A MONTHL" JOURNAL DEVOTED TO THE CHEMISTR", PH"SICS AND

THERAPEUTICS OF RADIUM AND RADIO-ACTIVE SUBSTANCES.

Edited and Publ ished by Charles H . V iol, Ph . D. , and W illiam H . Cameron , M . D .

w ith the ass istance of co llaborators work ing in the fields ofRadiochem istry , Radioactivity and Radiumtherapy .

Subscription per year, or 25 cents per copy'

in the United States and Canadain all other countries per year.

A ddres s all communications to the Editors, Forbes and Meyran Avenues ,Pittsburgh , Pa.

VOL. "I A PRIL, 1918 No. 1'

REPORT OF RESULTS OF RADIUM TREATMENT AT

THE COLLIS P. HUNTINGTON MEMORIAL HOS

P ITAL B"THE CANCER COMMISSION

OF HARVARD UN IVERSIT"*

B" \VILLIA M DUANE, PH . D BOSTON,

A N D

ROBERT B . GREENOUGH ,M . D .

,BOSTON .

The treatment o f cancer and al l i ed condit ions by radium has now

( June , 19 1 7 ) be en in operat ion at the Col l i s P . Huntington M emoria lHospital for a su ffi c i ent length

,

o f t ime to permi t conclu s ions w i th regardto i t s value to be formulated . Radium w as fi rst employed here in September

,19 1 3 , and from that t ime to the present day has been the main

interest and activi ty o f the cl in ical w ork carried on by the Cancer Commi s s ion .

The chie f respons ibi l i ty for thi s w ork mu s t be accorded to Dr.

J .Col l ins \Varren ,

Chai rman o f the Cancer Commis sion o f “ HarvardUnivers i ty . Dr . Warren early saw the neces s i ty foran independent andunbiased invest igation o f the value o f the many therapeut i c agents ad

v ocated from time to t ime as“ cu res” for cancer , and it i s due enti rely

to h is w i se foresight , hi s unl imi ted enthus iasm, and hi s unti r ing effortthat the hospi tal was establ i shed

,and the c l ini ca l w ork o f the Commi s

si on begun on a broad bas i s o f sc ient ific accuracy , and with resourcessuffici ent to mainta in these standards . During th i s peri od a numbero f

.

different individual s have taken a part in the w ork , but ow ing to thevery complete system o f records and cl ini ca l notes establ i shed by thefi rst Physi cian-in -Charge o f the Hospi tal

,Dr . Thomas Ordw ay, the data

obtained are now avai lable for study, and the resul ts can be accumulatedand stated w i th a considerabl e degree o f accuracy . The hospital wasopened during the peri od when Dr . E . E . Tyzzer was Director o f the

R ep r in te d f rom th e B os ton Med ica l Su rg i ca l J ou rna l , CL""V I I , 3 59-3 6 5,Sep temb e r 1 3 , 1 91 7 .

Cancer Commi ss ion , and he took a large part in the organization o f thework

,as wel l a s the more defini te respons ibi l i ty for the - pathologica l

work, the reports o f autops i es and the examination o f cl inica l patho logical materia l . The work with radium began in S eptember

,19 1 3 , with the

appointment to the Commi ss ion o f Wi l l iam Duane,Ph . D .

,Research

Fel low in Phys i cs . Dr . Duane has had charge o f the preparat ion andmeasurement o f the radium

,and o f the deta i l s o f i ts p racti ca l appl i cati on

to treatment o f the cases adj udged sui tabl e for radium therapy . In ad

dit ion to Dr . Tyzzer, Dr . O rdw ay and Dr . Duane, a number of othershave had a share in the col l ect ion o f the data on w hich thi s report i sbased : Dr . E l l i s Kel l ert and Dr . George Benet

,res ident physicians

,

Dr . Henry A . Chri st ian and Dr . Francis Peabody,consu lt ing phys i cians ;

Dr . J . Luc i en Morri s,Dr . F . S . Hammett , Dr. -Henry Lyman

,chemists ;

Dr . W . J . Kerr , Dr. Carl T . Harri s,Dr . Clarence T . Hyman

,hou se offi

cers ; Dr . Edward H . R i s l ey and Dr. Charming C . S immons,ass i s tant

surgeons ; Dr . George A . Leland , In , Out—Pat ient surgeon ; Dr. A . A .

Ghoreyeb,Research Fel low in Pathology ; M i s s I rene W . Mason and

M i s s Anna Gibson,matron- superintendents o f the hospi tal ; and many

consul tants in special l ines o f c l ini ca l work,i nc luding Drs . Harvey

Cushing,C . A . Porter, D . Crosby Greene

,Harri s P . Mosher

,E . A .

Crockett,W . P . Graves , George Derby , C . J . White,as wel l a s D r.

Robert B . Greenough ,Surgeon—in —Charge o f the Huntington Hosp ital .

Al l o f above—mentioned persons have in some degree contribu ted to theaccumulat ion o f the material upon Which th i s report i s based .

The present organization o f the hospi tal work i s as fol lows : A pati ent i s re ferred to the hospi tal by hi s own phys i c ian

,or b y another inst i

tution. Appl i cat ion cards are fu rn i shed wi th blanks for the princ ipal .

data whi ch it i s des i red to obtain . The pat ient i s then examined wi th aview to the diagnosi s and the question o f wh ether or no rad i cal operativetreatment i s a pos s ibi l i ty . When the opin ion o f a consultant i s neededthe servi ces o f the members o f the different department s o f the H arvardMedi ca l S chool are freely cal led upon

,and have been most generou sly

given . With the except ion of certain minor superficia l l es i ons o f thenon—metastas iz ing type

,it has always been the pol i cy o f the hospi tal in

operable cases , to advi se operat ion , and to withhold radium or other nonoperat ive treatment . I f operation i s cons idered advi sabl e the pati ent i sre ferred to one o f the larger hosp ital s

,or retu rned to h i s own phys i c ian

wi th thi s op in ion . A few cases have been received at the. HuntingtonH ospi ta l for radi cal operation

,but they are taken only for spec ial rea

sons,and are the excepti on s to the general ru l e .Pathologi cal reports in confirmation o f the diagnos i s o f cancer are

sought in every case . In the cases of post—operative recurrence o f cancer,the pathologi cal report upon the t i s sue remov ed at operat ion can usual lybe obtained . In advanced inoperabl e and ul cerated cases , a fragmento f t i s sue to confirm the d iagnos i s can u sual ly be secured with the curette,without undue danger o f spread o f the disease . Where the t i ssues areunbroken

,however

,i t has been the pol i cy o f the hospi tal to refrain from

employing the exploratory exc i s i on o f f ragments o f t i s sue,on the ground

that the danger to the‘

pati ent o f artific ial spread o f the di sease outweighed the advantages o f a certa in d iagnos i s . This rul e has beenbroken

,advi sedly

, from time to time , but only on rare occas ions .I f the case i s one whi ch i s cons idered su i tabl e for rad ium t reatment,

the matter i s di s cus sed with Dr . D uane ; the deta i l s in regard to dosage,s creening

,di stance , duration and frequency are determined

,and treat

RADIU M 3

ment i s begu n . Specia l methods o f appl i cation are devi sed for spec ia lcases , and the progres s o f the ca se i s fol low ed both by the radium expert ,and by the surgeon . Data

,cons i s t ing

.

o f measurements,photographs

,

t racings , etc . , are made, and the record i s continued . N o case i s d i5*

charged“cured

”or otherwi se, unt i l terminated by death . A foll ow —up

system , under M i s s Ruth Symonds , the Socia l S ervi c e Worker o f thehospi tal , has yi elded excel lent resul ts in trac ing up

“ l os t” cases . FromApri l , 19 1 2 , t i l l January 1 , 19 16 ,

out o f 1080 cases,the end—resul t s ( to

within s ix months ) w ere know n in al l bu t 39.

I t ha s been the pol i cy o f the hospi ta l to restri c t the u se o f radium topat ient s that cou ld be brought to the hospital to be cared for by thestaff ; only in thi s way can the ful l benefi t o f the radium be secured tothe pat ient , and the fu l l benefi t o f the data obta ined secu red to the

Commiss ion .

In report ing the resu l ts o f the use o f radium in the treatment o f cancer

,some prel iminary statements are advi sable . When the fi rs t report s

o f the therapeuti c u se o f radium were given out,a lapse o f t ime suffici ent

f or an unbiased and definite conclu s ion as to i t s benefi t s had not occurred .

In certain c l in i c s , al so , the cu stomary data for the surgica l diagnos i s o fmal ignant d i sease in i ts d ifferent s i tuat ions were not a lways obtained

,

and evidence in support o f the statements that the cases treated were actual ly cancer was not provided . The sensational publ i cations in the laypres s relat ing to the wonder fu l eff ects o f radium therapy

,and the drama

ti c and interes ting physi ca l phenomena o f radioactivi ty,al l helped to

rou se in the publ i c , and among the pro fess ion at large , an expectation o fbri l l iant resu l t s far in exces s o f what the facts now actual ly seem to warrant . Again , the obviously extravagant cla ims o f. some o f the earl i erexponents o f radium therapy served to arouse in the more conservativemembers o f the profess ion a natural pes s imi sm

,which led them to di s

t ru s t i t s value al together . As a fac t the real truth l i es somewhere between these two extremes . Radium i s not a cure for al l kinds o f cancer.There are many cases o f cancer in whi ch i t can be sa id to be o f nomaterial benefi t ; bu t there are al so many cases where i t s u se prolongs l i fe,rel i eves d i s tress ing symptoms , improves the general condi ti on and thefunctional act ivi t i e s o f the pat ient

,and mitigates , as does no other agent

w hich we have employed,the gradual ly progress ive symptoms o f ad

vancing incurabl e cancer . There i s a smal l group o f cases o f cancerwhere treatment with radium has apparently

,so far as our observat ions

extend,been capabl e o f eradi cating the

'

cl ini cal mani festat ions of thedi sease . I t would be prematu re to u se the word “cured in thi s connection

,as the time elapsed i s not sufficient to con form to the arbi trary

three or five year l imi ts common ly accepted in surgical l i terature , whichare admittedly themselves t ime standards too bri e f to cover the in frequent but wel l—establ i shed cases o f late recurrence . Thi s group o f casesincludes the more superficial and less rapidly metasta si-z ing forms o f carcinoma

,together w ith a few cases o f the deeper and general ly more

seriou s types o f di sease whi ch appea r to be,for some unknown reason,

individual ly more susceptible to radiat ion than the usual ca ses o f thesame character. In the large group o f cases in w hi ch radium has markedbeneficial eff ect a s pal l iat ive treatment , and in the smal l er group inwhi ch i t s effects are more permanent and complete in eradicat ing , thecl in i cal s igns of the di sease

,radium has al ready j ust ified the ve ry con

siderable outlay neces sa ry for i t s purchase, and the further difficul ti esand dangers o f i ts effect ive admini s trat ion .

4 RADIU M

The 1080 cases included in thi s report are those whi ch entered the hosp ital in the 28 months from Apri l

,19 1 2 ,

to January,19 1 6 . Radium

w as not u sed for t reatment here unti l S eptember, 19 1 3 , but i t was thenappl i ed to many o f the cases w hi ch had entered the hosp ital be fore thatt ime . 642 o f the 1080 cases rece ived radium treatment . The arbi trarydate o f January

,19 16 , was establ i shed in order that at l eas t a year might

have elapsed in every case reported be fore the resu l t s o f treatment w ereassembled for study . The end resu l ts given , however, are carri ed up todate ( January, and represent the resu lt s at periods from twelveto forty mon ths a fter treatment was begun— 4am average of two years andtwo months .During the period o f time menti oned the Commi s s ion has been us ing

only 2 35“mi l l igrams o f radium . Thi s amount has s ince been greatly

augmented through the kindnes s o f friends o f the Univers i ty .

The tabular l i s t o f ca ses i s as fol lows :Carc inoma (A )Buccal Cavity . ( 39A )

Li pPaletteJaw ( lower )Jaw (upper— antrum )Tongu e and floor o f mou thTons i lCheek (buccal sur face )

TotalS tomach

,L iver

,etc . (40A )

PharynxGal l—bladder and l iverPancrea sS tomach

TotalPeri toneum

,etc . (4 IA )Peri toneum and omentumIntest ine ( colon )Rectum

TotalUrinary O rgans

B ladder

TotalG .

—U .,Mal e

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

TotalG .

-U .,Female

VaginaU terusOvaryCl i tori s

Vulva

Skin , Face, etc . (44A )Ca rc inomaEpidermoid carc inomaRodent ul cer“

Epi thel i oma

Tota lO ther S i tes (45A )

ThyroidN eck glandsLarynxGlands o f groin

,axi l la

,etc .

Parot idN asal mucosa

Tota lSarcoma Al l i ed Tumors .

BoneSo f t partsM elanoti cEndothel iomaB rain tumorMyelomaM ixed tumorsHypernephroma

TotalBenign Tumors

M i sce l laneou sB reastKelo id

TotalM i scel laneou s Condit ions

°

Keratos i s senil i sTuberculos i sSyphi l i sLupus erythematosusLeukoplakiaLeukaemiaLymphomaEffect s o f radiumDea fnes sApprehens ionFibrosi s peni sM i scel laneou s d iseases (not rad ium )

Skin les ions— miscel laneou sChron i c inflammatory d i s easesN 0 diagnos i s

Grand Total

Certain groups o f cases o f cancer of special organs or regions havebeen al lotted to different members o f the staff for analys i s . These moredetai l ed analyses wi l l be publ i shed under separate t i tl es . I t w i l l besuffic ient in thi s introductory statement to formulate briefly the generalestimate which has been formed o f the value o f radium treatment o fcancer in i ts more common and importan t s i tuations

,and the evidence

in Support o f these conclus ions .

39A— CARCINOMA OF THE BUCCAL MUCOUS M EMBRANES— 1 39 CA SES.( a ) Cancer o f the l ip , 39 cases ; 19 t reated with radium ; 4 with

complete success ; 4 with improvement, and 1 1 with no benefi t . Squamous cel l carc inoma in thi s s i tuat ion i s res i s tant to 1 adium therapy . \Vhenthe disease has metastasized to the regional lymph nodes no . markedbenefi t f1 om radium has been observed . Local recurrence

,however

,

as in othe1 superfic ial s i tuati ons,can be affected favorably . I t i s our

op inion that a grave respons ib i l i ty res ts on those who advocate radiumtreatment in pre ference to operation for cancer o f the l ip

,i n even i t s

early s tages .

Cancer of the palate,8 ; tonsi l s , 7 ; buccal mucosa , 5 ; l ower"aw, 36 ;

upper j aw ,1 1 ; tongue and floor o f mouth

, 33— 100 cases in al l . S ixty

two o f these received one or more treatments wi th radium ; nine obtainedsome benefi t f rom treatment . In the others the course o f the di seasewas not material ly affected . The best resul t s w ere obtained in the caseso f recurrent cancer o f the "aw ,

w here a neck di ss ect i on,per form ed at

the t ime o f the original radi ca l operation, served to delay , i f not toprevent

,the glandular extens ion o f the d i sea se . In one such case loca l

recurrence at the s i te o f the original l es ion on the j aw was destroyedwith radium

,and there has been no return o f the di sease in s ixteen

months . As a resul t o f th i s experi enc e we have recently t reated a number o f cases o f otherwi se inoperabl e mouth ca i cinoma by a primary neckdis sect ion and subsequent radiat ion o f the local tumor

,and we are en

couraged to hope that thi s method may prove effect ive m a certa in number o f cases not otherwi se amenable to treatment

ALGA— CARCINOMA OF STOMACH ,LIVER ETC—

40 CASES .( a ) Carc inoma o f the esophagus , 1 2 cases . Five received radium

t reatment , and of these one obtained some rel i e f o f symptoms , althoughno permanent good was accompl i shed .

( b ) Ca1 cinoma o f the pharynx , 9 cases . All t reated w i th radium ,

and with nomaterial benefi t w i th the except ion o f one case whi ch showedtemporary improvement under prolonged treatment .

( c ) Carc inoma of the gal l—bladder,1 ; pancrea s , 1 ; and l iver, 1— 3

cases . The gal l—bladder case and the pancreas case both received ra

dium treatment,wi thout notabl e improvement .

( d ) Carc inoma o f the stomach , 16 cases . Only one rece ived radiumtreatment

,which wa s given three times

,with psych i c

, but no obvi ous physical benefi t to the pati ent .

RADIU M 7

4 I A— CARC INOM A or TH E PERITONEUM, ETC— 16 CASES .

( a ) Carc inoma o f the peri toneum and omentum,2 cases . N o bene

fi t f rom rad ium .

( b ) Carc inoma o f the intest ine , 5 cases . Two cases were givenradium w i thout benefit .

( c ) Ca1 cinoma o f the 1 ectum, 9 ca ses . In 5 radical ope1ation was

advi sed ; 3 accepted thi s advi ce , and 2 o f these are wel l four years andeight yea i s* a fter operation ; 3 1 eceiv ed radium t1 eatment

,with but

s l ight , i f any , imp i ovemen t in thei r condit i on .

4SA— CARCINOMA OF TH E URINAR" ORGANS— 3 CA SES .

Carc inoma o f the bladder, 3 cases . Two received radium treatmentand I obtained some rel i e f and i s s t i l l under treatment .

45A— CARC INOMA or TH E MALE GEN l TO-UR INAR" ORGANS — 7 CASES .

( a ) Carc inoma o f the prostate , 5 cases . Four received rad iumtreatment . Al l are dead

,but one o f these obta ined defini te

,but tem

porary, rel i ef .

( b ) Carcinoma o f the peni s , 2 cases , o f which one was advi sed toundergo operat ion , and the other rece ived radium treatment wi thoutbenefit .

42A— CARCINOMA OF TH E FEMALE GEN ITO-UR INAR" ORGANS -I IZ CA SES .( a ) Carc inoma o f the vagina , 6 case s . Four received radium

treatment ; al l are dead , the average duration o f l i fe being s ix month sf rom the t ime o f beginning treatment .

( b ) Carcinoma o f the vulva , 2 ; cl i tori s , 1 cas es . Al l rece ivedradium . In none has there been marked benefit f rom treatment .

( c ) Carc inoma o f the uteru s , 9 1 cases . These cases for m the bas i so f a Spec ial report by Drs . E . H . R i s l ey and G . A . Leland

, In ,covering

the period up to June,1916 , bringing the number o f cases to 1 1 3 . N inety

o f thes e cases rece ived radium treatment,as follos :

Group I . Cases cons idered inoperabl e, and h eated with radium ,

improved enough to j ust i fy rad ical operation : 5 cases ; 3 l iving, 2O w ithout

recurrence at tw elve and eighteen months a f ter operation , and one casef ree from recurrenc e for two years a fter operat ion

,then local 1 ecurrence,

and now under treatment .

Group 2 . Cases rece ived for prophylact i c treatment a fter radi calhysterectomy : 5 cases ; 2 f ree from recurrence twelve and fi fteen monthsa fter operation ; 2 recu rrent ca ses , and 1 untraced

,but free from r"

currence eight months a f ter operat ion .

Group 3 . Recu rrence a fter hysterectomy, 37 cases : I apparently

f ree f rom di sea se ; 2 doubt fu l , 5 l iving w i th recurren ce , . and 26 dead .

Group 4. Recurrence a f te-r curette and cautery : 2 1 ca ses ; 4 l iv ingw i th recu rrence and under treatment ; 1 l iving and w i thou t evidence o fd i sea se n ineteen months a fter beginning treatment

,but s ince then im

t raced .

Group 5. Inoperable cases : 2 2 ; none free o f d i sea se . Averagedurat ion o f l i fe a f ter beginning radium

,tw enty two months .

O f the 9 1 cases , 5 l iving and apparently free o f di sease, s ix , twelve,tw elve

,fi f teen and eighteen

b

months a fter beginning treatment ; 2 l ivingand apparently f ree f rom di sease eight and nineteen month s a fter beginning treatment

,but S ince then untraced . O f the 7, 2 were being treated

E n tere d Co l l i s P . Hun t ing ton Mem or ia l Hosp i ta l f or s u sp ec ted recu rren ce ,w h ich d id n ot exi s t . O r ig ina l op e ra t i o n b y D r . C. A . Por te r , 1 909.

8 RADIU M

on a prophylacti c bas i s , and showed , a fter operation , no evidence o f recurrence . The other 5 were recurrent or inoperable ca ses .

( d ) Carc inoma o f the ovary, 1 2 cases ; five received treatment wi thradium in varying amounts ; 1 c ase showed temporary improvement . anddied fi fteen months a f ter beginn ing treatment ; the others showed nomarked improvement under rad ium .

43A— CARCINOMA or THE BREAST — 143 CA SES .

Radi cal operat ion w as advi sed in 14 cases and accepted in 1 1 cas es , 8o f whi ch Show no evidence o f recurrence to date ; 49 cases rece ivedradium

,and 2 7 rece ived x—ray treatment ; 3 o f the radium

'

cases showeddefini te l ocal improvement

,but the internal progres s o f the d i sease w as

not affected . I t i s our opinion that x-ray treatment w i th mass ive dosesoffers more than radium in the pal l iat ive treatment o f recurrent cancero f the breast .

45A— M I SCELLANEOUS CARCINOM A —

46 CA SES .( a ) Carcinoma o f the thyroid , 7 ; parotid , 2 ; axi l lary glands , 1 ;

glands o f “ groin , 2 ; cervi ca l glands , 14 ; nasal mucosa , 3— 2 9 cases .N ineteen received radium ; only one o f these cases , a carc inoma o f thenasal mucosa

,i s apparently rel i eved o f hi s di sease . In al l o f the others

the progres s o f the di sease was not material ly affected .

(b ) Carc inoma o f the larynx : 1 5 cases ; 7 rece ived radium treatment

,and al l a re dead

,al though temporary improvement w as observed

in two cases .

44A— CARCINOMA or TH E SK IN , FACE, EARS, HAN DS, ETC — 196 CASES .Carcinoma

,83 ; epidermoid carc inoma , 58 ; rodent u l cer, 34 ;

“epith

elioma,

”2 1 . I t i s i n ca ses o f thi s superfic ia l type that radium produces

i ts most marked and benefic ial therapeut i c effects . O f the first group,

carc inoma, 33 ,or Show no evidence of return o f the di sease . E i ght

cases w ere operated upon w i thou t recu rrence,and only 10 cases

,or

fai l ed to obtain defini te benefi t f rom radium treatment . O f the 58cases o f epidermoid carcinoma

,1 5, or 2 570 ,

w ere rel i eved o f al l evi denceo f thei r di sease

,and only 9 ca ses , or fai l ed to Show definite benefit

from radium treatment .O f the 34 cases o f the rod ent u lcer (basa l cel l ) type o f carc inoma

o f the Skin,1 2

,or w e re rel i eved o f al l symptoms

,and 6 cases , or

Show ed only temporary benefi t , or none at a l l .O f the 2 1 cases o f “epi thel i oma

,

”9 w ere permanently rel i e ved,

Only one case obtained no benefit,and in one the benefit was

only temporary .

To sum up these 196 case s o f superfic ial carcinoma o f the skin , in69, or the di sease was apparently destro yed

,and in only 2 7 , or

did i t appea i to be so l i ttl e affected by 1 adium that the pati ent obta in ed no benefit In al l o f the other cases improvement was mani fest,although m a l imited number o f cases the di sease recurred a f t er apparen tdestruction by radium

,and i s again under treatment .

F — SARCOMA .

Bone,16 cases ; so ft parts , 2 2 ; melanot i c sarcoma , 8 46 ca ses .

Bone sarcoma,16 cases ; 3 t reated w i th radium ,

o f w hi ch 1 show ed noimprovement ; "

1'

s l ight improvem ent,and I apparently rel i eved o f all

evidence o f the di sease .

Sarcoma of Sof t part s,2 2 cases ; 9 treated w i th radium —

4 showedno improvement

,and in 5 s l ight pal l iat ive benefit was obta ined .

M elanot i c sarcoma, 8 cases ; three treated with radium wi th some

benefi t,but no permanent resu l ts .

RADIU M 9

M I SCELLANEOU S TUMORS.Endothel ioma , 2 ; bra in tumor , 9 ; myeloma , I ; mixed tumors , 4

°

hypernephroma, 4

— tota l,20.

In thi s miscel laneou s O f roup o f tumors no materia l benefit f rom ra

dium has been observed .

BEN IGN TUMORS .P apilloma

, 3 1 ca s es . These occu r in tw o groups : the papi l lomatao f old persons , assoc iated w i th keratose s , 2 5 ; and those o f younger persons , 16 . In o ld people papi llomata are readi ly su scept ible to rad iumtreatment . Tw elve o f the 25, or 4870 ,

w ere destroyed by radium,and

5 by cau st i c s . O f the other group , only 2 w ere subj ected to radium ,and

both o f these su ccess ful ly .

Keloid, 9 ca ses . S even treated by radium , and al l w i th benefit , a l

though prolonged treatment may be necessary , and a strong appl i cation,

made suffi ci ent to cau se a superfic ia l burn,the fibrous t i s sue o f kelo id

can be made to di sapp ear w i th radium,l eaving a flat and atrophi c scar .

The process i s pa in fu l,but rea sonably su re .

N am '

us,1 5 cases . Ten treated w i th radium

,and al l w i th benefit .

Here long—cont inu ed mild t reatment s are requ i red,but w i th perseverance

the common port w ine mark . a s w el l a s more prominent cavernou s angiomata

, can be made to dimin i sh in color and size , and become less conSpicuou s .

M I S CELLANEOU S CoN DIT i O N S .

Lenrop/akia Buccal is, 8 cases . Four treat ed with radium . The

common superfic ia l cases o f l eukoplakia can be made to di sappear w i thradium . The proces s

,how ever, i s pa in fu l , as a superficia l bu rn i s

requ i red to eradi cate the di s ease . I t i s to be advi sed on ly in the moreproduct ive ca ses , w here the ti s su es are heaped up in papi l lary masses , andfor the s imple mi lky gloss i t i s type

,fu lguration

,a s carried out by D 1

"

. C . G .

M ixter,has

,in ou r opin ion

,prov ed most effective .

L eu k emia,29 cases . Lymphati c , 7 ; myelogenou s , 2 2 . These cases

form the basi s o f a special report by Dr . Franc i s Peabody . The lymphati c cases have show n themselves r es i stant to treatment w i th radium ,

whil e those o f the myelogenous type almost invariably Show beneficia leff ects f rom radiati on o f the spleen . The blood pi cture returns tow ard ,i f not to

,n ormal , the spl een shrinks , the red blood cel l s increase , the

pat ient ’s general heal th and strength improve,he gains w eight

,and he

i s o f ten able to resume hi s regular occupat ion . I t i s rare,how ever

,for

the myelocytes ent i rely to d i sappear from the blood sm ear,and the di s

ea se i s subj ect to rem 1ssions and recurrences . I t w oul d be prematureto claim anv thing mor e permanent than a temporary remi s s ion o fsymptoms a s a resul t o f radium treatment , but this '

temporary remi s sionappears to be more lasting and more certain than that obtained by othermethods o f treatment w hich have been advocated for th i s di sea se .

Lymphoma, 40 ca ses . These cases f orm the basi s o f a specia l re

port by Dr . C . C . S immons and Dr . George Benet . Tw enty-one o fthese ca ses received treatmen t w i th radium . O f thi s number , 18 w ere caseso f typi cal Hodgkin ’s di sease

,1 ~w as lymphosarcoma

,and 2 were mal ig

nant lymphoma in si tuati ons other than in the lymph nodes . In the 18

cases o f the Hodgkin’s type,radium treatment almost inv ariablv pro

duced marked regress ion o f the lymphomatou s glands , w i th shrmkage

o f the tumor masses,and improvement in the general condi ti on . The

regressi on w as most marked in the more acces s ibl e glands ( neck ) andwas not obtained in the deeper l es ion s (media st inum ) . Furthermore ,

I O RADIU M

the regress ion was a lmost invariably temporary, and sooner or laterrecurrence o f the di sease took place. I t i s our bel i e f that more pers i s tent and heavier treatment, especial ly o f

' the media st inal glands,may

yield more sat i s factory‘

resu lt s . O f the lymphosarcoma group,one

case, although glands are st i l l present, has received marked benefit f romradium treatment, and i s now in good condi t ion eighteen months a fterbeginning treatment . O f the 2 mal ignant lymphoma cases

,both have

apparently obta ined a disappearance o f thei r d i sease,

— one o f the palateand one o f the rectum . The palate case recurred

,but the recurrence

also di sappeared , and the case i s now thi rty—three months wi thou t recurrence . The recta l case has been f ree o f di sease for twenty—four months

.

I t would appear that t i s sue o f the lymphoma type “

was espec ial lysusceptibl e to the action o f radiation

,and the u se o f radium in such cases

i s to be advi sed .

Kem tosis 5 6 111113 , 33 cases . One o f the les ions most amenable torad ium treatment . Twenty cases , or were rel i eved o f the di s ease

,

one case recurred and received further treatment,and only two proved

ent i rely res i stant to radiat ion . One or two mi ld appl i cations are u sual ly,

suffici ent to eradi cate the les ions,without the production o f a burn

,

'

or,

indeed, any materia l d i scom fort to the pat ient .SUMMAR".

As a resu l t o f the use o f about 2 35 mi ll igrams radium in the t reatment o f 642 ca ses o f cancer and al l i ed condi t ions at the Col l i s P . Huntington M emoria l Hosp i tal , f rom S eptember , 19 1 3 , to January , 19 16 ,

thefol low ing conclus ions are j u st ified .

1 . Many cases o f advanced,inoperabl e or recurrent cancer may be

given benefi t by treatment wi th radium .

2 . In such cases the rel i e f may include one or more o f the following advantages : Rel i e f o f pain

,diminut ion o f d i scharge in the s ize

di scharges l es s offens ive , rel i e f o f hemorrhage , diminution in the s iz eo f tumor masses , even to thei r tota l d i sappearance ; and the improvementin the general condit i on o f the pati ent . To these must be added the umdoubtedly benefic ia l psychi c effect upon the pati ent .

3 . In a very smal l number o f advanced and apparently inoperabl ecases

,improvement may occur such as to permi t a radi cal operati on to

be per formed .

4. In a certain proport ion o f cases o f superfic ial non—metasta s iz ingtypes o f cancer ( about and in a much smal l er number o f caseso f metastas iz ing cancer

,radium i s capable o f destroying the cl ini cal mani

festation s o f the d i sease Time,

has not elapsed suffic ient torepo rt these cases a s cu red

,and they are being kept

under observation . In a l imi ted number o f cases,

r ecurrence ,a fter apparent destruct ion o f the l es ion , has taken place . Incerta in s i tuat ions

,as on the eye- l ids

,radium treatment o f these l es ions

i s to be pre ferred to operation .

5. In keratoses,papi l loma and other ben ign skin di sea ses regarded

as precancerou s,

” radium i s eff ective in destroying the cl ini cal manifestation s o f the d i sease in f rom 48 to 60% o f cases .

6 . In myelogenous leukemia,the beneficia l effect s o f radium are

pronounced,and '

although recurrence o f symptoms may take place, thecl in i cal advantages o f radium therapy are very marked .

7 . In mal ignant lymphoma,lymphosarcoma

,and Hodgkin’s d i s

ease,the l es ions appear to be especial ly sens i t ive to radiation , and defini te,

though temporary,benefit i s obta ined . When in access ibl e s i tuations , i t

would appear that the di sease could be control led by radiation for acons iderabl e period o f t ime .

8. In the t reatment o f many other tumors and di seases radium hasbeen used

.

W i th benefi t depending largely upon the extent o f the di sease,i ts depth m the t i ssues , and the practi ca l ab i l i ty to apply suffic ient radia

t ion to modi fy or destroy t i ssue or tumor growth.Among the condi t ions

m which radium t reatment has proved o f spec ia l value may be meritioned : recurrent or inoperable carc inoma o f the cervix

,or of the body

o f the uteru s , Hodgkin’s d i sease and mal ignant lymphoma

,m y elogenous

leukemia , inoperable squamous cel l carc inoma o f the tongue, "aw and

bucca l mucous membranes , in non-metastas iz ing epidermoid cancer andin the more benign les ions o f keratoses

,papi l loma

,and other so fcalled

precancerou s condi tions .

9 . Radium therapy has proved, so far, to be o f l i ttl e benefi t in re

current carc inoma of the b reast, carc inoma o f the s tomach and intestine,carcinoma -o f the glands o f the neck , by extens ion from cancer o f thetongue, mouth and l ip , and in general in deeply seated metastati c extens ion o f cancer f rom any region .

10. The use o f radium in prophylaxi s o f recurrence a fter radi ca loperat ion , for the cure o f cancer, i s not advi sed . Where seriou s doubtex1stS as to the complete removal o f the primary tumor

,and where the

locat ion o f the susp i c iou s area i s superfic ial and access ible,and o f smal l

extent, radium may be u sed with benefi t, but where a large area i s tobe consi dered , as a fter operation for breast cancer, the difficu l t i es o f covering the whole area with sufficient radiation are such that the treatm ent i s not to be recommended.

1 1 . The combination of radium therapy and operat ion , by which atumor, otherwi se inoperabl e, i s exci sed as thoroughly a s pos sibl e , the remaining t i s sues cauterized , and subsequently subj ected to radiat ion , hasyielded sati s factory resu l ts in severa l cases . Thi s method o f procedurei s especial ly adapted to the more advanced cases o f rodent u l cer

,involv

ing the face . After a period o f radiation and observation o f the open,

granu lat ing wound , extending over several months , secondary plas ti coperat ions have been per formed to close the de fects

,and the resu l ts

,up

to the present t ime , in a very smal l number o f cases , have shown no re

turn o f the di sease .

1 2 . O f 642 cases treated w i th radium in th i s seri es , 354,or

received defini te benefi t .1 3 . Although many . cases o f advanced carc inoma show no appre

ciable benefi t f rom radium treatment , i t i s also true that in no case yet observed has radium appeared actual ly to accelerate the growth o f tumort i s sue . Pat i ents have suffered pain and inconvenience from the effectso f radium burns in certain instances

,but these have been o f a temporary

character . The consti tutional effects o f heavy doses o f radium are u npleasant

,and severe nausea and depress ion may occur ; but these , al so,

"

are chiefly temporary in character . With continued and excess ive dosage

,very pro found consti tut ional effect s may be obtained

,A seriou s

d iminution in the n umber o f white cel l s in the blood i s observed a ftercontinued heavy dosage . Thi s i s a more las ting phenom enon

,and may

be o f seriou s importance in relat ion to the pati ent’s res istance to in~

fection . On thi s subj ect we are not , as yet , ready to report . In no otherrespect have we found radium to exert an un favorabl e action upon thepatient .

1 2

14.The cons iderabl e expense o f purchase and the difficul t i es and

dangers o f admini s t rat ion o f radium therapy are more than j ust ified bythe resu l ts obtained .

REVIEWS AND ABSTRACTS

Edw ard H . R i s ley,M . D .

, (Boston ) , and George A . Leland, Jr.

,M .

D ., (Boston ) . Report o f Treatment o f Carcinoma o f Cervix at theHuntington Hospi tal for Period o f Four "ears . The Boston M edi ca land Su rgi cal Journal , CL""VII , pp . 89 1

—894,Dec . 2 7, 19 1 7 .

" Thi s paper‘ i s a report o f the resu l ts obtained in the treatment by

radium o f a seri es o f 1 1 3 cases o f carc inoma o f the uteru s at the Huntington Hospital f rom January , 19 1 2 ,

to June,19 16 , inclu s ive .

“ In order to form a proper est imate o f the value o f treatment i t i snecessary to div ide the cases into severa l definite groups ; otherwise,statement s in regard to resul ts in cancer o f the uterus are o f l i tt l e valueunless we cons ider th e groups separately .

”

GROUP I .

“Cases o f border— l ine operabi l i ty in w hi ch pre—operativeradium treatment aims at a reduct ion in the s ize and fixat ion o f the mass ,rendering the chance o f total ext i rpation more promi s ing .

”

GROUP I I . “Cases accepted for prophylact i c radiati on fol low ingradi cal hysterectomy .

”

GROUP I I I . “Those of recurrence fol lowing hysterectomy .

GROUP IV .

”

Those o f recurrence or continuation fol low ing curettage or cau teri z

’

at ion .

”

GROUP V .

“Those whi ch w ere primari ly and unqu est ionably inoperabl e . There have been no cases accepted for radium treatment a lonew here radi cal hys t erectomy seemed pos s ible .

“Case h i stori es have been exami ned espec ial ly w i th the idea o f forming some estimate o f what the first symptoms w ere that brought thepati ent to her physi c ian

,o f w hat type the loca l phys ical s igns and findings

w ere,o f forming as nearly as poss ible a probabl e prognosi s

,o f getting

an idea as to w hat the general effect s o f radium treatmen t were , and o fdetermining in w hat percentage o f cases a posi t ive pathologica l reportwas made .

“In the early months o f the hospi tal five cases w ere tr eated by intect1ons o f asc i t i c flu id . Tw enty- three cases were examined

,but for

some good reason w ere not treated and are nOt inc luded in the study ofthi s seri es . N inety cases w ere taken as a bas i s o f study . All o f theserece ived radium treatment .”

“I t has been very grat i fy ing to find that a la rge number o f our cases

are re ferred f rom other hospi tal s,both for consul tat i on and for t reat

men t. I t w as found that fi fty—Six cases were re ferred from other institution s

,and thi rty- four from phys ic ians el sew here . The oldest case

trea ted w as 68,the youngest 30, and the average about 50 years .”

“Fi rst symptoms w ere reported as flowing in 84 cases , pain in 5,and amenorrhea in 1 . Local phys i ca l s igns w er e recorded as fol l ows :u l c eration only

, 3’ cases ; S i nu s , 5 cases ; implantation on vaginal w al l , 2 1

ca ses ; implantation on abdominal w al l or in abdomen , 3 cases ; glandularmetasta ses ( at t ime o f admis s ion ) , 5 cases ; cervix n odular ( plu s othersign s ) , 19 cases ; mass in vaul t , 24 cases ; ul cerated or necrot i c mass , 35cases ; crater , 25 ca ses ; extens ion to vaginal w al l s , 28 cases ; bleeding of

greater o r l ess degree, 4 2 ca ses ; extension to broad l igaments , 33 ca ses ;

pelv i c masses , 7 ca ses ; i nvo lvement o f bladder , 6 ca ses ; invo lvemento f rectum

, 4 ca ses ; fixat ion o f u te ru s or broad l igaments,1 3 ca ses . Thusi t i s ev ident , there fore , tha t ca ses o f a l l grades o f severi ty w ere accepted

for treatment, and no effort w as made to pick out only the probablyfavo rable ones .”

“

The prognos i s w as stated as favorable,probably favorabl e

.or

border-hue 111 16 cases ; un favorable in 39 cases ; very un favorable orhopel ess in 2 2 ca ses ; and not sta ted in 13 . O f these reported as favorab le

, there a re today 3 al ive wi thou t recu rrence , 2 w i th a questi on o frecu rrence

, 4 not doing w e l l ( di sease progressing ) , 6 d ead , and 1 l osttrack o f . Al l o f the ca ses reported a s un favorable are dead except one

,

as are al l o f the hopeles s cases.

”

“Pathologi ca l reports made , ei ther at the Huntington Hospi tal,or

be fore entrance , w ere recorded in 38 ca ses . No pathologi ca l reportwas made , or at l eas t w as not recorded

.in 52 ca ses . Thi s smal l number

o f pathologica l reports i s a ccounted for partly from lack o f accu ratedata obta inabl e f rom pati ents coming to u s from remote regions andpartly because o f the pol i cy o f. the hospi ta l not to cut into su spi c i ou st i s sues becau se o f the very rea l danger o f di ssemination o f the di sea se

.

Pract i ca l ly all o f the ca ses , how ever,have been unmistakably carc inoma

as fa r a s cl in ica l s igns go . The di sease w as reported a s carcinoma in 1 2

ca ses , adeno- carc inoma in 7 cas es , squamou s cel l i n 9 ca ses , epi thel ia l in3 ca se s . Specimen taken but no pathologi cal report i n 7 ca ses .“

In general the effects of t he radium treatment are recorded as foll ows : temporary loca l benefi t

, 44 cases ; much improved , 5 cases ; ent i rerel i e f f rom pa in

, 5 cases ; some rel i e f o f pain in al l but a few compla iningo f th i s symptom ; complete rel i e f f rom bleeding, 14 cases ; hea l ing o fu lceration , 1 1 ca ses ; decrease in the s ize o f the grow th , 8 cases ; no improvement at al l in 1 3 cases ; increase in the grow th ( some rapid ) in 30ca ses ; fi stula ( vesi co-vaginal ) developed in 2 cases ; mass made moremovabl e in 8 cases .

M ortality . There w ere 2 deaths from di sease other than carcinoma,

-1 from pneumonia and 1 from pelvi c abscess . The resu lts remain un

know n in sp i te o f a very effic ient fol low -up sys tem in 7 cases . The totalmortal i ty dated Feb . 1

,19 1 7 ,

i s 62 ca ses . There are 2 1 ca ses in thi sseri es st i l l under treatment for Observation .

“The radium has been appl ied :‘Per vaginam in 89 ca ses .“Per rectum in 1 case .Over abdominal scar in 1 case .Over ingu inal glands in 2 cases .The dose in thi s seri es has averaged les s than 1000 mil l i curi e hours .Hemorrhage has been easi er to control than pain becau se the super

ficial u l cerati ons are more readi ly affected than the deep extens ions .The latter have been rarely improved. and i f so only temporari ly . Theheal ing o f the vaginal d i sease i s o ften accompanied by contraction o f thevagina

,w hich renders d ifficul t sati s factory apposi t ion o f radium to the

pers i sting deeper extens ions . Long exposure with screening o f thesuperfic ial radium rays has been pre ferabl e to short exposures w i thouts creening

,except in rare instances o f very superficia l vaginal recurrent

l es ions .”

GROUP I . The number o f cases treated as a prel iminary to operat ion i s v erv smal l— only 5. I t i s probabl e that pre—operat ive radium to

14 RA DIU M

the cervix and vaul t and over the abdomen acts in some measure l ike thePercy cautery in that i t k i l l s some cancer cel l s , and al lows some so ftening o f the mass wi thout s cattering cancer cel l s , checks fou l d i scharge,and leaves a somewhat cleaner mass to be removed .

”

“Many operators affirm that operat ion soon a fter radiation i s muchmore difficul t because o f greatly increased venous bleed ing

,and that the

operat ive difficul t i es are increased, al so becau se o f the foundat ion o f adhesions and fibrous t i s sue . We bel i eve

,however

,that pre—operat ive

treatment i s a l ine that should have the benefi t of much further trial .We are al so pos i t ive in our bel i e f that none o f these cases should be all owed to go without thorough post—operative radiation as w el l. I t i snever pos s ible to tel l , even in the wides t surgi cal d i rect i on , when al lcancerou s cel l s have been removed

,there fore

,these cases whi ch were

o f the border— l ine type would seem to be the type in whi ch post-operativeprophylacti c radiat i on was the logi ca l procedu re .

”

There were five cases o f border- l ine operabi l i ty ( as determinedby more or less fixation o f the broad l igaments or u terus ) , in w hich , a ftera certain amount o f the radium treatment , the mass became more movabl eand which were then cons idered operabl e . O f these, three are al ivetoday, one eighteen months a fter operation and without symptoms

,one

twelve months a fter operation and wi thou t recurrence,one twenty

months a fter operation but with local recu rrence. Two are dead,— one

died three weeks a fter operation ( cau se not s tated ) , and one free f romdi sease for two years a fter operat ion

,then recurrence and death

a f ter four months o f radium treatment . I f thi s m ethodi s given extens ive trial there may resul t numbers o f s eemingly inoperablecases whi ch wi l l be given a chance at operation and a poss ible further escape from extens ion o f the di sease .GROUP 1 1 .

“The pol i cy o f the hospi tal in the early days o f treatment w as to wai t for defini te s i gns o f recurrence be fore attempting anything in the w ay o f prophylacti c radiation . With the advent o f greaterfami l iari ty “with the condi ti ons under whi ch recurrence takes place andthe examination o f the great number o f su sp i c iou s cases, and al so wi ththe increas ing real izat ion that i t i s w i thin no man’s power to determine,even in the most extens ive and rad i cal removal o f glandular areas

,when

al l cancerou s cel l s have been removed , i t has gradual ly become ou r pol i cyto accept for prophylacti c radiat ion a fter hysterectomy these ca ses -inwhich

,in the surgeon’s op in ion

,the di sease probablv was not enti rely

eradi cated .

“In view o f the reports f rom other workers wi th radium and ourincreas ing efforts to deal wi th precancerous condit ions , i t seems rat ionalthat we should more and more frequently treat al l ou r mal ignant d i seasepost—operat ively by prophylact i c radiat ion

,ei ther with radium or x-ray .

Thi s i s certainly a logi ca l procedure,and i t is our hope tha t the pro

fession in genera l w i l l recognize thi s and send cases di rectly a fter oper~

ati on for a course o f prophylact i c radiat ion .

”

-“Our seri es shows an altogether too smal l number o f thi s type o f

cases— fiv e in al l ; o f these, three are now al ive and wi thout di sease fi fteen months a fter operation and one with di sease twelve months a f teroperaton . One cas e i s not traced to date, but was free from di sease foreight months a fter operation . One case d ied o f recurrence fourteenmonths a fter operat ion .

”

GROUP I I I . P ost-operativ e or R ecurrent Cases The fol low-upsystem in al l cases , now becom ing more and more effect ive 1n our hos

RADIU M I S

pitals , i s a l ready produc ing resu l t s in tha t we are beginning to get pos toperat ive cases back for observation regularly and are abl e to trea t themvigorou sly at the very firs t suspi c ion o f any recurrence i f for any reasonw e do not see fi t to inst i tu te prophylact i c treatment . The future outlookfor such cases seems good . Early radi ca l operat ion with early radia t ion o f recu rrence ought to produce greatly better resul t s .

“

I t can be pretty defini tely stated that very superfic ial or smallrecurrence in the vau lt o f the vagina

,espec ial ly those which mani fest

themselves a s superfic ia l u l cerations,are practi ca lly a lways favorably

aff ected by the radium . Dense nodu la r recurrences are more “difficul t topenetrate and more of ten accompanied by lymphat i c involvement andhence l es s favorable . Recurrences a f ter hysterectomy general ly occurin the vagina , ei ther along i t s w al l s or in the vaul t in the scar o f operat ion . I f taken early these cases general ly respond qu ickly to radium .

”

Thi s group compri ses 37 cases recurrent a f ter hysterectomy— 1 6

a fter the VVertheim operat ion and 2 1 a fter hysterectomy o f type nots tated . Three o f these have not been traced . E ight are a li ve today andwithout d i sease

,2 with a question o f recurrence and fiv e with defini te

recurrence . Twenty are dead,and the average du rat ion o f l i fe a fter

operation and the beginning o f radium treatment was eigh t months .GROUP IV.

“Thi s compri ses recurrent cases o f al l s tages o f re

currence ; a great many of them being advanced and wi th large masseso f mal ignant t i s sue to deal with

,

— a clas s carrying a prognosi s almostequal ly a s bad as the original ly inoperabl e cases . These caseswhi ch return for radiat ion

,

early a f ter fi rst su sp i c ion o f di sease can defini tely be given a hope ful prognos i s o f a cons iderable prolongat ion of l i f e

,with much rel i e f f rom pain and delay

in the progres s o f the di sease . The least favorable group o f cases i sthat in whi ch there i s recu rrence or cont inuat ion o f the di sea se fol lowingcurettage or cauteri zat ion .

”

Practi ca l ly al l Of these cases w ere received anywhere from twow eeks to eight months af ter the pal l iat ive operat ion , and in almost everycase there had been steady progress o f the di sease S ince the operativeprocedure . These cases have not done part i cularly wel l . I t i s bel i evedthat

,on the o ther hand , i f cases can be thoroughly cauterized , gett ing

rid o f practi cal ly al l o f the di seased area , a real crater formed o f thecervix and radium immediately placed in the cavi ty, better resul ts canbe obta ined . There were 2 1 cases . Tw o are not traced . One i s al iveand without recurrence nineteen months a f ter beginning radium , andthree w ere lo st S ight o f . Four others are al ive, but al l wi th di sease with an average o f ten months a fter beginning radium treatment . Fi fteen are dead , with an average durat ion o f eight monthsa fter inst i tu tion o f treatment .

”

.

GROUP V.As would be expected , every cl in i c shows a larger

number o f inoperabl e cases sent for radiation than any other type o f case .A general statement only in regard to thi s type o f case can be made,

'

asfol lows

.Probably only pal l iat i on can be hoped f or . A cure 1s rarely

to be expected in the l ight o f our present knowledge o f rad1um techn i c .There are enthus iasts who off er more hope fu l op inions , but the mass o fcases treated i s not yet large enough to be at al l convincing. However,much rel i e f from di stress ing symptoms can be brought about in th i s unfavorabl e type O f cases , even i f extens ion into the broad l1gaments andlymphat i c s destroys al l chance o f cure .

”

“There are 'three things that radium can do in pract i cal ly every case.

1 6 RADIU M

I t can check hemorrhage, stop to a large extent fou l d i s charge ( o f cou rsedepending on the s ize o f the grow th ) , and i n many cases i t does contro lpain . W e never pred i c t to pat ients that we surely can do any o f thesethings , bu t we can give them a reasonable a ssurance that such w i l l be thecase . Certa in ly energeti c radium treatment in the inoperable case offersmore in the way o f rel i e f f rom symptoms than the use o f the red hotcautery and curettage as formerly employed , and numerous wri ters bel i eve the pro longat ion o f l i f e i s greater .

“ In thi s connection,i t would seem w i s e in making any s tatement in

regard to radium,as wel l a s any other non-operat ive form o f treatment ,

to be conservat ive and cons ider wel l a l l the factors entering into theimprovement o f the pat i ent . The temporary improvement seen in manycases i s undoubtedly due

,in some instances

,to the recuperat ion o f the

system dependent on checked bleeding . The temperatu re ari sing f romthe absorption o f toxi c products i s low ered and a general improvement i sf el t by the pati ent , w ho thereby gains new courage f rom the psychi c a sw el l a s the phys i cal factors involved .

”

“Thi s group includes 2 2 cases compri sed enti rel y o f definitely inoperabl e cases ; only 1 has not been traced . There are 3 al ive , al l withd i s ease wi th an average durat ion s ince s tart ing radium treatment o f 2 2months . These are interest ing figu res , showing the apparent retardationof grow th and bettering o f general condit ions fol low ing radium in thistype o f case . Apparently the original grow th i s o f a more s low ly progres s ing nature under ra dium in these cases than recu rrent grow ths a fterhysterectomy .

"There are 18 cases dead

,a l l w i th di s ease w i th an average

du ration o f l i fe a fter the beginning o f radium treatment o f nine and ahal f months .”

“A summary o f these grouped cases Shows :Five w i thout di sease— one , 18 months ; one , 1 5 months ; tw o ,

1 2

months ; one less than 6 months .”

“Tw enty—one al ive ( tw o w i th qu esti on o f d i sease les s than 6 months )seven not traced but two free from di sease e ight or nine mon ths a f teri t started ; fourteen wi th di sease .

“S ixty—tw o are dead .

The points o f interes t and v alue brought.

ou t in thi s analys i s are asfol lows : Much symptomati c rel i e f can be expected f rom radium treatment

,espec ial ly in the checking o f hemorrhage and al l eviati on o f pain .

P rophylact i c radiation immediately fol low ing hysterectomy i s a logi cal ,sa fe and advi sable procedure and should reduce the number o f recurren ces .

The treatment o f early recurrences offers a- fa i r prognos i s .

Late treatment offers l i ttl e but al l evi ation o f symptoms and but l i ttl eretardat ion o f grow th . Inoperabl e cases are benefi ted by radium andthe period o f l i fe i s somew hat prolonged . Radium should be given moreextended and

'

earlier t rial in these cases . I t i s bel i eved that every caseOperated on should be requ i red to report for observat ion once a month forthe firs t year a nd once in three months for the second year and at frequent interval s for each succeeding year . Only in th i s way can earlyrecurrences be detected and early inst i tution of radium treatment be

s tarted .

”

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