epithelioma, carcinoma, and sarcoma of the skin lias 
already been referred to in the chapter on radium in general surgery. 
Among the other malignant growths of the skin which may be greatly 
benefited by radium are Paget's disease, xeroderma pigmentosum, and 
mycosis fungoides. 

B. BENIGN TUMORS 
(a) Keloids 

Keloids and certain cicatricial bands are very favorably influenced by 
radium. 

In keloids of recent formation, especially when they occur in cliil- 



A 

13 








Fig. 102. Cicatricial keloid, following a burn of the face. Before radiation. Slightly en- 
larged. The connective tissue cells are scanty and the elastic fibers even more so. 

A, Horny layer. B, Thinned rete mucosum. C, Keloidal tissue with elements arranged parallel 
to the plane of the section. D, Capillaries surrounded by a zone of cells. E, Deeper portions of 
the keloidal fibroma arranged perpendicularly to the plane of the section. 



RADIUM IN DERMATOLOGY 247 

dren, a very excellent result is frequently obtained. In some cases the 
skin may be quite normal in appearance after involution of the keloid. 
In other cases, the treated area may be too white or too red, or it may 
have a smooth, glazed appearance which, although differing from normal 
skin, is not unsatisfactory when compared with the keloid itself. Usually 
the keloid is levelled and pain is completely relieved. Compared with 
other methods of treatment, radium is easily the method of choice in 
the treatment of this condition. 

. j^l^ay** ^SxS^^T^.'^v- - *f* c ** f 3fr'*3^*3y"gf$3tiig*zt*3'g ll ^ 

' <Cv^<> * T - "*j " C *~ ***--~*&^3* 

:- 

- , .,,, 



" S - --""rf* 1 *. "* **** V ^ * *^~* *^" - 

- -" ~' " "-. * -"*' 






Fig. 103. Same keloid as in Fig. 102 after radiation. Highly magnified. Greater development 
of the connective tissue cells; polymorphism of these cells; notable increase of elastic fibers. 

//, Epidermis directly above corium in a state of transformation. B, Surface zone of the 
keloid transformed into young fibroma, rich in cells. C, Young fibroblasts forming a zone resem- 
bling a myomatous development. D, Deeper zone which has undergone less advanced changes. 

In keloids mixed with scar tissue, the prognosis is not so favorable as 
more intensive treatment must be given. 

The Technic of Treatment of Keloids. The technic of treatment of 
true keloids will vary greatly according to the age of the patient and the 
size and duration of the lesion. A tentative course of treatment may 
first be given. One-fourth or one-half strength varnish or glazed ap- 
plicators may be used. Screened with Yi mm. of lead and applied 
closely to the skin, a course of two to four hours in six periods may be 



248 



RADir.M TIIKU.U'Y 



given. At a distance of 2 mm., the time may be doubled. In children 
one-half or one-fourth of this dose should be used. In keloids of con- 
siderable thickness, radium salts or emanation in tubes instead of varnish 
plaques may be used advantageously. One hundred millicuries of radium 




Fig. 104. Keloid of right great toe. Photograph taken May, 1914. Patient referred by Dr. J. R. 

Buchbinder. 




l ; ig. 105. Patient in Fig. 104 after radium treatment. Photograph taken Jamuiry, 1915. 

emanation having a concentration of 5 millicuries per square centimeter, 
screened with 1 millimeter of lead and at a distance of 1 centimeter may 
be applied for eight or ten hours in periods of one or two hours each. 
The series of treatment may be repeated in about six weeks, but the sub- 
sequent course should be of less intensity. 



RADIUM IN DERMATOLOGY 249 

"Above all, the principle which governs the technie, and of which the 
operator must never lose sight, is the necessity for influencing the 
keloids to the extreme depth of their base, and acting on their peripheral 
prolongation's, which sometimes extend far beyond their visible limits. 
The treatment of a keloid should only be considered complete when the 
tissues show an almost normal elasticity on palpation, even at a depth. 

"It is possible then, to make use of total radiations of great power, 
composed largely of Beta rays, and employ them in frequently repeated 
exposures of short duration; or of 'surpenetrant' radiations of weak 
quantitative value, allowing them a sufficiently long action; or of the 
simultaneous application of several instruments acting opposite each 
other, by the system of 'cross fire.' By these means, which lead to the 
absorption of the growths, we can utilize the selective power of radium. 
But they are sometimes slow, and in order to gain time it is often well 
to act more energetically, undeterred by the fear of producing a certain 
degree of destructive inflammation. In the application of these different 
processes, two important data must be borne in mind, viz., (1) the great 
resistance shown by keloidal tissue, from which results the possibility of 
using fairly large doses, without producing any reaction worth mention- 
ing; (2) the futility of aiming at the entire avoidance of superficial inflam- 
mation. If the 'specific' dose be slightly exceeded, a small dry crust 
with a dry base is produced which will not in any way hinder the course 
of the treatment. If there is any hesitation as to which of two doses, 
intended to obtain simple modification without destruction, shall be 
chosen, there can, therefore, be no objection to deciding on the stronger. 
Keloids which respond most readily to the employment of specific doses 
are those of recent formation in process of evolution, and those of young 
children." ("NVickham and Degrais.) 

In the treatment of keloids mixed with scar tissue and also in dealing 
with fibroselerotic bands, the doses suggested above may be slightly in- 
creased so as to cause an actual destructive reaction. This procedure 
should be followed, however, only when the milder doses have failed. 
It must be remembered also that destructive doses may cause a reaction 
requiring weeks for healing and that telangiectasia may eventually occur. 
Even under these circumstances the final result, skillfully produced, is 
usually much to be preferred to the original lesion. As pointed out by 
Wickham and Degrais not all disfiguring scars are amenable to radium 
treatment. Depressed scars, e.g., such as those resulting from smallpox, 
cannot be remedied by radium. 



250 



RADIUM T11KRAPY 




Fig. 106. Keloid of back due to burn from a flat-iron. The tumor was situated between the spine 
and lower angle of right scapula. Photograph taken April, 1914. 



RADIUM IN DERMATOLOGY 



251 




Fig. 107. Patient in Fig. 106 after radium treatment. Photograph taken September, 1914. 
Only the lower portion of the keloid had been treated when the photograph was taken. Later the 
rest of the tumor was removed with radium. 



252 



RADIUM THERAPY 




1'ig. 108. Keloid of back of neck. Recurrence after surgical removal. 1'atient referred by Dr. 

Uayard Holmes. 



RADIUM IN DERMATOLOGY 



253 




Fig. 109. Patient in Fig. 108 after radium treatment. 



254 



RADIUM THERAPY 




Fig. 110. "Acne keloid" of back of neck. 



RADIUM IN DERMATOLOGY 



255 




Fig. Ill . Patient in Fig. 110 after radium treatment. 



256 



RADIUM THERAPY 




Fig. 112. Keloid of face following a htirn. Patient referred by Dr. T. R. Ilinchion. Photograph 

taken January, 1919. 



RADIUM IN DERMATOLOGY 



257 




Fig. 113. Patient in Fig. 112 after radium treatment. Photograph taken June, 1920. 



258 



RADIUM THERAPY 



(b) Angiomata and Lymphangiomata 

Angiomata and lymphangiomata, as a class, were most unsatisfactory 
to treat until the advent of radium. Many of the more modern methods, 
such as the injection of boiling water or hydrogen peroxide, desl motion 
by liquid air, C0 2 snow, electrolysis, etc., are more or less painful and 
on this account alone are unsatisfactory, particularly in the treatment 
of children. With these destructive methods, it is difficult or impossible, 








in extensive cases, to obtain uniformity of coloring of the affected areas. 
With radium, on the other hand, a fading rather than a destruction of 
the angioma can often be brought about. While a certain place is left 
for other methods, radium is our most satisfactory agent in dealing with 
most cases of angiomata and lymphangiomata. Not all cases respond 
equally well, but in favorable and selected cases a good cosmetic result 
may be anticipated. 
In considering the treatment of angiomata with radium from a clin- 



RADIUM IN DERMATOLOGY 



259 



ical standpoint, we may follow, in the main, the grouping suggested by 
Wickham and Degrais. On the basis of treatment, these authors have 
divided vascular nevi into the following groups : 

1. Flat, superficial angiomata, level with the skin. 

2. Flat, deeply infiltrating angiomata, level with the skin. 




Fig. 115. Same angioma as in Fig. 114, after treatment with radium by tiie method of 
"selective reaction," i.e., without visible macroscopic inflammation. Slightly enlarged (120 di- 
ameters). The epidermis is of normal thickness and freed from interpapillary encroachments. The 
derma is composed of connective tissue rich in. cells of mature fibroblast type, which are arranged 
parallel to the epidermis. The connective tissue and elastic fibers have a uniformly regular arrange- 
ment, vessels are scanty, hairs and follicles have disappeared, only traces of sudoriparous glands. 

A, Epidermis resting on basal tissue which is hardly recognizable. H, Zone below the epider- 
mis, where the cells are abundant and parallel to each other and to the epidermis. CC, Traces of 
sudoriparous glands. D, Star-shaped connective tissue cells which have not yet evolved into mature 
fibroblasts. 



face. 



Raised angiomata, usually with hard and more or less sclerotic sur- 



4. Raised angiomata, usually soft and sometimes pulsatile and erectile. 

5. Deep, subcutaneous and submucous angiomatous tumors. 

The above groups include the more common types of angiomata. These 



260 



RADIUM THERAPY 





RADIUM IN DERMATOLOGY 



261 




. o 

re o 




2G2 



RADIUM THERAPY 




Fig. 120. Cavernous angioma of lower lip. Patient referred by Dr. S. I,. Fridus. 



KAD1UM IN DERMATOLOGY 



2G3 




Fig. 121. Patient in Fig. 120 after radium treatment. 



264 



RADIUM THKRAPY 




Fig. 122. Flat angioma of side of face, neck, chin and lower lip. 



RADIUM IN DERMATOLOGY 



265 




Fig. 123. --Patient in Via. 1-- after radium treatment. Tlic result in this case was better than in- 
dicated by the photograph. The angioma was removed by "selective reaction." 



2(56 



KAIUUM THERAPY 





RADIUM IN DERMATOLOGY 



267 





268 



KADIUM THERAPY 




Fig. 128. Slightly elevated angioma of side of face. Lesion was of dark. ]iurpli>li-ri'il colur. I'a- 
tient referred by Dr. H. Kdward Sauer. 



RADIUM IN DERMATOLOGY 



269 




' Fig. 129. Patient in Fig. 128 after radium treatment. The result in this case is not^ as pood 
as indicated in the photograph as a few tclangifc use:-, have appeared in the last year. Tin s< arc 
easily concealed, however. 



270 



RADIUM THERAPY 




Fig. 130. Angiosarcoma (?) of left arm; note tumor of arm and fiat angioma of back of arm. 

Photograph taken April, 1916. 



RADIUM IN DERMATOLOGY 



271 




Fig. 131. Patient in Fig. 130 after radium treatment. Note the disappearance of tumor 
and normal outline of arm. Method o dressing with strips of rubber tissue. A superficial derma- 
titis is also shown. Photograph taken June, 1916. Patient was well five years later. 






272 



RADIUM THERAPY 





= 3 
o 

as 






RADIUM IN DERMATOLOGY 273 

different types, however, merge into each other and different forms may 
be present in the same person. 

The Technic of Treatment of An'iomata. The method of treatment 
\vith radium naturally varies with the type. For most superficial angio- 
mata, nothing equals the "toiles" or the glazed plaques. For deep 
angiomatous tumors, tubes may be employed, although the flat appli- 
cators answer equally as well. 

1. Flat Superficial Angiomata ("Port-wine Stains"). In the treatment 
of this type of tumor, one cannot too strongly insist upon the necessity 
of the avoidance of inflammatory reaction. The production of slight 
redness and scaling of the skin is sometimes permissible, but an endeavor to 
bring about more rapid results by strong treatment will only be fraught 
with disaster. If the dosage is too powerful or the technic unskillful, the 
coloring may not be uniform and telangiectasia may occur. As an ex- 
ample of the technic, we may suggest the use of a ] /(>o strength "toile." 
With this style of applicator screened with 1 /iiio or vfio mm. of aluminum 
and applied closely to the skin, an exposure of from two to four hours in 
periods of an hour each on successive or alternate days will suffice. In 
children, one-half of the above dose should be given. If a slight fading 
of the angioma occurs in six or seven weeks, sufficient will have been 
accomplished. Subsequent series of treatments should be of less inten- 
sity. With no class of cases is a refined and skillful technic more neces- 
sary in order to accomplish good results. Sometimes only a partial 
fading of the angioma can be brought about. 

2. Flat, Deep 1 .// Infiltrating Angiomata. Th? method of treatment of 
this type of angiomu is similar to that employed in the first group, except 
that it is permissible to use stronger dos-o.s. Angiomata of the first group 
can sometimes be quite well concealed by the artifices of the toilet. An- 
giomata of the group that we are now considering are often so deeply 
colored and unsightly that no amount of artificial coloring or disguising 
really conceals them. We are justified, therefore, in proceeding some- 
what more boldly. With the same apparatus and screen used in treating 
tumors of the first group, we may give an exposure of five hours in 
periods of an hour each on successive days. With one-fourth strength 
apparatus, screened with one-tenth millimeter of lead and applied closely 
to the skin we may give a total exposure of from three to four hours. 
At a distance of 2 millimeters, six or eight hours may be given. Only a few 
square centimeters should be treated at one time until the effect is ob- 
served. Severe reactions should be avoided. In subsequent courses of treat- 
ment, instituted after six weeks or two months have elapsed, the screening 
may be increased to -/K, mm. of lead and a total exposure of five or six hours 
in several periods of one or two hours each may be given. It is difficult to 
obtain goo'd results in this group, but in some cases the final appearance 
is excellent. 



274 RADIUM THERAPY 

3. Rained "Hard", Angiomata. This group comprises a considerable 
number of clinical types with no exact limitations. The size and extent 
of the tumors vary greatly. In some, the surface may be smooth; in 
others papillated and irregular. A varying degree of hardness is noted 
on palpation, some being quite sclerotic. In this group, one is justified 
in producing definite reaction. With % strength applicators, applied 
closely to the skin, a total exposure of two hours when unscreened, 
or five hours when screened with Vio mm. of lend may be given as a first 
course. Screened with Vio nun. of lead plus 2 mm. of rubber, ten hours 
may lie given. Not over 4 square cm. should be treated ill one time. The 
treatment should be divided into several periods of one hour e;ieh. AY lieu 
the rend ion subsides, a less intensive course with double Hie thickness of 
screen may be given. 

4. Raited, "Soft" Aii</ioni<ilii. Tn this group are included variously 
si/.ed tumors. A frequent lype is the "cavernous angioma," seen partic- 
ularly in infants. This tumor is elevated one or more centimeters above 
I lie skin level, and is frequently limited to an area of several square 
centimeters. In more extensive cases, the entire side of the head may be 
involved so that there is great deformity. It is in this group that radium 
is particularly satisfactory in its effects. One should endeavor to utilize 
to the fullest extent the selective action of radium. Success frequently 
attends doses that produce little or no inflammatory reaction. The "cross 
fh-e" method suggested by Wickham, in which the raised tumor is attacked 
from different sides, is especially useful. With one-quarter strength 
applicators, screened with one-tenth millimeter of lead and applied 
closely to the skin, an exposure of three or four hours in several periods 
may be given on one area. At a distance of 2 millimeters, eight hours 
may be given. As in the previous instances, not over 4 square cm. should be 
treated until the effect is observed. The course may be repeated in six or 
eight weeks. In the case of very extensive tumors in infants, an exposure 
of two hours when the applicator is closely applied may be sufficient for 
the first course of treatment. Subsequent courses should be of less intensity. 

5. Deep, RubcutdHfous and Snbnnicous Tumor*. Very extensive tumors 
may be treated successfully. Tn these eases the deep penetrating method 
should be used. It is best to treat separate sections of the tumor succes- 
sively so as not to give an overdosage. Tubes may be used in this type 
of tumor, although plaques are more satisfactory. One hundred and fifty 
millicuries of radium emanation, having a concentration of 5 millicuries 
per square centimeter, screened with 2 millimeters of brass and placed at 
a distance of two centimeters, may be used on an area of about 30 square 
centimeters for ten hours in several periods of two or three hours each. 
Full-strength radium plaques may be used in a similar manner. 

The "cross fire" method should be utilized to the utmost in order to 
spare the skin. At intervals of six or eight weeks, subsequent courses of 
less intensity may be needed, although two, or at most three, courses are 



RADIUM IN DERMATOLOGY 



275 





276 



RADIUM THERAPY 




Fig. 136. Pigmented nevus of left lower eyelid and face. 



RADIUM IN DERMATOLOGY 



277 




Fig. 137. I'atient in Fig. 136 after radium treatment. 



278 



RADIUM THERAPY 





KADHJM IN IIKUMATOLOGY 



270 





280 



THERAPY 



usually sufficient. Oftentimes, large angiomatous tumoi's may be made 
to disappear without inflammatory reaction, the overlying skin being 
scarcely or not at all affected unfavorably. The writer has treated with 




Fig. 142. Tuberculosis verrucosa cutis of first phalanx of left middle finger. 




Fig. 143. Patient in Fig. 142 after radium treatment. 

radium more than three hundred angiomata of various types. In some 
cases, the results have been excellent. In a few cases, there has been 
no noteworthy improvement. 



RADIUM IN DKRMATOLOGY 



281 



The Technic of Treatment of Lymphangiomata. These rare tumors 
yield in excellent fashion to radium. Abbe reported upon the treatment 
of the first cases in 1915 and a few months later I reported an extensive 
case involving the buttock and thigh that had been successfully treated. 
In lymphangiomata affecting the mucous membranes and particularly 




Fig. 144. -Tnlu -rcnlusis \ernicosa cutis of first phalanx of li-ft thumb. 




FiK- 145. Patient in I'ig. 144 after radium treatment. 

the tongue, radium is of unique value and can hardly be replaced by any 
other agent. The method of treatment is similar to that for angiomata 
of the third group. 

(c) Nevus Pigmentosus 

Pigmcnted nevi involving an area of several square centimeters are 
amenable to radium. Very minute nevi should be treated by other meth- 



'JS2 



RADIUM TIIKUAI'Y 



ods. Growths that are very unsightly in consequence of rugosities and 
great thickening. Hie presence of hair, and very dark pigment, are espe- 
cially likely to yield to treatment. Radium lias unfortunately no selec- 
tive action on pigmented nevi and in order to cause them to disappear 
destructive doses must lie iised. The final result therefore may not be 
as good as in angiomata, due to the fact that the treated area may lie 




Fig. 14fi. Lupus vulgaris of right check in girl aged 13. 

unevenly colored and there may be points of repigmentation. We do 
not therefore recommend the use of radium in faintly pigmented nevi. 
The Technic of Treatment of Pigmented Nevi. Great care should be 
used in the treatment in order not to give excessive doses. With one- 
quarter strength applicators, applied closely, an exposure of one or two 
hours may be given without screening. Following this, an exposure of 
two hours with a screen of % millimeter of lead may be given. This 



RADIUM IN DERMATOLOGY 



283 



procedure produces a slightly destructive action. The treatment may 
be repeated, but with less intensity, in eight weeks. The final result will 
depend very largely upon the judicious selection of cases and perhaps 
most of all, as in other cosmetic difficulties, upon the skill and care with 
which the treatment is carried out. 

"Fordyce's disease" of the mucous membrane of the cheek and lips 




Fig. 147. raticnt in Fig. 146 after radium treatment. 

lias been treated successfully by Hayward Pinch, myself and other writ- 
ers. A glazed plaque of % strength, unscreened, may be used and a sharp 
reaction may be produced. An exposure of forty-five to sixty minutes 
may be given and repeated, if necessary, in a few weeks. 

In various other benign tumors of the skin, radium has been found to be 
of value. Among these may be mentioned especially linear nevus, in which 
radium is of the greatest value. Dermatitis papillaris capillitii, molluscum 



284 



RADIUM THERAPY 




Kig. 1-48. Lupus vulgaris of right cheek. 

contagiosum, multiple benign cystic epithelioma and some types of xan- 
thoma are also susceptible to radium. 

C. CHRONIC INFECTIONS 

(a) Tuberculosis 

In certain types of skin tuberculosis, radium is of value. Tuberculosis 
verrucosa cutis frequently responds well. Destructive doses, such as may 



RADIUM IN DERMATOLOGY 



285 




itf. 149. Patient in Fig. 148 after radium treatment. 



be obtained by using % strength applicators with a screen of ^Q mm. of 
lead for five or six hours in several periods of one to two hours each, may 
be used. In lupus vulgaris, radium is only of limited vise, being, in the 
writer's judgment, distinctly inferior to the Pinsen light. In using radium, 
the best plan of procedure consists in using % or % strength glazed appli- 
cators with a y w mm. lead screen. A total exposure of six to twelve hours 
may be given in divided doses. Only small lesions should ordinarily be 



286 



RADII' M THKRAPY 



treated. Large lupus patches may even spread at the border and become 
worse under radium treatment if insufficient doses or unskillful technie 
are. used. It is the general experience that radium has practically no 
selective action on lupus tissue. In lupus vulgaris of the mucous mem- 
branes, radium often has a very beneficial effect. Doses of less intensity 
than those used for the skin should lie employed. 

(b) Blastomycosis 

In 191.'!, the writer reported the results of the radium treatment of blas- 
tomyeosis of the eyelid. Since that time, several other cases of blastomy- 
cosis of the skin have been treated successfully. Radiation similar to that 





Fig. 150. Ulastoniycosis of left inner cantlins 



Kit;. 151. Patient in FIR. 1.^1 after railium 
t reatment. 



used for tuberculosis, but of less intensity is efficient. Degrais, Wickliam 
and others have found local radium treatment of value in aiding resolu- 
tion of syphilitic skin eruptions. The technie is similar to that described 
above as suitable in tuberculosis. 

Radium has been used successfully by Kahler, Guttman and others 
in rhinoscleroma and by Ileverdald in aetinomvcosis. 



1). INFLAMMATORY AND GRANULOMATOUS INFILTRATIONS OF 

UNCERTAIN NATURE 

In this group of dermatoses, radium is of considerable value. In 
psoriasis, lichen planus, lichen chnmicus simplex, chronic eczema and 



RADIUM IN DERMATOLOGY 



287 




Fig. 152. Lupus erytlu-niatusus <>f nose and checks. 




Fig. 153. Patient in Fig. 152 after radium treatment. Photograph taken two months after 

treatment. 



288 



KADI I'M THKRAl'Y 



lupus erythematosus, radium treatment offers, in selected cases, a great 
amount of relief. 

In psoriasis of the nails, radium is particularly useful. In obstinate 
patches of psoriasis that do not yield to ordinary measures radium may 
be used successfully. It must lie remembered, however, that neither 
radium nor any other measure prevents recurrence of the patches. With 




rythematosus involving nose and chetk^. 



Fig. 154. ly 



% strength applicators, screened with % mm- of lead, an exposure of 
one or two hours and often less, in several periods, is usually sufficient 
to cause involution. Inflammatory- reaction should be avoided. 

In lichen planus confined to small areas radium often relieves the 
itching and hastens involution. In lichen planus of the mucous mem- 
branes, radium is especially valuable. The technie of treatment is the 
same as that suggested for psoriasis. Not more than % of the dose em- 
ployed on the skin should be used on lesions of the mucous membranes. 



RADIUM IN DERMATOLOGY 



28!) 



In lichen chronicus simplex, radium often gives the most striking 
relief, the itching frequently disappearing very promptly. Short appli- 
cations of ] /4 to % strength glazed applicators, unscreened, are advisable. 
Two or three exposures, each lasting three minutes, and repeated at 
intervals of a week, are efficient. Inflammatory reaction should be 
avoided. 

Certain cases of chronic eczema may yield to similar treatment. 

The writer has treated more than 50 cases of lupus erythematosus 




Fig. 155. Patient in Fig. 154 after radium treatment. 

with radium. In this curious and puzzling disease, radium is one of 
our most valuable agents. Considerable judgment is necessary in treat- 
ing this disorder, and caution should be practiced until the degree of 
irritability of the individual case is made evident. Most cases require 
only a moderate reaction to produce evolution. Treatment may be car- 
ried out by employing % strength glazed applicators, screened with 
Yin mm. of lead. One-half hour exposures may be given on successive 
or alternate days until four or five treatments have been given.- The 



290 



RADIUM THERAPY 




Fig. 156. Lupus erytbematosus involving right cheek and upper lip. 



RADIUM IN DERMATOLOGY 



291 




Fig. 157. Patient in Fig. 156 after radium treatment. 



292 



RADIUM THERAPY 




Fig. 158. Lupus erythematosus of four years' duration. 



RADIUM IN DKRMATOLOGY 



293 







Fig. 15y. Patient in Fig. 158 after radium treat men t. Involuted areas show the scarring of the 
disease and are of a lighter color than the normal skin. 



294 RADIUM THERAPY 

effect is noted and the treatment is repeated as soon as the reaction, which 
may last for from two to four weeks, has subsided. Care must be taken 
that the edge of the applicator overlaps for at least five to ten millimeters, 
the visible edge of the disease. This treatment is usually adapted only to 
the cases of "fixed type." Freedom from the disease for several years 
may be experienced in certain cases. In other cases, a relapse may occur 
in a few months, or even sooner. In some cases of lupus erythematosus, 
little benefit is derived from the treatment. In leukemia cutis, radium 
is of value and may cause resolution of the involved areas. 

E. HYPERTROPHIES 

In many of the disorders classed as hypertrophies, radium is of con- 
siderable value. In clavus, callositas, and the various keratoses, such as 
keratosis senilis, x-ray keratosis, angiokeratoma, etc., radium is of value. 
The general method of treatment of these disorders consists in the use 
of % strength apparatus, unscreened, for one-half to two hours, or 
screened with ^Q mm. of lead for three to four hours. 

Warts and Papillomata 

Although often regarded as trivial, the subungual and periungual wart, 
and the palmar and plantar wart deserve special mention because they 
are peculiarly resistant to the ordinary dermatologic measures. The 
plantar wart may cause great distress and pain on walking. As a rule, 
all these growths yield easily to radium treatment. One-fourth strength 
glazed apparatus unscreened applied carefully for from one-half to 
two hours is usually sufficient to cause involution. A still better method 
in some cases, because the reaction produced is negligible, consists in 
using the same apparatus, screened with %<> mm - of lead, for four hours 
in periods of one hour each. In certain rare disorders, such as acanthosis 
nigricans and Darier's disease, radium treatment would undoubtedly 
be of value insofar as the removal of localized areas of the disorder is 
concerned. R. L. Sutton has used radium successfully in a "synovial 
lesion" of the skin. 

F. NEUROSES OF THE SKIN 

We have already spoken of the relief obtained by the use of radium 
in certain itching dermatoses, notably lichen chronicns simplex, lichen 
planus, and eczema. There are other disorders classed as neuroses in 
which the subjective symptoms are prominent, but in which little or 
nothing is seen objectively except the lesions produced by scratching. 
Localized pruritus, such as pruritus ani and pruritus vulvae, is fre- 
quently relieved by radium. In these affections, the best method of 
treatment is by means of unscreened glazed apparatus. Exposures of 



RADIUM IN DERMATOLOGY 295 

three to five minutes' duration repeated several times at intervals of 
a week, may be given. The total amount of radiation should never be 
sufficient to produce an inflammatory reaction. In various other affec- 
tions, the analgesic action of radium has been made use of. In hyper- 
esthesia, following herpes zoster, in neuritis and in intercostal and sci- 
atic neuralgia, Wickham found radium of value. He used approximately 
% strength apparatus screened with %o mm. of aluminum and gave 
applications of from ten to fifty minutes. Reaction in the skin should be 
avoided in this class of cases. 

G. DISORDERS OF THE APPENDAGES OF THE SKIN 

(a) The Sebaceous and Sweat Glands 

In selected cases of acne rosacea radium is of value. In rhinophyma 
very good results have been obtained by Wickham and Degrais and oth- 
ers. In these cases, % strength glazed applicators, screened with %o mm. 
of lead, are usually employed and a slight reaction may be produced. 
A total exposure of two or three hours in several periods will usually 
be sufficient. Subsequent courses may be given at intervals of three to 
six weeks. Oood results may follow the local treatment of acne varioli- 
formis although, of course, no influence is exerted in preventing the for- 
mation of new lesions. In hyperidrosis, radium is sometimes of value. 
The glazed plaques are the most convenient form of apparatus. Inflam- 
matory reaction should never be produced. 

(b) Hair and Hair Follicles 

In the extreme cases of hypertrichosis which may cause so much men- 
tal anguish as to wreck the happiness of the individual, radium may 
occasionally be employed. Sometimes, however, in order to produce per- 
manent alopecia a degree of atrophy must be produced that is undesir- 
able. Telangiectasia may also be caused. In selected cases, however, we 
have obtained very excellent results. In hypertrichosis, the following 
technic may be used. All areas that are not to be affected must be cov- 
ered by at least 5 mm. of rubber covered lead. One hundred fifty me., 
screened with 2 mm. of brass, may be arranged on a wooden pad 6x8x2 
cm. At a distance of 2 cm., which is the thickness of the wooden pad, an 
exposure of thirty hours in two periods may be given. In cases in which 
temporary alopecia is desired, as in ringworm and sycosis vulgaris, ra- 
dium may be used instead of x-rays, though often inferior in convenience 
to the latter agent. Radium is perhaps safer in inexpert hands. In 
extensive ringworm of the scalp, we have used the following technic. 
Blocks of soft wood or cork (2x2x1 cm.) may be arranged to form an 
applicator having a superficial area of 100 square centimeters. Radium em- 



296 



RADIUM THERAPY 




Fig. 160. Sycosis vulgaris. 




Fig. 161. Patient in Fig. 160 after removal of hair with radium. 



anation tubes may be arranged on this applicator in the ratio of 1.25 me. 
per square centimeter. Screened with one millimeter of silver and at a 
distance of one centimeter, an exposure of forty-five hours may be given 
in three periods of fifteen hours each. Temporary alopecia results. 



CHAPTER XVIII 

RADIUM IN OPHTHALMOLOGY, OTOLOGY, RHINOLOGY AND 

LARYNGOLOGY 

OPHTHALMOLOGY 

A. Malignant Tumors 

Epithelioma of the Eyelid has been referred to in the chapter on 
Radium in Dermatology. 

Epithelioma of the Conjunctiva has been successfully treated by Wick- 
ham and Degrais and others. 

Sarcoma of the Orbit has been considered in the chapter on Radium 
in General Surgery. 

B. Vernal Conjunctivitis 

In vernal conjunctivitis radium is of considerable value. Sometimes 
the most rebellious cases are completely relieved. Treatment should be 
carried out cautiously. A "full strength" applicator unscreened may 
be employed and a fifteen minute exposure given. In two weeks the 
exposure may be repeated, but only if inflammatory reaction has been 
slight or absent. Instead of the above type of applicator radioactive 
deposit may be collected on lead foil and used in a similar manner. 
Abbe, Allport,. Butler, Davidson and Lawson, Schnaudigel, Shine, Shiun- 
way, and many others have reported successful results. 

C. Trachoma 

Radium is often of benefit in this intractable condition. The teclmic 
is similar to that suggested for vernal conjunctivitis. 

D. Cataract 

Cohen and Levin have reported upon the use of radium in twenty-four 
cases of immature cataract and claim improvement in 87.5 per cent of the 
cases. Twenty to forty milligrams of radium element were used. 
Gamma rays only were utilized. The radium was applied over the closed 
eyelid at a distance of two centimeters for two hours. 

W. S. Franklin and F. C. Corcles have apparently confirmed these results. 
Those authors have treated thirty-one cases of immature cataract of 
which 84.3 per cent showed a change for the better ranging from an 
improvement of three to four letters on the test chart to a complete dis- 
appearance of the process. They used the following teclmic. At a dis- 

297 



298 RADIUM THERAPY 

tance of 1.2 cm. from the eye, 10 mg. hours were given twice a week for 
four weeks and then once weekly until the process was stationary. The 
gamma rays from about ten milligrams of radium element contained in 
a glazed plaque having an area of 50.26 square millimeters were utilized. 

OTOLOGY 

In granulomata and papillomata in the external auditory canal, radium 
is frequently of great value. I have treated a number of cases in which 
recovery has been brought about. Fifty inillicuries screened with 0.5 mm. 
of silver plus 0.5 mm. of gold may be used in the external auditory canal 
for six hours in periods of one hour each on alternate days. In "tinnitus 
aurium" radium has not been of marked benefit. Little improvement 
can be expected from the treatment of "chronic deafness" due to mid- 
dle ear disease. I have treated in conjunction with 0. T. Freer a number 
of cases of this character without definite benefit. 

RHINOLOGY 

Carcinoma and sarcoma of the nasal passages have been considered 
under Radium in General Surgery. In chronic ethmoiditis with recur- 
ring polypoid degeneration, radium has been used with good results by 
0. T. Freer and T. Melville Hardie. A platinum tube having a wall thick- 
ness of 0.3 mm. and containing 50 me. of radium emanation may be 
inserted into the ethmoid sinus for five hours in periods of an hour each. 

LARYNGOLOGY 

A. Malignant Growths of the Larynx 

Carcinoma and sarcoma of the larynx have been mentioned under 
Radium in General Surgery. The technic of intralaryngeal radiation is 
described below. 

B. Benign Growths of the Larynx 

1. Papilloma of the Larynx. Abbe has reported a remarkable and suc- 
cessful case of papilloma of the vocal cord in which complete relief was 
obtained. The singing voice was restored and recovery has been main- 
tained for more than ten years. In this patient a preliminary tracheot- 
omy was performed and anesthesia was continued through the tracheot- 
omy opening during the radium application. One hundred milligrams 
of radium were applied, by means of a wire passed through the trache- 
otomy wound into the mouth, for thirty minutes. 

In a personal communication to the writer, Abbe states that other 
similar cases have since been treated and have done equally w T ell. 



OPHTHALMOLOGY, OTOLOGY, AND LARYNGOLOGY 299 

G. B. Nc\v, of the Mayo Clinic, states that "the treatment of multiple 
papilloma of the larynx in children has been improved wonderfully by 
the addition of radium. 

"The patient is suspended with the Lynch suspension apparatus, the 
papillomas are cleared out, and while thus suspended the radium is 
placed in the larynx in children with tracheotomy." 

2. Angioma of the Larynx. G. B. New, of the Mayo Clinic, has re- 
ported the results of the treatment of an angioma of the larynx occurring 
in a child. The growth caused "dyspnea which would have been very 
difficult to benefit in any other way. The angioma was entirely cleared 
up by the external application of radium." 

3. Chronic Infections. Laryngeal Tuberculosis. The results of treat- 
ment of this condition have varied. In a case of laryngeal tuberculosis 
treated in conjunction Avith Dr. 0. T. Freer several years ago the result 
was not favorable. In this case the radium was held in the larynx by 
means of an intralaryngeal applicator. Fifty milligrams screened with 
one millimeter of silver was applied in periods of ten to fifteen minutes 
each, a total exposure of three hours being given. In another case in which 
two small lesions were present on the right vocal cord complete resolu- 
tion was obtained by external applications. In this case, two hundred 
millicuries screened with two millimeters of lead and placed at a dis- 
tance of two centimeters were applied for thirty hours in periods of fif- 
teen hours each. 

Technic of Laryngeal Applications. Surface Radiations over the Lar- 
ynx. It is frequently possible to influence favorably benign and malig- 
nant tumors of the larynx by surface radiations alone. Benign tumors 
may be cured by surface radiations alone but malignant lesions require 
intralaryngeal radiations as well. At a distance of 3 cm., 250 me. screened 
with 2 mm. of lead may be applied for twenty hours in periods of ten 
or more hours each. Four hundred me. may be applied at a distance of 
6 cm. for thirty hours in several periods. 

Intralaryngeal Radiations. In the technic of intralaryngeal radiations, 
a strong vise-like clamp (Fig. 162) is fastened to the forehead by a strap 
acting as a head-band. A metal forehead plate serves as a base for the 
clamp. Long stemmed applicators (Fig. 163) made of copper tubing 
ending in a holder (Fig. 164) securely grasp the screen containing the 
emanation tube which is thus placed exactly upon the desired area in 
the larynx. In making a laryngeal application the larynx is first anes- 
thetized with cocaine flake crystals made into a mud by contact with a 
slightly moist swab. The local anesthesia is then reinforced with anes- 
thesine powder insufflated into the pharynx and larynx. In order to 
introduce 'the emanation tube into the larynx, the applicator is seized by 
the thumb-plate (Fig. 163) and the screen is inserted into the larynx 
with the aid of the laryngeal mirror. Except in the case of papilloma of 



300 



RADIUM THERAPY 



the larynx in children, neither direct laryngoscopy nor suspension hir- 
yngoscopy is needed. When the screen has been introduced into the 
larynx, an assistant passes the stem of the applicator into the space be- 
tween the jaws of the clamp which he closes upon the applicator stem, 
thus fixing the screen in place. Usually the tube may be retained for 




Fig. 162. The Freer clamp for the intralaryng-eal application of radium. The clamp seen from 
above affixed to the forehead plate of the head-strap and open to receive the tubular stem of the 
applicator. 




F.A.HARDY*Cd 



Fig. 163, The applicator held in the jaws of the Freer clamp with the screen containing radium 
emanation in the glottis as indicated by heavy dotted lines. 



OPHTHALMOLOGY, OTOLOGY, AND LARYNGOLOGY 



301 



from ten to sixty minutes without retching or distress. The hollow stem 
carrying the emanation tube is attached to an electric suction pump 
which serves to keep the throat constantly free of saliva and secretions. 
The use of moderately large doses is of great value in the treatment of 
feeble patients. An exposure of 400 me. hours may be given in the course 
of a week or more. 

With intralaryngeal and surface radiations combined I have treated, 
in conjunction with Dr. 0. T. Freer, 19 carcinomata of the larynx. Of 
these 5 were extrinsic, 14 intrinsic. Clinical recovery has occurred in 
9 of the intrinsic and in one of the extrinsic cases, and has been main- 
tained for from 2 to 12 months. One case recently developed a metas- 
tasis in the humerus but the larynx is clinically well. Of the remaining 



FAHARDYsCO. 




Fig. 1^4. A, Enamel silver tube containing capillary glass emanation tube: B, Screen fastened 
to tubular copper applicator at a a by means of copper wire soldered into grooves at sides of ap- 
plicator and run through eye of screen. Screen holds one enamel tube only; C, silver screen with 
cap; wall thickness of screen 1 mm. These screens hold from 2 to 6 emanation tubes and are 
identical with the screens used for surface radiation previously illustrated; D, silver screen seen 
on edge, fastened into notch of holder by No. 24 copper wire a a shown by heavy dotted line to 
indicate passage of wire through holes passing through jaws of notch, walls of screen, and its cap 
and thence into interior of tubular holder through holes at a a. The wire is shown twisted in the 
saliva hole of the holder in order to lock the screen safely to the holder; /:, holder and screen seen 
on the flat to show the holes at (a) connected by a groove, the holes being bored to pass copper wire 
through jaws of notch, screen, and its cap and thence into the interior of the tubular part of the 
holder; /', socket holder to hold screens for use in the glottis. The holders must be individually 
made to fit each screen. The advantage of this holder lies in the firmness with which it grasps the 
screen. 

9 patients, seven were too far advanced for more than palliation and 
two who have been under treatment for only a short time were also of the 
advanced type. In one case of multiple papillomata of the right vocal 
cord and in one case of diffuse, hypertrophic laryngitis with great deform- 
ity accompanied by loss of voice for fifteen months, complete recovery 
occurred. In both cases the voice was restored and the larynx shows no 
trace of the pathological process, the cords appearing white and normal. 



302 RADIUM THERAPY 

A rapidly growing sarcoma of the right vocal cord recently under 
treatment completely disappeared leaving the larynx nearly normal ex- 
cept for some cicatricial retraction. Relapses are to be anticipated in a 
certain percentage of the cases of malignant tumors of the larynx. 

The intralaryngeal treatment is usually reinforced by deep gamma 
radiations applied to the surface of the skin over the laryngeal region. 
The applicators and the technic of intralaryngeal radiations which we 
have just described have been devised and made of practical utility by 
Dr. Otto T. Freer. 

Hypertrophy of the Tonsils 

C. A. Simpson, W. A. Wells, the writer, and others have found radium 
of value in the treatment of certain cases of hypertrophied tonsils. 

Simpson has used a double strength dermatological applicator contain- 
ing 30 mg. of radium element. This was wrapped in rubber dam and 
applied unscreened for one hour. Wells has inserted radium contained in 
metal needles into the tonsil. In some cases, 100 me., screened with 
1 mm. of silver plus 1 mm. of rubber may be applied for 1 hour to each 
tonsil. The normal tissues of the throat must be carefully protected. 

In selected cases, radium treatment may be substituted for operative 
removal of the hypertrophied tonsil. 



CHAPTER XIX 
RADIUM IN DISEASES OF THE DUCTLESS GLANDS 

A. LEUKEMIA 

Renon, Degrais and Desbouis were among the first to use radium in 
the treatment of myelogenous leukemia. The radium was applied di- 
rectly over the spleen. After referring to twelve cases treated by other 
French workers, these authors reported five cases under their own care 
in which satisfactory remissions were obtained. Of the five cases re- 
ported, death occurred in two, two years and two months after the first 
exposure. Two cases were in good health six months after the first treat- 
ments. In the fifth case, splenectomy had been performed prior to the 
radium treatments. In spite of this, however, radium applied over the 
splenic area produced a marked decrease in the leucocytes, which fell 
from 143,000 to 21,500. This effect may be accounted for, most probably, 
by the exposure to the rays of the large volume of blood circulating in the 
cavity of the abdomen. Later, Renon, Degrais and Tournemelle reported 
a sixth case of leukemia in which radium was used with benefit. Numer- 
ous cases have been reported more recently by Giffin, Hay ward Pinch, 
Ordway, Peabody and many others, including myself, in which a favor- 
able influence has been exerted by radium. Giffin has reported thirty 
cases and Peabody has observed thirty-six cases of leukemia in which 
radium treatment was used. I have treated fifteen cases. 

All of the cases just referred to were treated in the usual way, i.e., by 
the surface application of the radium over the spleen. 

The beneficial effects of the radium treatment of leukemia are quite 
uniform. 

A certain degree of improvement occurs in the general condition of 
practically all of the cases. Headache may be relieved and the "buzz- 
ing" in the ears sometimes complained of may disappear. In certain 
cases the improvement in the general condition is quite remarkable. 
Even in the bedridden, sufficient improvement in the appetite and strength 
may occur so that the usual occupation of the patient may be resumed. 
The effect on the spleen is to reduce it perceptibly in practically all cases. 
Frequently the spleen becomes almost .or quite nonpalpable. The spleen 
usually shows the greatest reduction in size in about one or two months 
from the beginning of the treatment. 

The blood picture shows very definite effects of the treatment. The 
number of leucocytes usually begins to decrease in from one to three 
days after radium is applied and may progressively continue to diminish 
for several days or even weeks after the exposure. In one of Peabody 's 

303 



304 



RADIUM THERAPY 



cases of myelogenous leukemia in which radium was applied on the first 
and thirteenth days only, the leucocyte count fell from about 100,000 to 
6,000 in twenty-five days. In a case of chronic lymphatic leukemia, 
previously reported by the writer, the leucocytes fell from 113,000 to 
5400 in 28 days. Many other even more striking illustrations of the 






\ 



Fig. 1<>5. Chronic lymphatic leukemia. Greatly en',..:'^ '! OerTtOl ;i::'l .t\i!lary lymphatic glands. 
White blood count 113,000. Photograph taken January 12, 1917. Patient referred by Dr. Charles A. 
Elliott. 

improvement in the leucocytosis might be cited. With regard to the 
differential leucocyte count, the relative as well as the absolute percent- 
age of myelocytes is usually strikingly reduced. The relative percent- 
age of neutrophilic polynuclears remains about the same but the abso- 



RADIUM IN* DISEASES OF DUCTLESS GLANDS 



305 



lute number is usually markedly diminished. The relative percentage 
of small lymphocytes shows an increase after the reduction in the leuco- 
cyte count but the absolute count of the small lymphocytes is much 
diminished. The relative percentage of large mononuclears is usually 
increased. 




Fig. 166. Patient in Fig. 165 showing rcmissioii of the disease after radium treatment. The 
cervical glands have become practically normal and the axillary glands are markedly reduced. White 
blood count 7,500. Photograph taken February 3, 1917. 

In the majority of patients, there is usually an improvement in the red 
blood count and in the percentage of hemoglobin. If hemorrhage, such 
as epistaxis, purpura, etc., is present it usually ceases. While it has been 
held by some that hemorrhage may even be caused by radium treatment, 



806 RADIUM THERAPY 

I believe this to be very unlikely. In any series of cases, hemorrhage 
may occur, but as it is a symptom that is not uncommon in the natural 
course of the disease, it is difficult to ascribe it to the effects of radium. 

Technic of Treatment. The best guide to the amount of treatment is 
furnished ordinarily by the condition of the white blood count. One 
should not attempt to bring the leucocytic count down to normal. Prob- 
ably a count ranging between 15,000 and 30,000 will be found to accord 
with a satisfactory clinical condition. Peabody has stated that patients 
seem to do well clinically if their white count is not over 50,000. Exces- 
sive radiation may result in actual harm. 

The technic of the application of radium is simple and while similar 
results may be obtained by different methods, it is our belief that 
too large doses should lie avoided. The radium may be applied to differ- 
ent areas of the spleen successively, or to the lymphatic glands, as tin- 
case may require. Although some advocate radiation of the long bones 
in myelogenous leukemia, this has not been thought advisable, nor in 
our experience necessary in order to produce remission. Ordway used, 
in one of his cases, an applicator of about "double" or "triple" strength 
(50 to 60 me. concentrated on 4 square cm.). With this apparatus the 
spleen was covered by radiating successively every 9 square centimeters 
of skin surface. The metal filter was 3 millimeters of lead and the distance 
(obtained by 15 to 20 thicknesses of filter paper or 25 to 30 layers of 
sauze) was apparently about 5 to 10 mm. additional. Exposures of 
four to six hours over each area were given. Three series of treatments 
were given four to six weeks apart. Great symptomatic improvement 
followed, although the patient died about eight months after the first 
series of treatments. Giffin has used a technic similar to that just de- 
scribed. Fifty to one hundred milligrams of radium element were em- 
ployed. The screening finally used was two millimeters of lead plus one 
half inch of wood. The enlarged spleen was mapped out into squares 
3x3 cm., each square receiving successively two to four hours' radiation. 
The total length of time for the complete radiation of the spleen varied 
from twelve to forty-eight hours, the usual time being twenty-four to 
thirty-six hours. The exposure was repeated every week until remission 
was progressing satisfactorily. Peabody has stated that the experience 
of himself and his coworkers does not enable them as yet to state 
definitely the best dosage. There is some evidence, however, leading 
them to believe that one or more powerful treatments followed by an 
intermission of several weeks until the effects of the radium are over, 
are preferable to repeated small doses. My experience leads me to prefer 
this latter method. Ordinarily 200 millicuries (1% me. to each square 
cm.) screened with 2 millimeters of lead and at a distance of 3 centi- 
meters may be used. An exposure of six hours twice weekly may be 
given over successive areas until the splenic area, or in lymphatic leu- 
kemia, the area over each group of lymphatic glands has been covered 



RADIUM IN DISEASES OF DUCTLESS GLANDS 307 

or until a satisfactory diminution in the leucocytes is evident. The 
course may be repeated in six weeks hut may be given earlier or later as 
thought advisable. It must be emphasized, however, that great judg- 
ment is required in determining the size of the dose and the frequency 
of its repetition. Various factors must be considered, these being prin- 
cipally the effect of the treatment on the general condition, on the size 
of the spleen and especially the effect on the white blood count. Radium, 
applied to the spleen in the manner indicated, may cause a constitutional 
reaction, such as nausea, vomiting, malaise and headache. These symp- 
toms usually pass off within twenty-four hours. An excessive amount 
of treatment may result in marked leukopenia and an increase in the 
anemia. These symptoms should be guarded against by caution in re- 
peating the exposures. If they do occur or if hemorrhage supervenes, 
transfusion should be resorted to. Locally a skin reaction may occur, 
but with the technic advised this will be slight or absent. 

In applying a radium pad to the splenic area, the outer aspect of the 
pad should be protected so that the patient's arm. will not rest inad- 
vertently on the radium tubes. 

Results of Radium Treatment of Leukemia. Complete remission or at 
least a satisfactory clinical condition may be expected in from three 
weeks to three or four months. Patients may remain apparently well 
for several months or even several years. Recurrences may take place 
but these usually yield, at least for a time, to further treatment. Surgi- 
cal removal of the spleen is probably advisable in selected cases when 
the remission of the disease is at its height. 

In twenty of Giffin's cases, eighteen of which were treated with radium, 
splenectomy was performed when the reduction in the size of the spleen 
rendered the operation advisable. One patient died as the result of 
operation. Ten patients were living and in good general condition, nine to 
nineteen months after the splenectomy. Giffin concluded, however, that 
the natural course of the disease was probably not altered by splenectomy, 
although the patients may be made more comfortable by the operation. 

In addition to the usual method of treating leukemia by exposing the 
spleen or lymphatic glands to surface radiations, a few workers have inves- 
tigated the effects of radium when administered constitutionally. The re- 
sults of this method of treatment have varied. Von Noorden and Falta 
did not obtain beneficial results from the inhalation of radium emanation. 
Proescher and Almquest injected soluble radium salts intravenously but 
without marked benefit. Falta, Kriser and Zehner obtained remissions in 
leukemia by the injection of thorium X, the action of which is similar 
to that of radium. Radioactive deposit dissolved in water has also been 
injected by a few workers. For the present, however, the method of 
treatment of leukemia by exposure of the spleen or lymphatic glands to 
surface radiations is to be preferred. Radium treatment is probably the 
method of choice, in the treatment of leukemia at the present time. It 



308 RADIUM THERAPY 

sometimes succeeds in producing remission when all other methods, in- 
cluding the use of benzol and x-rays, have failed. 

B. HODGKIN'S DISEASE (LYMPH ADENOMA) 

The affected glands in TTodgkin's disease frequently disappear very 
promptly. In only one of eleven cases treated have we seen rebellious- 
ness to the treatment. In two cases of that form of the disease, in which 
nodular tumors appear on the bones (sternum, skull bones, etc.) very 
marked susceptibility to the radium rays was noted. Tn several cases 
we have seen remissions which have persisted for more than one year. 
It is probable, however, that recurrence takes place sooner or later in 
most cases. The treatment is ordinarily given by means of deep radia- 
tions. The enlarged glands may be treated serially in order to spare 
the patient as much as possible the systemic reaction (nausea, malaise) 
which frequently follows heavy doses. 

Four hundred millicuries screened with 2 millimeters of lead may be used 
at a distance of 6 centimeters for a total of 30 hours in periods of ten or 
more hours each over each area. The concentration of the radium may 
be. 5 me. per square centimeter. Treatment may be given twice weekly 
or less often until the areas involved have been radiated. Occasionally 
less powerful treatments may be given for three or four days in succes- 
sion if the systemic disturbance is slight. 

C. GOITER 

In the various types of goiter, radium treatment may be helpful. 

In the simple parenchymatous type there is general enlargement of 
the thyroid gland and the follicles, Avhich are usually newly formed. 
contain colloid material. The results of radium treatment in this type 
may be very beneficial. 

The vascular type of enlarged thyroid may also respond well. In 
favorable cases the neck may decrease in size several centimeters. 

In the type of goiter in which large cysts occur, the walls of the cysts 
frequently undergoing calcification, but little benefit is to be expected 
from radium treatment. 

Exophthalmic Goiter 

Abbe, of New York, treated the first case of this disease with radium 
in 1905. Following Abbe's report many other authors, including Aikens, 
Burrows, Clagett, and Dawson Turner have reported favorably upon the 
results of radium treatment. Radium may be used when the ordinary 
methods of treatment prove unavailing or when operation is considered 
inadvisable. In cases that respond favorably, improvement in all the 
toxic symptoms may be noted in three to six weeks and in some cases, 
very much more quickly. Tachycardia, tremor and exophthalmos are 



RADIUM IN DISEASES OF DUCTLESS GLANDS 309 

frequently diminished. The high blood pressure which is so frequently 
present is often diminished and after several courses of treatment may 
become practically normal. In some cases operation may be performed 
if thought advisable after a certain degree of improvement has been 
brought about by radium. It has been held that operation is rendered 
more difficult by previous radiation. It must be remembered that strik- 
ing remissions may occur in the natural course of the disease so that it 
is sometimes difficult to judge of the effects of treatment. 

Technic of the Treatment of Goiter. The method of treatment involves 
the use of moderately deep penetrating rays. Aikens, who has observed 
about one hundred cases, advises in the .beginning of treatment a total 
exposure of from 150 to 360 milligram hours. Subsequent courses of 
50 to 150 milligram hours may be given. Many other authors use larger 
doses than those just indicated. I ordinarily use not less than 150 milli- 
curies, screened with 2 millimeters of brass and placed at a distance of 
3 centimeters. Five millicuries may be concentrated on each square 
centimeter. A total exposure of twenty hours on each of three areas 
is given. In certain cases of large goiters we use 500 millicuries con- 
centrated on an applicator having a superficial area of fifty square centi- 
meters. This is screened with 2 millimeters of brass and applied at a dis- 
tance of 6 centimeters. An exposure of fifteen hours may be given to each 
lobe and to the isthmus of the thyroid. The three exposures should be 
given several clays apart. Depending upon the severity of the disease, 
the dose may be diminished or increased in different instances. In some 
cases, following the treatment there is an exaggeration of the symptoms 
for several days or even for a week or more. Improvement then usually 
sets in and by the end of a month or six weeks may- be very decided. 
The course of treatment may be repeated at intervals of six or eight 
weeks. Subsequent courses of treatment may be of less intensity. The 
amount of treatment may be regulated by the basal metabolism test. 

In addition to the radium treatment, supplementary measures includ- 
ing rest, diet and suitable drugs should be used. 

D. ENLARGED THYMUS GLAND 

Brayton and lleublein have treated with radium 34 cases of enlarged 
thymus gland in children. In every instance there followed a prompt 
and lasting disappearance of all symptoms. These authors state that 
"every infant who lias 'queer spells' who has habitual attacks of cough- 
ing, choking, dyspnea, or cyanosis should have an x-ray examination of 
its chest in the hope of finding a condition (pathologically enlarged 
thymus) which is so easily and satisfactorily cured." Their technic 
consisted in using 100 miligrams of radium element screened with 0.5 
mm. of silver. The radium was applied at a distance of one half inch 
from the skin to four different points over the thymic area and allowed 
to remain for two hours over each point. 



CHAPTER XX 
RADIUM IN INTERNAL MEDICINE 

Radium <nid thorium X are the Iwo principal radioactive substances 
used in internal medicine. The biologic action of these two substances 
is similar but not absolutely identical. Proescher states that while all 
radioactive substances produce a more or less marked numerical increase 
of the red blood cells, thorium X is the only one causing pronounced 
destruction of the leucocytes. The more rapid decay of thorium X as 
compared with radium explains its more intense biologic effect. The 
investigations of the effects of thorium X have enabled us to fill up 
some of the gaps in our knowledge of the effects of radium. In the fol- 
lowing pages its action will be considered in connection with that of 
radium. 

We may discuss the internal administration of radium under the fol- 
lowing headings: (a) the administration and elimination of radium, 
(b) its physiologic effects, (c) morphologic changes in the tissues caused 
by radium, (d) therapeutic indications. 

A. THE ADMINISTRATION AND ELIMINATION OF RADIUM 
(1) The Administration of Radium 

Radium may be administered either in the form of radium salts, 
radium emanation or the active deposit. The effects of both the salts 
and the emanation appear to be practically identical except that the 
action of the emanation is naturally more evanescent and therefore per- 
haps more desirable on account of the rapid elimination from the body 
of a gaseous element. Less experience has been had with the actual 
administration of the active deposit but it seems probable that the effects 
are the same as those of the salts and the' emanation. 

Administration of Radium Salts 

Radium salts are usually administered by giving, by mouth, water con- 
taining the salt in solution or by the injection of a solution of the salt 
intravenously. The drinking water is usually of a strength of one 
microgram of radium element to 30 c.c. of distilled water. The ordinary 
dose is 120 to 240 c.c. per day. For injecting intravenously, 10 to 100 
micrograms of radium element in the form of a soluble salt dissolved 
in 2 c.c. of normal salt solution may be used. Injections are usually 
given every week or ten days until the patient has received 300 micro- 
grams. 

310 



RADIUM IN INTERNAL MEDICINE 311 

Administration of Radium Emanation 

Radium emanation may be administered by means of drinking water 
in which the emanation is dissolved, by inhalation, or by baths. Radium 
emanation in solution may be given by mouth. The strength of "emana- 
tion drinking water" is usually 1.5 to 2 millicuries per liter of water. 
About 250 c.c. is the usual daily dose. If the inhalation method is \\sed 
the patient may sit in a small room known as an "inhalatorium," the 
air of which is impregnated with the emanation mixed with oxygen. 
The air which is breathed is purified by being passed over caustic soda 
and is then returned into the room. This is objectionable on account of 
the respiratory products which are continually being reinhaled. By 
another method, the patient inhales a stream of air or oxygen mixed with 
the emanation and exhales it into the open air by a valve arrangement. 
This is a better though more wasteful method. The quantity of emanation 
in the air inhaled varies from 0.003 to 0.3 microcurie per liter of air. 
Inhalation treatments may last an hour or more. The results of treat- 
ment by the inhalation method seem to differ in no wise from those 
obtained by the administration by mouth of emanation drinking water 
and the latter is certainly the more convenient and economical method. 
Gudzent, Falta and some others, however, make considerable use of the 
inhalation method. Emanation baths may also be given, but the good 
effects claimed seem to be due solely to the emanation that is inhaled. 

Administration of Radioactive Deposit 

II. ,1. Bagg has investigated the pathologic tissue changes accompany- 
ing the injection of the active deposit. White rats were injected intra- 
venously and subcutaneously. Pathologic changes in the various or- 
gans liver, lungs, kidneys, adrenals, spleen, bone marrow, brain and 
vascular system were noted and described in detail. Among the effects 
were fatty degeneration in the liver, granular degeneration and erosion 
of the kidney cells, destruction of the cells of the bone marrow and their 
replacement by blood, and congestion and hemorrhages in practically 
all of the organs. A similarity was noted in the tissue reaction due to 
radium applied externally and that due to the active deposit when in- 
jected subcutaneously or intravenously. Doses of less than ten milli- 
curies of radium emanation were not fatal to the experimental animals. 
Larger doses caused death within a few hours or days. The doses used 
in human beings have varied from fifty to two hundred and fifty milli- 
curies of active deposit dissolved in two to six c.c. of solution. In one 
ease severe toxic symptoms developed after the injection of 250 me. 
Similar doses in other patients produced no ill effects. 

(2) The Elimination of Radium 

Prom our knowledge of its chemical affinities it would be expected that 
radium, when held in the body, would be found wherever the other 



o!2 RADIUM THERAPY 

alkali earth elements are found, inasmuch as radium is an element closely 
akin to calcium, barium and strontium. According to Seil, Viol and 
Gordon, analysis of the dead tissues of animals and humans who have 
had radium administered has shown that the bones, as might be expected, 
do contain the highest concentration of radium. Following the bones, 
in the order of radium content, come the liver, lungs, blood vessels and 
spleen. Cameron, Viol and Proescher examined dead tissue from a human 
being who had suffered from uterine cancer. The patient had received 
1 mg. of radium element intravenously 3 months prior to her death. 
These authors found that the cancerous tissue did not contain a greater 
relative amount of radium than other tissues and not as much as the 
bones and some other organs. 

The method of the elimination of radium has been studied by Belling- 
ham-Smith, Brill and Zehner, Seil, Viol and Gordon, and many others 
with general agreement as to the main trend of the observations. 
Bellingham-Smith found that radium injected into mice was excreted 
principally by the small and large intestines and to a lesser extent by 
the urine. According to this author, soluble salts, however adminis- 
tered, are rapidly eliminated, mainly by the intestine, but also by the 
urine. Insoluble salts, given by the mouth, are directly excreted by the 
bowel without being absorbed, but when given by injection are excreted 
very slowly by the bowel. After administration of the emanation in 
solution, a general but brief radioactivity is caused throughout the or- 
ganism. Elimination, which takes place almost entirely by the Kings, and 
to a very slight extent by the kidneys, is complete in 4 hours. Ketron 
found that only a very minute quantity (0.025 micrograms) was elimi- 
nated by the skin after the intravenous injection of 100 micrograms. 
Seil, Viol and Gordon have made one of the most extensive studies of the 
excretion of soluble radium salts when administered both intravenously 
and by the mouth. The following ^conclusions were reached by these 
authors: The principal part of the radium is excreted by the feces with 
either method of administration. Most of the remainder is eliminated 
by the urine. A minute amount is eliminated by the lungs in the form 
of radium emanation which is being constantly formed by the disintegra- 
tion of the radium held in the body. As might be anticipated, when 
radium is administered by the mouth a smaller proportion of the ex- 
creted radium is eliminated by the urine than when it is injected intra- 
venously. From 25 to 35 per cent of the radium taken by mouth remains in 
the body for 4 or 5 days after ingest ion. If radium is injected intravenously, 
55 to 65 per cent remains for the same length of time. From this time 
on, the rate of elimination is about the same whether ingested or injected. 
By the 10th day the daily rate of excretion is less than 1 per cent. As 
a result, there is an exceedingly slow elimination of the balance of the 
radium, the process going on for months. The first rapid elimination 



RADIUM IN INTERNAL MEDICINK 313 

takes place before the radium has become "fixed" in the tissues. When 
"fixation" of the radium has taken place all methods of elimination are 
much slower. By fixation is meant that the radium that is not eliminated 
at once is probably carried in the blood stream in solution or suspension 
until it becomes absorbed by the various tissues in proportion both to 
their alkaline earth salt content and to their accessibility by the blood. 
On the basis of the foregoing studies, these authors suggest a rational 
method of maintaining radium in the system. If, for example, it is 
desired to maintain about 50 micrograms of radium element in the body, 
one may give an intravenous injection of about 100 micrograms. After 
the lapse of about ten days, 2 micrograma may be given every few days 
by mouth to replace that which is eliminated. 

B. PHYSIOLOGIC EFFECTS OF RADIUM 

Experiments on different animals as well as on human beings to deter- 
mine the effects of radium have been carried out by Bellingham-Smith, 
Cameron and Viol, Dominici and Faure-Beaulieu, fJudzent, Jaboin, 
Proeseher, Salant and Meyer, Wickham and Degrais and many others. 

We may first consider the effects of therapeutic doses. These effects may 
bo discussed under the following headings. (1) the general physiologic 
effects, (2) the effects on the heart, circulation and respiration, (3) the 
effects on metabolism. 

(1) General Physiologic Effects 

One of the chief subjective benefits derived by many patients taking 
radium in therapeutic doses is a feeling of "bien etre." Whether this 
is entirely subjective, it is, of course, difficult to say. In arthritic 
cases especially, a certain amount of. relief from pain may be experienced. 
The majority of patients taking radium emanation solution have a 
definite diuresis and a slight laxative effect is sometimes observed. Some 
patients experience a definite so-called "reaction." S. Lowenthal first 
called attention to this phenomenon. The reaction is characterized by 
an aggravation of symptoms, after a certain amount of treatment has 
been given. There may be, e.g., an exacerbation of any joint symptoms 
that have been present. General disturbances, including "tired feel- 
ings." "malaise." and a desire for sleep, may occur. In other patients 
there may be excitement and sleeplessness. These symptoms pass off 
after a time if the treatment is discontinued. According to Gudzent, 
these phenomena are frequently of favorable prognostic import. 

(2) Effects on the Heart and Circulation 

The effects of a radioactive Ringer's solution on the isolated frog's 
heart have been studied by Maass who found that the heart became di- 
lated and its action arrested. By rinsing out the heart with normal 



314 RADIUM THERAPY 

Ringer's solution, its normal activity returned. The heart showed less 
activity with each experiment, indicating according to this investigator, a 
lowered resistance. In mammals, however, Plesch and Karczag could not 
duplicate these results. Zwaardemaker has described a new and hitherto 
unknown effect of the radiations on the heart. This author found that 
a frog's heart kept actively beating by artificial circulation ceased to 
pulsate if the potassium was extracted from the circulating medium. 
If the heart was then radiated with a few milligrams of radium for thirty 
minutes it again began to beat. If a certain quantity of uranium salt 
was added, the heart again stopped. Renewed radiation again started 
the action of the heart, 

While these experiments are extremely interesting from a scientific 
standpoint, no therapeutic deductions have as yet been drawn from them. 

Certain of the experiments on blood pressure have a practical aspect. 
In various experiments on dogs and human beings carried out by Loewy, 
Plesch and Gudzent with inhalations of radium emanation and injections 
of thorium X, the blood pressure in general was markedly decreased. 
According to Gudzent, the decrease in blood pressure, which may be 
lowered for long periods and may even become and remain normal in 
certain gouty and arthritic patients, is due to the destructive effect on 
the vasoconstrictor siibstances produced by the suprarenal glands. 

Respiration. In animals and in healthy human beings, no especial 
effect on the respiration from therapeutic doses can be observed. In 
cardiac dyspnea and in pneumonia. Plesch has reported an acceleration 
and increase of respiration. 

(3) Effects on Metabolism 

The influence of the administration of radium on metabolism has been 
studied by Falta, Gudzent, Krieg, Lowenthal, Plesch, Rosenbloom, 
Wilke, and many others. The investigations tend to show that the excre- 
tion of uric acid and of purin is increased. The entire nitrogen excretion 
is also increased. Following an injection of one hundred micrograms of 
radium element intravenously, Rosenbloom found that there was a con- 
siderable increase in the ethereal sulphur output. In three patients 
whose metabolism while taking radium emanation water (3 ounces, five 
times a day or 20,000 Mache units in all) was studied by McCrudden, 
no marked metabolic changes were made out. Only one definite change 
was observed a slight increase in the rate of creatinin excretion. The 
results of the studies of various authors have shown, in general, marked 
differences in the effect on metabolism and in some patients little or no 
effect has been observed. We may also mention here the investigations 
of Knudson and Erdos who studied the metabolism of a case of leukemia 
that was being treated by surface applications of radium over the spleen. 
The conclusions of these authors were as follows: The excretion of 



RADIUM IN INTERNAL MEDICINE 315 

nitrogen, urea, ammonia and phosphates was enormously increased after 
the application of radium. The uric acid output was only slightly in- 
creased compared to the other nitrogenous bodies. Surface applications 
of radium over the spleen accelerated the disintegration of nuclein tis- 
sues resulting in the increases mentioned above. An increased production 
of uric acid that was anticipated on account of the disintegration of 
nuclein was not observed. The effect on the phosphates was remarkable, 
there being at times an increase of four hundred per cent over the 
excretion observed at the beginning of treatment. 

We may now consider the effects of toxic doses of radium. The follow- 
ing description of the effects of a lethal dose has been given by Gudzent : 
If an animal, e.g., a rat, receives an injection of a soluble radium salt 
of sufficient strength, no changes are at first apparent which indicate 
injury to the organism. The animal eats, sleeps, moves about, and passes 
urine and stools in a normal manner. In a few days, however, the picture 
changes. The animal appears to be ill, refuses food, and sits about in 
a "crumpled up" position. Its respiration increases, fever is present, 
and it passes bloody stools and urine. The animal then grows weaker 
and weaker and usually dies in convulsions. As to the exact cause of 
death it has been held that it may be due to the effect of the radium as a 
toxic substance. 

Experiments with barium, an analogous chemical element, do not bear 
out this view. To cause death with barium one must use a dose several 
hundred times greater than the lethal dose of radium. The toxic symp- 
toms are also dissimilar. The death of the animal, therefore, after a 
sufficient dose of radium internally, appears to be due solely to the effect 
of the radiations. Gudzent has estimated the lethal dose of radium when 
injected in the form of a soluble salt to be about .007 mg. of radium 
element per kilogram of body weight. For a body of 70 kilograms the 
fatal dose would thus be about 0.5 mg. According to the experiments 
of Cameron, Viol and Proescher, this estimate is low. These authors 
have carried out an extensive series of experiments with injections of 
soluble radium salts. They state that they have used doses as high as 
five milligrams of radium element in 2 c.c. of normal salt solution intra- 
venously in human beings and have never seen from these doses the 
slightest ill effects. They regard doses of fifty to one hundred micro- 
grams intravenously as therapeutically correct and absolutely safe. By 
the inhalation method, Proescher and Viol found that a concentration 
of 26 millicuries of emanation per liter of air (70 million Mache units) 
produced death in animals. Lazarus-Barlow exposed animals to the 
gamma rays of five grams of radium bromide. The minimum lethal dose 
of gamma rays for the rat was an exposure of six hours, the animal 
dying about forty-two hours later. For the rabbit an exposure of nine 
to ten hours was necessary. 



316 RADIUM THERAPY 

C. MORPHOLOGIC CHANGES IN THE TISSUES CAUSED BY 

RADIUM 

Inasmuch as the effects of radium taken internally are due to the 
action of the rays, one would expect that similar changes would be pro- 
duced in the tissues whether the radium is administered internally or 
radiations are used externally. Experimental investigations have proved, 
in a general way, the truth of this supposition. There is, of course, this 
very evident difference : in the case of the internal administration of 
radium, the whole organism, and especially its most radiosensitive struc- 
tures, is affected by the rays, but if radiations are used externally, the 
effect is practically limited to the part irradiated. By radiation of 
animals in toto, however, effects may be produced that are practically 
identical with those caused by the administration of radium. 

We may now consider the changes produced in different tissues. 

The Blood Vessels 

Lethal injections into animals of thorium X produce an intense 
hyperemia of almost all the organs. Hemorrhages frequently occur; 
sometimes a single vessel is affected but at other times the hemorrhage 
may extend over large areas. The capillaries and smaller vessels show 
the most marked injuries. 

The Blood. Leucocytes 

If small doses of radium salts (%ooi> mg.) or thorium X ( 1 /ioo<> to 
] /!oo m R-) & re injected intravenously or if inhalations of radium emana- 
tion (5 to 100 or more Mache units) are given, a transient leucocytosis 
appears a few hours later. The number of leucocytes may even increase 
to 20,000 (Gudzent and Levy). The next day, after a slight decrease 
to below the initial amount, the leucocytes become normal. If larger 
doses of thorium X (0.5 mg.) are injected, leucocytosis develops quickly. 
A leucopenia appears later. The leucocytes may decrease to 1000 or 
even lower according to the dose. If very large doses are administered 
the leucocytes may even disappear from the blood altogether just prior 
to the death of the animal. 

According to Proescher and Alniquest, thorium X has a more destruc- 
tive effect on the leucocytes than radium. With superfatal doses of 
radium these authors were unable to destroy all the circulating leu- 
cocytes or myeloid cells of the bone marrow. 

Erythrocytes 

In contradistinction to the leucocytes, the red blood cells are not 
markedly sensitive to injections of radioactive substances. After small 



RADIUM IN INTERNAL MEDICINE 317 

doses, no change at all, as a rule, is seen. Sometimes, however, there 
may be an increase in number of erythrocytes as observed by Dominici 
in the horse and Brill and Zehner in dogs and rabbits. The last 2 
authors found that the erythrocytes were increased in some cases to 13 
million per c.c. This increase may be maintained for weeks. The hemo- 
globin was also increased but not proportionally to the increase in the 
number of erythrocytes. Proescher and Almquest have reported similar 
results. By the injection of larger doses of thorium X, the red blood 
cells may be damaged so that both a numerical decrease and a decrease in 
hemoglobin may occur. 

In pathologic conditions, such as secondary and pernicious anemia, 
the crythrocytps appear to be more sensitive than in normal individuals. 
Proescher found that in such cases the injection of soluble radium salts 
(0.1 to 0.4 mg.) increased the red blood cells to normal in a few days. 
Oudzent has reported the same effect from the injection of small doses of 
thorium X (0.01 to 0.1 mg.). 

Spleen, Bone Marrow and Lymphatic Glands 

Gudzent states that the key to the understanding of the changes in 
the blood picture lies in the knowledge of the changes in the organs 
mentioned above which are, as we have seen, very radiosensitive. The 
changes produced by radium administered internally are practically 
identical with those caused by external radiations. These changes have 
already been described in a previous chapter. 

Suprarenal Glands 

Falta and his coworkers and later von Domarus and Salle called at- 
tention to the changes produced in the suprarenal gland and its func- 
tions. Injections of thorium X produced, in general, degenerative 
changes together with hemorrhages in the cells of these organs. The 
blood pressure of the animals was reduced in consequence of the dis- 
appearance of the substances causing vasomotor constriction. The effects 
on blood pressure depended on the dose but both small and large doses, 
after an initial increase, caused a decrease. In certain cases, the blood 
pressure rose again but did not attain to the point initially present. 

Other Organs 

The effects of injections of radioactive substances on other organs 
heart, kidney, pancreas, etc. are much less pi-onounced than on the 
previously mentioned structures. Traces of injury to the cells of certain 
areas may be detected but these changes are never of a general nature. 
Functional disturbances probably occur but these have not been as yet 
sufficiently investigated. 



318 RADIUM THERAPY 

Effects of Large and Frequently Repeated Injections 

A problem of importance is that of the possible constitutional effects 
of large and frequently repeated injections. The experiments of Silva 
Mello tend to throw some Ijght on this question. This author found that 
the injection of a single dose of thorium X, if not immediately fatal, 
might so injure an animal as to cause its death in the course of a few 
weeks or months. The most obvious effects that were observed in the 
meantime were (1) leucopenia, (2) anemia (decrease in erythrocytes and 
hemoglobin), (3) marked decrease in weight. Evidences of regenerative 
processes were observed also in the bone marrow. If such an animal re- 
ceived a second injection, which was not large enough to cause death by 
itself primarily, the animal quickly succumbed. The blood, spleen, bone 
marrow and lymphatic glands showed evidences of the greatest damage. 
It may be assumed that the animal was sensitized by the first dose. 

Equally interesting were the results of repeated injections of tho- 
rium X into animals in doses that were not large enough singly to cause 
perceptible severe injury. In these animals a certain degree of resist- 
ance apparently developed. Considerable quantities could be borae 
without any of the previous symptoms (leucopenia, anemia, loss of 
weight) developing, until, after a time, the animals rather quickly suc- 
cumbed. In these animals the spleen was the only organ showing marked 
effects. The bone marrow was nearly always unaffected. 

Inasmuch as it may be assumed that the effects of repeated injections 
do not differ materially from those of repeated external radiations which 
are delivered over very extensive areas, these experiments show the need 
of caution in the use of powerful and repeated exposures for therapeutic 
purposes. They also suggest the need of care on the part of the operator 
who is handling large quantities of radium in order that he may avoid 
injury to himself from the persistent exposure to the rays. 

D. THERAPEUTIC INDICATIONS 

The fullest details as to the use of radium and other radioactive sub- 
stances in internal medicine are to be found in the recently published 
monograph of Falta. 

Among the many diseases in which radium has been used with alleged 
benefit are the following: 

1. Arthritis deformans, articular rheumatism (subacute and chronic) 
and various other types of arthritis. 

2. Gout. 

3. Myalgia ("muscular rheumatism"), neuralgia and neuritis (sciatica, 
tabetic pains, etc.). 

4. "High blood pressm-e," arteriosclerosis, angioneurotic edema, neu- 
roses of the heart, myocarditis. 



RADIUM IN INTERNAL MEDICINE 319 

5. Certain chronic inflammatory and suppurative processes. 

6. Bright 's disease and diabetes. 

7. Leukemia, Hodgkin's disease, and various forms of anemia (per- 
nicious anemia, chlorosis, etc.). 

8. Dermatoses (psoriasis, scleroderma). 

9. Malignant disease. 

1. Arthritis Deformans. It has long been the custom for sufferers 
from chronic joint diseases to visit springs in different parts of the world 
and drink the waters. With the discovery that most of these springs 
contained radium emanation in solution it became of great interest to 
determine the effect of radioactive substances artificially prepared. It 
may be noted that none of the springs at the various health resorts con- 
tains more than the most minute quantity of radium emanation (about 
1 to 30 millicuries per million quarts). It would seem, therefore, that 
radioactive substances in doses sufficient to produce definite physiologic 
effects might be of even greater benefit. Hayward Pinch (London Ra- 
dium Institute) has reported very favorable results from the administra- 
tion of radium emanation water especially in arthritis deformans. In 
this author's experience pain was relieved and the mobility of the joints 
was increased provided no bony or cartilaginous changes had occurred. 
In some cases the results were quite remarkable. Cameron and many 
others have also seen favorable results in various types of arthritis. 
Gudzent, who has made one of the most extensive reports, states that 
many different types of arthritis, including certain cases of gonorrheal 
origin, are benefited. The arthritides in children, according to the same 
author, react favorably in contradistinction to those in the aged which 
do not respond well. In the treatment of arthritis, in general, benefit 
appears in the favorable cases usually between the 3rd and 8th week. 
Some cases do well when the treatment is interrupted for a few weeks 
and is begun again. Unfavorable symptoms, such as a permanent aggra- 
vation of the joint disorder or albuminuria, which have been alleged by 
some authors to have been caused by the radium have never been ob- 
served by Gudzent. 

2. Gout. Falta, Gudzent and others have reported favorable results 
in the treatment of gout. The last named author states that of 86 cases 
who had exensive treatment (emanatorium inhalations, "drink cure"), 
77 per cent to 89 per cent were improved and 9 per cent to 11 per cent 
unimproved. In the course of time, however, most of the patients ex- 
perienced recurrences. In a few patients no return of the disorder had 
taken place when the report was made. 

3. Myalgia. Benefit has been reported in some cases of the above 
disorders, the pain particularly being relieved according to many in- 
dividual reports (Falta, Gudzent, Sommer, Kemen, Strasburger, etc.). 
Gudzent has never seen benefit, however, in neuralgia of the trigcminus. 



320 RADIUM THERAPY 

4. High Blood Pressure. The reduction of high blood pressure has 
been observed by many authors. Gudzent states that in some cases the 
blood pressure may be permanently reduced. Other authors, however, 
doubt the' permanency of any reduction that may occur. Hay ward 
Pinch has seen good effects from the use of radium emanation drinking 
water in angioneurotic edema. In arteriosclerosis, neuroses of the heart 
and myocarditis, benefit has been reported by some, authors. In the last 
named diseases, the field for possible error in the interpretation of results 
is, of course, very great. 

5. Chronic Inflammatory Processes. Lachmann states that he has seen 
good effects from the administration of radium in inflammatory disorders 
of the female pelvic organs. Several authors (Levy, etc.) have reported 
favorable results in the treatment of various disorders of the mouth, 
such as leukoplakia, pyorrhea, etc. 

6. Blight's Disease and Diabetes. Benefit has been reported by cer- 
tain authors in these disorders. 

7. Pernicious Anemia. Proewher recommends, on the basis of some 
excellent experimental studies, the intravenous injection of soluble ra- 
dium salts in pernicious anemia and other forms of anemia. Gudzent 
also has seen good results from the injection of thorium X in pernicious 
anemia, chlorosis, and secondary anemia. The favorable results in per- 
nicious anemia, are of course only temporary. According to Failla good 
results have been obtained by the injection of the active deposit in leu- 
kemia and Hodgkin's disease. The use of external radiations over the 
spleen is so satisfactory that there seems to be a small field, at present, 
for the use of radium internally in these disorders. The improvement in 
leukemia by any method of treatment is temporary although remissions 
may extend over considerable periods of time. 

8. Dermatoses. Individual reports of good effects in psoriasis and 
scleroderma have been made. 

9. Malignant Disease. Good effects have been reported by some 
authors from the administration of radium in various forms of malignant 
disease. Failla has reported good results from the injection of the active 
deposit in lymphosarcoma. It seems to the writer that for the .present 
at least we must rely in malignant disease solely upon the effects of local 
radiations with radium rather than upon its constitutional effects when 
ingested or injected into the body. The radiosensitiveness of certain 
normal structures, such as the spleen, renders it unlikely that the internal 
administration of radium will ever be of practical utility in the treatment 
of most types of malignant disease. Long before the tumor itself will 
be unfavorably affected, normal structures may be seriously injured. 

The experimental work referred to above, i.e., the injection of active 
deposit, etc., is of course valuable from a scientific standpoint. 



RADIUM IN INTERNAL MEDICINE 321 

In the field of internal medicine, the evidence seems to indicate that 
radium may be of benefit in 

(a) certain chronic joint disorders (notably rheumatoid arthritis and 
the joint disturbances of gout), 

(b) high blood pressure, 

(c) pernicious and other forms of anemia, 

(d) certain painful affections, such as some forms of neuritis, which 
it sometimes seems to ameliorate. 

There is so much possibility of error in estimating the value of radium 
when administered internally that many of the reports of benefit and 
cures must be accepted with the greatest caution until further experience 
has been accumulated. 



CHAPTER XXI 

PROFESSIONAL INJURIES DUE TO RADIUM 

Both local and constitutional injuries may be caused by persistent 
exposure to radium rays. 

LOCAL EFFECTS 

We have already described the acute inflammatory phenomena known 
as the "radium reaction" that may result from radium rays that are 
allowed to act with sufficient intensity on the skin. The various manipula- 
tions required in making therapeutic applications render a certain amount 
of daily exposure to the rays almost unavoidable. As a result of these per- 
sistently repeated slight exposures, many workers suffer from a peculiar 
chronic dermatitis that affects especially the ends of the first two fingers 
and thumbs. The skin becomes roughened and loses its elasticity. Fis- 
sures and atrophic changes in the skin may develop. The nails become 
brittle and thin. Exaggerated longitudinal striation and splitting of 
the nails may occur. Tiny wartlike epithelial tumors may form on the 
flexor surfaces of the ends of the fingers and thumbs. These tumors vary 
in superficial extent from one millimeter to one-half centimeter or more 
and may project one or several millimeters above the level of the skin. 
They resemble a certain type of senile keratosis. They cannot be scraped 
off except with the greatest difficulty but when they are removed, a 
depression is left reaching nearly or quite to the corium. Even when 
removed they recur sooner or later and may persist for years becoming 
worse or better as the individual is more or less exposed to the rays. 
Fortunately there has not been observed as yet any tendency to the 
development of epitheliomata in connection with radium keratoses. Sub- 
jectively the affected finger ends may show "anesthesia, paresthesia of 
varying degrees, tenderness, throbbing and even pain. The persistence 
of such effects is noteworthy." (Ordway.) 

CONSTITUTIONAL EFFECTS 

Those who are exposed more or less continuously to the gamma rays 
from radium may show, various systemic symptoms, such as headaches, 
malaise, "nervousness," attacks of dizziness, menstrual disorders, etc. 
The most common of these symptoms is probably a feeling of undue ex- 
haustion noted at the end of the day. In women, menstrual disturbances 
may occur. At first menorrhagia may be present. The menstrual func- 
tion may then become irregular and amenorrhea may result. Normal 

322 



PROFESSIONAL INJURIES DUE TO RADIUM 323 

menstruation returns, however, after a somewhat prolonged absence from 
radium work. Many workers in radium after a certain amount of ex- 
posure to the gamma rays develop definite blood changes. Gudzent and 
Halberstaedter examined twelve radium workers and found that blood 
changes were present in all. The effect on the white blood cells was 
shown by a relative and absolute lymphocytosis, which was present in 
every case. In two cases, the hemoglobin was decreased but the number 
of red blood cells was apparently not affected. It is probable that the 
lymphocytosis mentioned above was an early effect of the rays, analogous 
to the initial lymphocytosis noted after therapeutic injections of radium. 
Others who have studied the blood changes in radium workers have 
found that leukopenia is practically always produced by persistent ex- 
posure to the gamma rays. Mottram and Clarke investigated the leu- 
cocytic blood-content of twenty laboratory and clinical workers engaged 
in handling considerable quantities of radium. The polymorphonuclear 
leucocytic and the lymphocytic blood content of all were found to be 
decidedly below normal. The leukopenia manifested itself a few weeks 
after exposure. After a holiday of two months, the polymorphonuclear 
leucocyte and lymphocyte counts rose decidedly but fell again upon 
reexposure to the rays. Hayward-Pinch also found a leukopenia in 
radium workers. This author states that the total number of leucocytes 
may even fall as low as one thousand per cubic millimeter. The hemo- 
globin and number of red blood cells in radium workers are not as mark- 
edly or as constantly affected as the white blood cells. At first the hemo- 
globin may be slightly increased. Later it may be diminished. Sooner 
or later the number of erythrocytes is also decreased. 

No connection between the leukopenia and any condition of ill health, 
can, at present, be traced, although the possibility of untoward effects 
must be borne in mind. The constitutional effects of the gamma rays 
can be minimized or obviated by a sufficient amount of care in handling 
the radium. 

For the protection of those engaged 'in radium work, various devices 
have been installed. To guard against the local effects of the rays we 
use (a) special forceps of different patterns. One type resembles the 
ordinary surgical tissue forceps, except that the radium forceps are 
twelve inches long (Fig. 22). 

With these the radium tubes as well as the large radium pads can be 
conveniently grasped. Another type of forceps has three prongs at 
one end, with which even the smallest tubes may be picked up and held 
securely (Fig. 23). (b) Special "holders" for screwing together the dif- 
ferent parts of screens or other radium apparatus (Figs. 25 and 26). 
(c) A special instrument by means of which one may wrap up the radium 
tubes in dental rubber dam without handling them with the fingers 



324 RADIUM THERAPY 

(Fig. 24). All metal instruments used in handling radium apparatus 
should be covered with rubber tubing. Since using these devices the 
local untoward effects of the radium have not been observed. 

For guarding against the gamma rays which are the main cause of the 
constitutional effects we use (a) heavy lead "angle plates." These should 
be at least five centimeters thick and may be set in a table or shelf at 
which the technicians may sit while manipulating the radium tubes. 
We have devised also a movable apparatus for the protection of the opei'- 
ator. This consists of an upright heavy cast iron plate attached to wheels. 
The apparatus can be easily moved about so as to stand between the 
radium applicator and the operator (Fig. 34). (b) Baskets lined with lead 
for transporting the radium pads from the making-up room to the patient. 
The baskets may be carried about by means of a sling. By this procedure 
the radium is constantly kept at some distance from the body and the 
gamma ray effect on the spleen and other important organs is minimized. 

In addition to these precautions we have found that it is imperative 
that radium workers should abstain from work for at least two days per 
week and should have frequent vacations of one or more months' 
duration. 



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326 RADIUM THERAPY 

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radiotherapie, Compt. rend. Soc. d. biol., Paris, 1904, Ivii, 982-984. 

and Delamosse, A.: Die Wirkung des Radiums auf das Blut, Zentralbl. f. inn. 

Med., 1908, xxix, No. 42, pp. 1037-1039. 
Auerbach, N.: Die Bchandlung von Gicht und Rheumatismus mit Radium, Discussion 

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Augustin, B., and Szendeffy, A. von: Die Bakterizide Eigencshaft radioafctlver Sub- 

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Deutsch. med. Wchnschr., 1905, xxxi, No. 30, pp. 1192-1193. 

Beseitigung der durch Radiumstralilen bewirkten Gefasserweiterungen, Munchen. 

med. Wchnschr., 1907, No. 38, p. 1877. 

Kalte und Uviolbehandlung in Verbindung mit Riintgen und Radium, Munchen. 

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The Effect of Intravenous Injections of Radium on a Persistent Positive Wasser- 

mann Reaction, Med. Ree., New York, October 9, 1915, Ixxxviii, 610. 

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Physiol., 1904, iv. 
Sagg, H. J.: Pathologic Changes Accompanying the Injection of an Active Deposit of 

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The Action of Buried Tubes of Radium Emanation upon Normal and Neoplastic 

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The Effect of Radium Emanation on the Adult Mammalian Brain, Am. Jour. 

Roentgenology, September, 1921, viii, 536-547. 
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mittels Roentgenrohren, Strahlentherapie, 1914, v. 427-430. 

Bailey, Harold C.: Radium in Uterine Cancer, Jour. Am. Med. Assn., July 14, 1917, 
Ixix, No. 2, p. 145. 

and Bagtj, H. J.: Radium Therapy in Vulval and Vaginal Cancer, Abstracted in 

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med. Wchnschr., 1915, No. 49, pp. 1670-1673. 

liulthazard, V.: fitude physiologique et therapeutique des radiations emises par les 
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p. 174. 
Vcrrues planes traitfies par le radium, Bull. Soc. franc, de dermat. et syph., 

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Die Radiumthcrapie in der Dermatologie, Strahlentherapie, 1914, iv, 322-375. 



o28 RADIUM THERAPY 

Die Bndiurn thorapic maligner Tumoren, Strahlenthcrapie, 1914-1915, v, 51-69. 
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Arch, d 'electric, med., 1908, xvi, 243-249. 
Barduszi, D.: Sul valore terapeutico delta radio-attivita di alcune acquo termominerali, 

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Siena, 1905, xvii, 601-604. 
Barringer, Benjamin, S.: The Treatment by Radium of Carcinoma of the Prostate 

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A Case of Carcinoma of the Prostate Controlled for Three and One-half Years 

by Radium, Internat. Jour. Surg., August, 1919, xxxii, 239. 

Radium Treatment of Carcinoma of Bladder, Ann. Surg., December, 1921, Ixxiv, 

Carcinoma of Prostate, Surg., Gynec., and Obst., 1922, xxxiv, 168-176. 

'Barrow, W.: Treatment of Malignant Uterine Conditions with Radium, Kentucky 

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Banhford, Murray, and Bowen: Third Scientific Report of Imperial Cancer Research 

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489. 
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Le Traitement des nevrodemites par le radium, Jour. med. de Bruxelles, 1910, 

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Die Grenzen der Radiumtherapio fiir don tiefliegenden Krebs nach dem heutigen 

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Becliold, H., and ZicgJer, I.: Vorstndien iiber Gicht, Biochem. Ztschr., xx, 189; 1910, 
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Denudation of Inoperable Cancer; an aid for Efficient Radio-therapy, Minnesota 

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Radical Surgery as an Aid to Efficient Radiotherapy in Apparently Hopeless Cases 

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Beckton, H., and Suss, S.: The Effect of Radium Emanation on Altmann's Granules, 
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Acad. d. sc., 1904, cxxxviii, 184. 



BIBLIOGRAPHY 329 

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330 RADIUM THERAPY 

and Engclmann: Demonstration eines transportation Inhalationsapparates fur 

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332 RADIUM THERAPY 

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BIBLIOGRAPHY 333 

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No. 49, pp. 953-957. 



334 RADIUM THERAPY 

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Clap, Edmund W.i Progress in Ophthalmology, Boston Med. and Surg. Jour., January 
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336 RADTCM THERAPY 

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BIBLIOGRAPHY 337 

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338 RADIUM THERAPY 

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BIBLIOGRAPHY 339 

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340 RADll'M THERAPY 

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BIBLIOGRAPHY 341 

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342 RADIUM THERAPY 

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Boston Med. and Surg. Jour., 1917, clxxvii, 686-691. 
Splenectomy Following Radium Treatment for Myeloeytic Leukemia, Med. Rec., 

New York, 1918, xciv, 1020-1023. 

(.ilrlnist, T. Casper: Cancer of the Skin. Maryland Med. Jour., 1915, Iviii, 157-161. 
Giraud: Untcrsuchung iiber die Absorption der Strahlen des Radiums durch einige 

organische Substanzen, Strahlentherapie, 1913, iii, 82-85. 

Glacsmer, Erna: Das Strahlenkarzinom, Strahlentherapie, 1914-1915, v, 275-283. 
Glaessgcn, I.: Quellemanatorien und natiirliche Radiumsolbader, Radium in Biol.. u. 

Heilk., 1911, i, 65-68. 
Gloclcer, R.: Ueber Absorption und Streuung der Rontgenstrahlen, Fortschr. a. d. Geb. 

d. Rontgenstrahlen, 1918, xxv, No. 5, pp. 421-436. 
Goclcel, A.: Radioaktive Emanation im Quellgas von Tarasp (Engadin), Chem.-Ztg,, 

1905, xxix, :i08. 
Ncueres iiber Radioaktivitat von Luft und Boden, Med. Klin., 1910, No. 44, pp. 

1748-1750. 



344 RADIUM THERAPY 

Goldberg, S. W., and, London, E. S.: Zur Fragc der Beziehungen zwischen Becquerel- 

strahlen und Hautaffektioncn, Dormat. Ztschr.. 1903, x, 457-462. 
Gorges: Zur Mesothoriumbehandlung bei gichtischen und nicht akutcn rhcumatischen 

Leiden, Berl. klin. Wchnschr., 1913, No. 29, pp. 1345-1347. 
Garner: Ueber die Anwendung von Radium bei rheumatischen Erkrankungen, Miinchen. 

med, Wchnsehr., 1910, No. 27, pp. 1448-1451. 
Gottie, Leopold: Die Wirkung und Anwendung der Joachimsthaler radioaktivcn Gruben- 

wiisser, Zentralbl. f. d. ges. Therapie. 1907, xxv, 169-173. 

Die Joachimsthaler radioaktiven Wasser in dor Therapie, Wien. med. Wchnschr., 

1910, No. 18, pp. 1039-1044. 

Radiumbad St. Joachimsthal, Wien. und Leip/ig, 1911, Braumiillcr. 
Graliley: Ueber den wechselnden Gelialt der Atmosphare an Radiumcmanation, Ein 

Beitrag zur Erklarung klimatischer Einiliisse auf biologische Vorgange, Ztschr. 

f. klin. med., 1910, Ixxi, 338-343. 
Graetz, L.: Ueber neue physikalische Strahhmgsforschungen, (Becquerelstrahlcn und n. 

Strahlen), Miincheu. med. Wchnschr., 1904, li, No. 14, pp. 598-602. 
Graff, E., von: Ueber die bisherigen Erfahrungen mit Radium und Rontgenstrahlen bei 

der Krebsbchandlung, Strahlentherapie, 1914-1915, v, 627-643. 

Graham, George H. : Radium and Its Medical Uses, Arch. Roentg. Ray, 1907, xii, 31-39. 
GrasnicTc, W.: Die Wirkung der Radiumstrahlen auf thierisches Gewebe, Arch. f. 

mikr. Anat., xc, Part I, pp. 1-38. 

Graves, Wm. P.: Radium Treatment of Nonmalignant Uterine Bleeding, Some Im- 
mediate After-effects, New York Mod. Jour., June 5, 1920, cxi, 969-972. 
Gray, J. A.: Secondary Gamma Rays Produced by Beta Rays, Proc. Roy Soc., 1911, 

Ixxxv, Series A, pp. 131-139. 
- and Wilson, W.: The Heterogeneity of the Beta Rays from a Thick Layer of 

Radium E, Philosophical Mag., 1910. xx, 870-875. 
Gray, B. W., and Eamsy, Sir William: The Half -life Period of Radium; a Correction, 

Jour. Chcm. Soc., 1910, xcvii, 185-186. 

and The Density of Niton (Radium Emanation) and the Disintegration Theory, 

Proc. Roy Soc., 1911, Ixxxiv, Series A, 536-550. 
Greef: Ueber Radiumstrahlen und ihre Wirkung auf das gesunde und blinde Auge, 

Deutsch. med. Wchnschr., 1904, xxx, 452-454. 
Green, Alan, ~B.: A Note on the Action of Radium on Microorganisms, Proc. Roy. Soc., 

London, 1904, Ixxiii, 375-381. 
Green, Stanley: Notes on Two Cases of Rodent Ulcer Treated by Radium, Lancet, 

London, March 19, 1904, p. 794. 
Greenongli, Robert B.: Radium in the Treatment of Carcinoma of the Buccal Cavity, 

Boston Med. and Surg. Jour., 1918, elxxviii, 598-602. 

The Value of Radium in the Treatment of Disease, Rhode Island Med. Jour., 

May, 1921, iv, No. 5, pp. 71-76. 

The Treatment of Tumors by X-fays and Radium, Boston Med. and Surg. Jour., 

June 16, 1921, clxxxiv, No. 24, pp. 622-627. 
Greinacher, H.: Radium, Leipzig, 1907, Veit & Co. 

Die Messung der Radium und Roentgenstrahlen, Naturw. Wchnschr., 1910, xxv, 

657-668. 

Die radioaktiven Elcmente und ihre Konstanten, Ztschr. f. Phys. u. diatet. Therap., 

1910, xiv, 138-141. 

Ueber einen direkt zeigendcn lonenmessapparat (lonometer), Radium in Biol. und 

Heilk., 1913, ii, 137-143. 
Grin, L.: Radiumemanation als Diuretikum, Miinchen, med. Wchnschr., 1911, No. 52, 

pp. 2792-2793. 
Grineff, D.: Ueber die biologische Wirkung des Mesothoriums. Der Einfluss des Thor- 

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Gruner, Paul: Kurzes Lehrbuch der Radioaktivitat, Berlin, 1911, A. Franke. 
Gudernatsch, J. F., and Bagg, n. J.: Disturbances in the Development of Mammalian 

Embryos Caused by Radium Emanation, Reprinted from the Proc. Soc. Exper. 

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Gudzent, Fritz: Ueber Dosierung und Methodik der Anwendung radioaktiver Stoffe 

bei inneren Krankheiten und die erzielten therapeutischen Heileffekte, Radium 

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Der Einfluss von Radium auf die harnsauren Salze Deutsch. med. Wchnschr., 1909, 

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Kritische Bemerkungen zur der Arbeit: Vorstudien fiber Gicht von Bechold und 

Zeigler, Bioehem, Ztschr., 1909, xxiii, 275-277. 



BIBLIOGRAPHY 345 

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1910, pp. 1153-1155. 



346 RADIUM THERAPY 

Guyot, G.: Experimentelle Untersuchungcn fiber die Wirkung des Radiums auf das 
Hautgewebe, Arch. f. Dcrmat. 11. Syph., 1909, xcvii-xcviii, 211-260. 

Gusmam, Zaearia,?: Radiumtherapia Contribution a la tecenica en aplicaciones en recto, 
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1914, xliii, Part II, pp. 228-242. 
Uaecker, V., and Lcbedinsky, N. : Ueber kombinierte Aether- und Radiumwirkung auf 

Embryonalzcllen, Munehen. med. Wchnschr., 1914, No. 1, pp. 7-8. 
Ilaendly, Paul: Die Wirkung der Mesothorium und Bontgenstrahleo auf das Kiirzi- 

nom, den Uterus und die Ovarien, Striihlentherapie, 1913, iii, 300-307. 
Anatomische Befunde boi n.it Mesothorium und Rontgcnstrahlcn behandelten Carci- 

nomen, Arch. f. Gynak., 1913, c, 49-69. 
Halm, Otto: A New Radio-active Element which Envolves Thorium Emanation, Proc. 

Roy. Soc., 1905, Ixxvi. Series A, pp. 115-117. 

Ein neues zwischenprodukt im Thorium, Physik. Ztschr., 1907, viii, 277-281. 
Der Zerfall der radioaktiven Elemente, Beiheftc z. Med. Klin., 1907, pp. 33-64. 
Ein kurzlebiges Zwischenprodukt zwischen mesothor. und Hadioathr., Physik. Ztschr., 

1908, ix, 246-248. 

Ueber eine neuo Erscheinung bei der aktivierung mit Aktivium, Physik. Ztschr., 

1909, x, 81-88. 

Ueber Gesetzmafsigkeiten V>ei des Emission von B Strahlen und fiber die Absorp- 

tion derselben in Materie, Berichte d. Deutsch-physik, Gesellsch., 1910, viii, 
468-474. 

Ueber Mesothorium und Radiothorium, Physik. Ztschr., 1911, xii, 148! 
Ualban, J.: Protektive Wirkung der Radiumemanation auf die sekundaren Sexual- 

charaktere der Tritonen, Zentralbl. f. Gynak., 1914, No. 13, pp. 466-470. 
llnlbirstadter, L. : Experimentelle Untersuchungen an Trypanosomeu iibcr die biolo- 

gische Strahlenwirkung, B:rl. klin. Wchnschr., 1914, No. 6, pp. 252-253. 
Mesothorium Treatment of Hyperkeratoses of the Hands Due to the Roentgen 
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Halliun, M. d' : Radium Treatment, Paris Med., June 11, 1921, xi, No. 24, p. 475. 
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Strahlentherapie, 1917-1918, viii, 161-165. 
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Radium Teehnic in Treating Cancer of the Esophagus, Jour. Am. Med. Assn., 

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May 16, 1903, pp. xxix-xxx. 

and Anderson, H. E.: On the Sensation of Light Produced by Radium Ray and 

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Haret: Die Behandlung der Prostntahypertrophie durch die Radiotherapie, Strahlen- 
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Harris, T. J.: Radium in Cancer of Larynx with Particular Reference to Dosage and 
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Harrison, Frederick C.: The Use of Radium in Post-operative Conditions, Internat. 
.Jour. Surg., April, 1917, xxx, No. 4, pp. 97-103. 



BIBLIOGRAPHY 347 

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Ixxvii, Part II, pp. 165-209. 



IMS KADHTM THERAPY 

Das Schieksal des mit Railiiiin K's'vahlten Spermachromatins iin Sceigclci, Arch. 

f. mikr. Anat., 1912, Ixxix, Part II, pp. 201-241. 
Parthenogenesis bei Wirbeltieren, hervorgerufen durcli artfremden radiumbestrahl- 

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D i)s Radium als Hilfsmittel fiir entwicklungsphysiologische Experimente, Deutsch. 

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Mesothoriuniversuche an tierischcn Keimzcllen, Sitzungb. d. k. preussisehe Akad. 

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Die Badiumkrankheit thierischer Keimzellen. Kin Beit rag zur experimontellen 

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Versuehe an Tritoneiern uber die Einwirkung bestrahlter Samfaden auf die tier- 

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KeiniNScliadigung durcli ehemische Eingriffe, Sitzungb. d. k. preussisehe Akad. 

d. Wissenseh., 1913, i, 564-582. 

Jlertwig, Paula: Dureh Radiumbcstrahlung hervorgerufene Veranderungen in den 
Kerntcilungsfiguren der Eier von Ascaris megalocei>hala, Arch. f. mikr. Anat., 

1911, Ixxvii, Part II, pp. 301-312. 

Das Verhalten des mit Radium bestrahlten Spermachromatins iin Froschei, Arch. 

f. mikr. Anat., 1913, Ixxxi, Part II, pp. 173-182. 
Dureh Radiumbestrahlung verursachte Entwicklung von halbkernigen Triton- und 

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Hewlett, C. W.: The Mass Absorption and Mass Scattering Coefficients for Homoge- 
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Lithium, Carbon, Nitrogen, Oxygen, Aluminum ami Iron, Phys. Rev., 1921, 

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Heyerdalil, 8. A.: Actinomycosis Treated with Radium, Jour. Am. Mcd. Assn., Decem- 
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350 RADIUM THERAPY 



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356 RADIUM THERAPY 

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358 RADIUM THERAPY 

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060 RADIUM THERAPY 

Einige neucsto Angaben viber die Anwendung <lcr Radium emanation bei Gicht, 

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362 RADIUM THERAPY 

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364 RADIUM THERAPY 

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366 RADIUM THERAPY 

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Q 

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368 RADIUM THERAPY 

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370 RADIUM THERAPY 

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376 RADIUM THERAPY 

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StoTdasa, Julius: Bedeutung der Radioaktivitat in der Physiologic, Strahlentherapie, 
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Stoklasa, 3., and Zdobnicky, V.: Influence des emanations radioactives sur la vegeta- 
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378 RADIUM THERAPY 

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380 RADIUM THERAPY 

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Die Behandlung des Lupus mit Radium, Deutsch. med. Wchnschr., 1910, No. 25, 

pp. 1167-1170. 

Radium in der Heilkunde, Hamburg and Leipzig, 1911, Leopold Voss. 
Biologische und therapeutisehe Erfahrungen mit den Radiumersatzpraparate 

Mcsothorium, Strahlcntherapie, 1912, i, 483-500. 
Wick, L.: Die ivarmen Quellen u. Kurorte. Braumiiller 's Badebibliothck Gasteins No. 

IV. 
Ueber die Beziehungen der Radiumemanation in der Gasteiner Therme zu deren 

Heilkraft, Berl. klin. Wchnschr., 1906, No. 15, pp. 475-476. 
Wickham, Louis: Quelques notes sur 1'emploi du radium en therapeutique, Ann. de 

dermal, et <lc syph., 1906, vii, 817 836. 
Le Radium, Principales Applications Therapeutiques, Presse med., 1908, No. 100, 

pp. 801-803. 
Radium und Hadiumtherapie bei Hnutkrajikheiten, Berl. klin. Wchnschr., 1909, No. 

38, p. 1740. 
Ueber die Behandlung von Hautkrankhciten mit Radium, Berl. klin. Wchnschr., 

1909, No. 40, p. 1833. 

Ueber die Behandlung der Epulis mit Radium, Gaz. d. hop., 1910, p. 85. 

Die durch Strahlcn hervorgerufenen histologisehen Gewebsveranderungen, Strahlen- 
therapie, 1913, iii, 64-81. 

Allgemeine Histologische Veranderungen gewebe unter dem Einfluss der Strahlen- 
wirkuiiK, Berl. klin. Wchnschr., 1913, No. 22, pp. 1006-1008, 1058-1062. 

and Degrais: Naevus vasculaire chez un nourrisson traite par le radium, Presse med., 

1906, p. 806. 

and Radiumtherapie et epithelioma cutane, Presse med., 1907, p. 565. 

unit Kmploi du radium dans le traitement des cancers epitheliomateux de la 
peau et des muqueuses, Presse med., 1908, p. 726. 

and Application du radium au traitement des cancers epitheliaux, Bull, de 1'Ass. 

franc, d. cancer, 1908, i-ii, 156-172. 

and Traitement des angiomes par le radium, Rev. d. med., 1908, xxviii, 567-579. 

and Die Radiumbehandlung des Krebses, Fortschr. a. d. Geb. d. Rontgenstrahlcn, 

1910, xvi, 73. 

and Radiumtherapie, Trans., S. Ernest Dore, New York, 1910, Funk and Wag- 

nails. 

and Traitement des cheloides par le radium, Arch, d 'electric, med., 1910, xviii, 

327. 
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382 RADIUM THERAPY 

and Radiunjtherapie, Cancer, Cheloides, Naevi, Lupus, Pruritis, Nevrodermites 

Eczemas, Applications gynecologiques, ed. 2, Paris, 1912, J. B. Bailliere and 
Sons. 

and - Kann das Radium der Chirurgie bei der Behandlung maligner Tumoren 

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and Radium as Employed in the Treatment of Cancer, Angiomata, Keloids, Local 
Tuberculosis and other Affections, London, 1913, Adlard and Son. 

and Le Radium, son emploi dans le traitement du cancer, Paris, 1913, Baillifire 

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Veranderungen der Epidermis, Strahlentlierapie, 1913, iii, 527-530. 
Wieprecht, Hans: Die Radioaktiven Eigenschaften einiger Solquellen nord- und Mit- 

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Wilke, A.: Ueber den Einfluss einiger physikaliwher Heilmethoden auf die Harn- 

saureausscheidung, Ztschr. f. phys. u. diatct. Therap., xiii, 430-438. 
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Wilkins, H. F., and Gewin, Wm. C.: The Use of Radium in the Treatment of Menorr- 

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Wilkinson, Will: Radiotherapy of Glands, Southwestern Med., September, 1921, v, 6-14. 
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Early Treatment of Some Superficial Cancers, Especially Epitheliomas by Pure 
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and Ellsworth, Samuel W.: Treatment of Superficial New Growths by Pure Radium 

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Wilson, Arthur C.: Uranium Salts in Cancer, Lancet, London, February, 1905, p. 387. 
Wilson, W.: The Decrease of Velocity of the B-Particles on Passing through Matter, 

Proc. Hoy. Soc., London, 1911, Ixxxiv, Series A, pp. 141-150. 
WinUer, Ferdinand: Ueber die Wirkung der Radiumemanation, \Vien. Med., 1912, pp. 

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Temperatur und Zusammensetzung, Med. Klin., 1909, No. 49. 

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Wood, Francis Carter: The Campaign Against Cancer, Jour. Cancer Research, Septem- 
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INDEX 



Absorption (see Coefficient of absorption) 
Absorption of alpha rays, 43, 45, 70 
beta rays, 43, 45, 47, 70 
gamma rays, 43, 44, 46, 70 

in water, 49-68 

radiation in apparatus, 129-133 
in tissues, 133, 134 
method of calculating, 129-134 
radium emanation, by various gub 

stances, 24, 25 
selective, 104 

Acanthosis nigricans, treatment of, 294 
Acne, treatment of, 295 
Actinium, discovery of, 18 

emanation, 20 

Actinium series, atomic weights of, 20 
period of decay, 20 
radiation from, 20 

Actinomycosis, treatment of, 240, 286 
Alopecia, as result of radiation, 295, 296 
Alpha rays, absorption of, 43, 45, 70 
coloration effects due to, 72 
effect on blood cells, 82 
fluorescence, caused by, 71 
ionizing effect of, 69 
properties of, 40 
secondary radiation from, 44 
source of, 26 
therapeutic effects of, 88 
Altmann's granules, 88 
Amenorrhea, due to radium treatment, 

242 

Ampoules, emanation, described, 112, 113 
instrument for inserting, 113, 153, 156 
use in treatment of carcinoma, 107, 198, 

202, 203 

of epithelioma, 160, 188, 189 
of tumors, 144, 145, 156, 157 
Anemia, pernicious, treatment for, 320 
Angiomata, treatment of, cutaneous, flat, 

deep, 89, 111, 258 280 
superficial 273 
raised, hard 274 

soft or cutaneous 274 
subcutaneous 274-280 
submucous 274-280 
technic 273-280 

Angiosarcoma, treatment of, 270 
Apparatus, therapeutic, containing ra- 
dium emanation, 109-115 
ampoules or bare tubes, 112, 113 
needles, 113, 114 
tubes, 112, 113 
containing radium salts, needles, 109, 

110 
plaques, 110, 111 



Apparatus, containing Cont'd 

tubes, 109 
for use of radioactive deposit, on 

metals, 114 
on wire, 114, 115 
solution 115 

various types of, effects, 124 128 
Applicator, (see Apparatus, therapeutic) 
Arthritis deformans, treatment of, 313, 

319 

Auditory canal, treatment of affections of, 
298 



Bacteria, effects of radium rays on, 73, 74 
Bare tubes (see Ampoules) 
Barium, associated with radium, 22 
Baths, radium emanation, 311 
Beta rays, absorption of, 43, 45, 47, 70 
effects on tumors, 90, 91, 92 
ionizing effect of, 69, 118 
properties of, 41 
screens for, 88 
secondary radiation from, 44 
therapeutic use of, 88 
Birthmarks (gee Nevus) 
Bladder, carcinoma of, treatment, 211, 

212 

Blastomycosis, treatment of, 286 
Blood coagulation of, 82 

effect of radium rays on, 80-82, 316- 

318 

thorium X on, 316, 318 
Blood pressure, effect of radium treat- 
ment on, 314, 320 
Blood vessels, effect of radium rays on, 

82, 96 

thorium X on, 316 

Bone, sarcoma of, treatment, 236, 237 
Bone marrow, effects of radium rays on, 

80, 86, 87 
Brain, effect of radium rays on, 85 

tumors of, 233 

Breast, carcinoma of, treatment, 212-221 
Bright 's disease, treatment of, 320 

C 

Cancer, effect of radium rays on, 90-102 
(see also Carcinoma, Epithe- 
lioma) 
Carcinoma, effect of radium rays on, 87, 

90-102, 158-227 

treatment for, of bladder, 211, 212 
of breast, 212-221 
of cervical glands, 202, 203 
of cervix uteri, 94, 150, 151, 221-227 



385 



386 



INDEX 



Carcinoma, treatment Cont 'd 

of esophagus, 205, 206 

of fundus uteri, 226 

of inferior maxilla, 199-202 

of intestines, 206 

of larynx, 204, 205 

of lingual, bucral and pharyngeal mu- 
cous membranes, 189 

of mouth, 189, 199 

of ovary, teratoid, 228 

of penis, 208 

of prostate gland, 209, 211 

of rectum, 207, 208 

of stomach, 206 

of superior maxilla, 199 

of testes, 228 

of thyroid gland, 203 

of tongue, 198 

of tonsil, 198, 199 

of urethra, 208 

of uterus, 94. 150-151, 221-227 

of vulva, 208 

Carnotite, composition of, 21 
deposits of, 21 
discovery of, 21 

Cartilage, effect of radium rays on, 83 
Cataract, treatment of, 297-298 
Cells, malignant, effect of radium rays on, 

79, 80, 90, 102, 104, 145, 158- 
160 

normal, action of radium rays on, 77- 

80, 86-87, 104, 108, 145 
stimulation of, by radium rays, 80, 93, 

96, 98, 99 

Cervical glands, carcinoma of, treatment, 
202, 203 

Cervix uteri, carcinoma, of, treatment, 94, 
150, 151, 221 227 

Coagulation of blood, as affected by ra- 
dium. 82 
thorium X, 82 

Coefficient of absorption, of beta rays, 118 
of gamma ravs, 118, 138 
of x-rays, 138 

Conglutinal giant cells, 96 

Contractures, 188 

Cosmetic applications of radium, 106, 111, 
245, 246 

Orookes tube rays, 41 

Curie, unit of radium emanation, 24 
D 

Darier's disease, treatment of, 294 

Deafness, treatment of, 298 

Debierne-Duane-Failla apparatus for ra- 
dium emanation, 29, 35 

Decay (see Bndium, Radium emanation 
and Radioactive deposit) 

Delta rays, 44 

Dental modeling compound, 149, 189 

Dermatitis, following radium treatment, 

105 
papillaris capillitii, treatment of, 283 

Dermatology, radium in. 245-296 

Diabetes, treatment of, 320 

Distance, as factor in radium technic, 119, 
120, 124-129, 147 



Dosage, radium rays, deep effects, 129, 
130, 133139, 149, 152, 154, 
155, 161 

duration of exposure, 140-141, 143- 
144, 155 

for children, 117 

frequency of repetition, 150, 155, 
160 

intensive, 160 

skin, permissible, 121-124, 155 

tissues, previously treated, 106, 188 

toxic, 315 

x-rays, deep effects 137-139 (see also 
under names of disease and or- 
gans) 

Ductless glands, diseases, treatment of, 
303-309 

E 

Ear, (see Auditory Canal) 

Ectropion, treatment, 188 

Eczema, chronic, treatment of, 286, 289 

Edema, angioneurotic, use of radium for, 

320 

Electrometer, Wulf string, 50 
Electrons, theory of rearrangement in ra- 
dioactive substance disintegra- 
tion, 27 

Electroscope, use in measurement of, 
gamma ray activity, 35, 36, 51-53 
Wilson tilted, 53, 54 
Emanation, actinium, 20 

radium (gee Radium emanation) 
thorium, 20 

Kndometritis, treatment of, 244 
Kpithelioma, diagnosis of, 160, 161 
treatment of, basal cell, 161-188 
cystic, 284 
eyelid, 147 
lip, 188, 189 
mucous membrane, 149 
nasal mucosa, 188 
skin, 160-188 
squamous cell, 160, 161 
Epithelium, histologic effect of radium 

rays on, 78 
Erythrocytes, as affected by radium, 317, 

318 

as affected by thorium X, 317 
Esophagus, radium treatment of, 151 

carcinoma of, 205, 206 
Ethmoiditis, chronic, treatment of, 298 
Excessive radiation, results of, 100 
Eye, effects of radium rays on, 85, 86 
Eyeball, phosphorescence produced in, 8S 
protection of, 147 



Failla machine for cutting glass tubes, 

113 

method of distinguishing tubes, 112 
modification of apparatus for prepara- 
tion of radium emanation, 29 
technic for inserting emanation am- 
poules, 156 



INDEX 



387 



Ferments, effects of radium rays on, 86 
Fibromyoma of uterus, treatment of, 241 

244 

Filters (see Screens) 
Filtration of rays, 45 
Finsen light, for lupus vulgaris, 285 
Fluorescence, due to alpha rays, 71 
Forceps, for handling radium tubes, 147, 

148, 323, 324 
Simpson, 148, 324 

' ' Fordyce 's disease, ' ' treatment of, 283 
Freer apparatus for treatment of larynx, 

205, 300-302 
Freer needle holder, 153, 204, 211 

G 

Gamma rays, absorption of, 43-44, 46, 70 

in water, 49-68 

activity, growth of, 33, 34 
measurement of, 35, 36 

effects, deep, 137-139 
on tissues, 88, 89 
on tumors, 90, 92, 93, 97 

intensity of, 63, 125-129 

ionization of, 42, 69, 118 

penetrability of, 70 

properties of, 41, 42 

screens for, 46, 70, 88, 117, 118 

secondary radiation from, 44 
Goiter, treatment of, 83, 308, 309 
Gout, treatment of, 319 

H 

Hair, affected by radium rays, 295, 296 
Heart, effect of radium treatment on, 313, 

314, 320 

Heat, in treatment of cancer, 199 
Helium, atom given off from radium, 24, 

26 
Hemorrhage, after radiation, 96, 305, 300 

myopathic, treatment of, 244 

reduced, in leukemia, 305 
Henry's law, 25 

Herpes zoster, treatment of, 295 
Hodgkin's disease, treatment of, 308, 320 
Hyperesthesia, use of radium, 295 
Hyperidrosis, treatment of, 295 
Hypertrichosis, treatment of, 295 
Hypertrophies, skin, treatment of, 294 

tonsil, treatment of, 302 



Idiosyncrasies, individual sensitiveness to 

radiations, 108 

Immunity, produced by radiation, 99-102 
Inflammation, due to radium rays, 75, 88, 

103-105, 149, 245, 322 
Inhalation of radium emanation, 311, 319 
Injuries, professional, due to radium, 322- 

324 
Insufficient radiation, stimulation due to, 

98, 99 

Intensity of gamma rays, 63, 125-129 
radium rays, 49 



Intensity of radium rays Cont'd 

affected by secondary radiations, 139- 

142 

distance as varying, 119, 120, 124-129 
x-rays, 49, 50, 137-139 
Internal medicine, radium in, 310 321 
International Eadium Standard, 36 
Intestines, carcinoma of, treatment, 206 
Intratumoral radiations, 107 , 144, 140, 

155-157 

Ionization, effected by alpha rays, 69 
beta rays, 69, 118 
gamma rays, 42, 69, 118 
radium rays, 89 

Ionization chambers, use in absorption of 
radiations, 49, 50, 51, 52, 60, 
66, 68 



Janeway dental modeling compound, 149, 

189 
Joly and Stevenson, steel needles, 113 

K 

Keloids, treatment of, 246-257 
Keratosis, treatment of, 294 
Kidneys, effect of radium rays on, 84 



Laryngology, use of radium in, 298-302 
Larynx, treatment for angioma, 299 
carcinoma, 204, 205 
papilloma, 298, 299 
sarcoma, 230 

technic of applications, 299-302 
tuberculosis of, 299 
Lecithin, theory, of cause of chemical 

changes in cells, 86 
Leucocytes, effect of radium rays on, 81, 

304, 316 

thorium X on, 316 
observation of, during treatment, 102 
Leukemia, radioactive deposit treatment, 

320 

radium ray treatment, 81, 303-308 
lymphatic, 304, 305 
myelogenous, 303, 304 
technic of, 306, 307 
Leukemia cutis, treatment of, 294 
Leukopenia, brought on by exposure to 

radium rays, 323 

Leukoplakia, treatment of, 189,198 
Lichen chronicus simplex, treatment of, 

286, 289 

Lichen planus, treatment of, 288 
Liver, effects of radium rays on, 84 
Lupus erythematosus, treatment of, 287- 

294 

Lupus vulgaris, treatment of, 282 284, 286 
Lymphadenoma (fee Hodgkin's disease) 
Lymphangiomata, treatment with radium 

rays, 258, 275, 281 

Lymphatic glands, effects of radium rays 
on, 80, 86, 87 



388 



INDEX 



Lymphosarcoma, radioactive deposit treat- 
ment, 320 
radium ray treatment, 230, 238, 239 

M 

Malignant cells, effect of radium rays on, 
79, 80, 90-102, 104, 145 

Maxilla, inferior, carcinoma of, treatment, 

199-202 
superior, carcinoma of, treatment 190 

Melanosarcoma, treatment of, 229 

Menopause, due to radium treatment, 241, 

243 
due to x-ray treatment, 242 

Menorrhagia, treatment of, 244 

Mesothorium, discovery of, 18 

Metabolism, effect of radium treatment 
on, 314, 315 

Metastasis, treatment following, 160, 198- 
202 

Metritis, treatment of, 244 

Metrorrhagia, treatment of, 244 

Mica, "pleochroic halos" due to radio- 
activity, 72 

Microcurie, defined, 36 

Millicurie, a unit of measurement, 36 

Millieurie hours, computation of, 141, 142 
defined, 140 

Milligram hours defined, 140 

Molluscum contagiosum, treatment of, 
284 

Mouth, radium treatment of, 149, 189, 
199 

Muscle, effect of radium rays on, 83 

Myalgia, treatment of, 319 

Myopathic hemorrhage, treatment of, 244 

N 

Xails, as affected by radium rays, 322 
Nausea, due to radium reaction, 103 
Needle holder, Freer, 153, 204, 211 
Needles, containing radium emanation, 

113, 114 

containing radium salts, 109, 110 
Joly and Stevenson, steel, 113 
use in treatment of tumors, 144, 145, 

155, 156 
Nervous symptoms, effect of radium rays 

on, 84, 85 
Neuralgia, intercostal and sciatic, use of 

radium, 295 
of trigeminus, 319 
Neuritis, use of radium for, 295 
Nevus, treatment with radium rays, 259 

280 

linear, 279, 283 

pigmentosus, 268, 269, 276-278, 281 
vascular, 266 
Niton, 24 
Noble gases, 24 
Nose, sarcoma of, treatment, 188 

O 

Otology, use of radium in, 298 
Ovary, carcinoma of, treatment, 228 
effect of radium rays on, 84 



Packages, radium, preparation of, 153, 

154 

Pad, radium, 152-154 
Pancreas, effect of radium rays on, 84 
Papillomata, treatment of, 294 

larynx, 298, 299 

Parotid tumors, treatment of, 203-204 
Penis, carcinoma of, treatment, 208 
Phosphorescence, caused by radiation, 71 

in eyeball, 85 

Photographic action of radiation, 71 
Pitchblende, 21 
Plaques, radium, therapeutic use of, 100, 

110, 111, 124-130 
use in opithelioma, 161 (see names 

of diseases and organs) 
Pleochroie halos (sec Mica) 
Polonium, discovery of, 18 (see Radium 

F) 

"Port-wine stains", treatment of, 273 
Portals of entry, for insuring intensity 

below skin surface, 135-139, 

152 
Postoperative radiation, 159, 160, 189, 

203, 204, 211, 212 
Preoperative radium treatment, 159, 160, 

212 
Proctitis, following radium treatment, 

225 
Prostate gland, carcinoma of, treatment, 

209-211 

Protactinium, 20 
Protective devices, against radiations, 

147, 323, ?,24 

Pruritus, treatment of, 294 
Psoriasis, treatment of, 286, 288 

B 

Radiation, teehnic of, 146-157 

intratumoral 155-157 

surface, deep radiations, 150-155 

superficial radiations, 146-150 
Radiations (see Absorption) 
effects of, chemical, 72 

coloration, 71, 72 

decomposition, 72 

disintegration, 72 

heat production, 70 

ionization, 69 
iluorescence caused by, 71 
light emitted by, 71 
penetrability of, 69 70, 150-152 
phosphorescence, caused by, 71 
photographic action of, 71 
properties of, 40 
secondary, formed by screens, 48 

produced by rays, 44 
surface, 116, 117 
Radioactive deposit, active change, 26 

administration of, 311 

collection, on foil, 114 
on wire, 115 

described, 26, 114 

pathologic effects of, 311 



INDEX 



389 



Radioactive deposit Cont'd 
rate of decay, 115 
slow change, 26 
solution of, 38, 39, 115 
therapeutic use of, 26, 27, 114, :;in 

313 

Radioactive rays (see Radiation and Ra- 
dium Rays) 

Radioactive substances, defined, 40 
period of decay, 18 
series described, 19 
transformation theory, 18, 27 
Radioactivity, discovery of, 17 
Radiographs, x-ray and made with ra- 
dium radiations, 71 
Radiosensibility (see Sensitiveness to ir 

radiations) 

Radiothorium, discovery of, 18 
Radium, administration of, 310, 311 
analgesic action of, 295 
atomic weight, 22 
chemical nature of, 22 
content of various organs of body, 312 
decay, 24, 

period of, 18 

disintegration, theory of, 27 
effects of on tissues, morphologic, 31G 

physiologic, 313-315 
elimination from body, 311-313 
extraction of, process, 22 
in internal medicine, 310 321 
metallic state, 22 
occurrence in nature, 22, 23 
origin of, 21 
spectrum, 22 

standard, international, 36 
of various countries, 36 
Radium A, a decay product of radium 

emanation, 25, 26 
properties, 28 
Radium B, described, 26 

properties, 28 
Radium C, described, 26 

properties, 28 
Radium C,, described, 26 
Radium C 2 , described, 26 

properties, 28 
Radium D, described, 26 

properties, 28 
Radium E, described, 26 

properties, 28 

Radium F, or polonium, 18, 26 
effect on skin, 88 
properties, 28 

Radium G, atomic weight, 26, 27, 28 
described, 26 
properties, 28 
Radium emanation, absorption of, by 

different substances, 24, 25 
administration of, 311 
activity of measurement, 35-38 
atomic weight, 24 
baths, 311 

chemical behavior, 24 
decay, 25 

period of, 25, 34 



Radium emanation Cont'd 

rate of, 33, 111 
inhalation of, 311 
preparation of, 29-39, 111, 112 
solution of, preparation, 38, 39 

therapeutic use, 81 
spectrum, 24 
Radium rays, effect of, biologic, 88-102, 

149-150 

ionizing, 42, 69, 89, 118 
on animal life, lower forms, 74, 75 

higher forms, 75, 76 
on bacteria, 73, 74 
on blood, 80-82, 316-318 
on blood pressure, 314, 320 
on blood vessels, 82, 96 
on bone marrow, 80, 86, 87 
on brain, 85 
on cartilage, 83 
on cells, normal, 86, 87 
on connective tissue, 81, 82 
on eye, 85, 86 
on ferments, 86 
on heart, 313, 314, 320 
on kidneys, 84 
on leucocytes, 81, 304, 316 
on liver, 84 

on lymphatic glands, 80, 86, 87 
on muscle, 83 

on nervous system, 84, 85 
on ovary, 84 
on pancreas, 84 
on salivary glands, 84 
on skin, 76 80, 87, 127, 128, 155, 

245 

on spleen, 80, 81 
on stomach, 83, 84 
on testis, 84 

on thyroid and thymus glands, 83 
on vegetable life, 74 
sterilizing, 93-94, 159 
stimulating, on cells, 80, 93, 96, 98, 

99 
Radium salts, preparation of, 22 

therapeutic use of, 22, 109, 310 
Reaction, radium, amenorrhea, 242 

due to intratumoral radiations, 107, 

108 
due to surface radiations, 103-106, 

295, 296 
following treatment of epithelioma, 

189 

of fibroids, 242, 243 
of spleen, 307 
inflammatory, 75, 88, 103-105, 149, 

245, 322 

leukopenia brought on, 323 
menopause, 241-243 
nausea, 103 

physiologic, 313, 322, 323 
secondary or deferred, 106 
selective, 104-245 

telangiectasia, 105, 106, 269, 273, 295 
Rectum, carcinoma of, treatment, 207, 

208 
radium treatment of, 149 



390 



INDEX 



Respiration, effect of radium treatment 

on, 314 

Rhinology, use of radium in, 298 
Rhinoscleroma, treatment of, 286 
Ringworm, treatment of, 295 

S 

Sagnac, Rays of, 48 

Salivary glands, effects of radium rays on, 

84 
Sarcoma, treatment with radium rays, 97, 

228, 229, 232-239 
treatment for, of bone, 236, 237 
of larynx, 230 
of mediastinal, 230, 232 
of nose and nasopharynx, 188 
of orbital tissue, 230 
of periosteal, 230 
of skin, 229 

of tonsil and postnasal space, 230 
of vocal cord, 302 
Scars, resulting from radium application, 

245 

treatment of, 246-249 
x-ray, treated with radium, 188 
Screen holders, 149, 150 
Screens for alpha rays, 45, 70 
beta rays, 45-47, 70, 88, 117, 118 
cosmetic applications, 245, 246 
deep effects, 118, 120, 130, 143 
eyeballs, protection of, 147 
gamma rays, 46, 70, 88, 117, 118 
plaques, 110, 111, 143 
tandem, 151 

treatment of angiomata, 273, 274 
carcinoma of bladder, 211, 212 
of breast, 216 
of cervix uteri, 225 
of esophagus, 205, 206 
of inferior maxilla, 202 
of larynx, 205 
of penis, 208 

of prostate gland, 210, 211 
of rectum, 207, 208 
of stomach and intestines, 206, 207 
of superior maxilla, 199 
of thyroid gland, 203 
of urethra, 208, 209 
esophagus, 151, 205, 206 
fibromyoma of uterus, 242, 243 
keloids, 247-249 
lupus erythematosus, 289, 294 
lupus vulgaris, 285 
metritis, 244 

nevus, pigmented, 282, 283 
sarcoma, 232, 233 
skin, 77-79, 143 

tuberculosis verrucosa cutis, 284, 285 
tumors, 91, 117 

parotid, 204 

various types, 46, 47, 150, 151 
"window" 47 
(see also names of diseases and organs 

treated) 
Sebaceous glands, use of radium for, 295 



Selective absorption, defined, 104 
Selective action, of radium rays, 104 
Selective reaction, 104, 245 
Sensitiveness to irradiations, carcinomata, 

158-160 
x rays, 159 

malignant cells, 98, 101, 102, 104, 145 
normal cells 104, 108, 145 
Simpson ampoule inserting instrument, 153 
Simpson forceps, 148, 324 
Skin, dosage, permissible, 121-124, 155 
effects of radium rays on, 76-80, 87, 127- 

128, 155, 245 
histologic changes of, due to radium 

rays, 76-80, 127, 128, 245 
treatment of, radium, 245-296 
chronic infections, 284-286 
disorders of appendages of, 295, 296 
hypertrophies, 294 
inflammatory and granulomatous 

infiltrations, 286-294 
neuroses, 294, 295 
tumors, benign, 246 284 

malignant, 160-202, 246 
(see also names of diseases affecting 

skin) 

Spinthariscope, 71 
Spleen, effects of radium rays on, 80, 81, 

86, 306, 307 
of thorium X on, 80 
protection from rays, 225 
Springs, mineral, radium emanation con- 
tents of, 25 
Sterilizing effects of radium rays, 93, 94, 

159 
Stimulation of cells by radium rays, 80, 

93, 96, 98, 99 
Stomach, carcinoma of, treatment, 206 

effect of radium rays on, 83, 84 
Suprarenal gland, as effected by thorium 

X, 317 
Sweat glands, use of radium in treatment 

of, 295 

Sycosis vulgaris, treatment of, 295, 296 
Synovial lesion of skin, treatment of, 294 
Syphilis, skin eruptions,' treatment of, 286 

T 

Technic of radiation, 146-157 (see also 
names of diseases amenable to 
radiation) 

Telangieetasia, following radium treat- 
ment, 105, 106, 269, 273, 295 
Temperature due to radium reaction, 10."? 
Testis, carcinoma of, treatment, 228 

effect of radium rays on, 84 
Thermolumiuescence, 71 
Thorium, discovery of radioactive proper- 
ties of, 18 
emanation, 20 

Thorium series, atomic weights of, 19 
period of decay of, 19 
radiation from, 19 

Thorium X, biologic action of, 88, 89, 310 
effect on blood, 82, 310, 316, 317 



INDEX 



391 



Thorium X, effect Cont 'd 

on spleen and other organs, 80 
effects of large injections of, 316, 318 
in treatment of anemia, 320 

leukemia, 307 

Thyroid gland, enlarged, treatment of, 309 
Thyroid and tliymus glands, carcinoma 

treatment, 203 

effect of radium rays on, 83 
"Tinnitus aurium, " treatment of, 298 
Tissue, connective, effect of radium rays 

on, 81, 82 
Tissues, effect of radium rays on, 77-80 

malignant, treatment, 79, 80 
Tobacco, as affecting leukoplakia, 189 
Toiles, described, 110 

use in treatment of nevus, 273 
Tongue, carcinoma of, treatment, 198 
Tonsil, carcinoma of, treatment, 198, 19!) 
hypertrophy of, treatment, 302 
sarcoma of, treatment, 230 
Toxic doses of barium, 315 

of radium, 315 
Trachoma, treatment of, 297 
Tuberculosis, of larynx, treatment of, 299 
Tuberculosis verrucosa cutis, treatment of, 

280, 281, 284-286 
Tuberculosis adenitis, treatment of, 240 

sinuses, treatment of, 240 
Tubes, emanation, 112, 113, 124 130 
"ba.re, " 112, 113 (see also ampoules) 
for radium salts, 109, 110 
Tumors, effect of radium rays on, 89, 90- 

92, 144, 145 
intratumoral radiations, 107, 144, 145, 

155-157 

screens in treatment for, 91, 117, 204 
treatment of, 153-157, 158-160 
Jirnin, 233 

malignant, inoperable, 159, 160 
malignant, operable, 159 
mediastinal, 230, 231 
of eyelids, 234, 235 



Tumors, treatment of Cont'd. 
parotid, 203, 204 
subcutaneous and submucous, 274-280 

TT 

Uraninite, deposits of, 21 
Uranium, radioactive properties of, discov- 
ered, 18 

radium content of, 21 
Uranium series, atomic weights of, 20 
period of decay of, 20 
radiations from, 20 
Urethra, carcinoma of, treatment, 208 
Uterus, carcinoma of, treatment, 94, 150, 
loi, 221-227 



Vagina, radium treatment of, 147 
Vernal conjunctivitis, treatment with ra- 
dioactive deposit, 114, 297 
Vocal cord, sarcoma of, treatment, 302 
Vulva, carcinoma of, treatment, 208 

W 

Waters, mineral, radium emanation in, 25 
Warts, treatment of, 294 



X-rays absorption of, 49, 50 
discovery of, 17 

effect on blood making organs, 86 
immunity experiments with, 99, 101 
keratosis, treatment of, 294 
penetrating power of, 44 
radium treatment following use of, 188 
reaction causing menopause, 242 
scars treated with radium, 188 
sensitiveness of carcinomata to, 159 



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