Application Of Radium Research Articles

Cancer of the cervix complicating pregnancy, showing the harmful effects of radium on the fetus

Since radium has come to be recognized as the choice of treatment in the vast majority of cases of cancer of the cervix, it is the purpose of this paper to call attention to the damage to the fetus that may result from the application of radium during pregnancy.

RADIUM IN THE TREATMENT OF CANCER OF THE CERVIX UTERI

The purpose of this paper is threefold: First, to describe the technic of radium treatment of carcinoma of the cervix uteri as used in the Howard A. Kelly Hospital; second, to compare our later statistics with those of former years to determine the value of the advancements made in technic since the first case of cervical cancer treated in our clinic, in 1908, 1 and, third, to review briefly some statistics of other clinics. TECHNIC Any form of medical or surgical technic should be as simple as efficiency and accuracy will permit, and, as far as possible, comfortable for the patient. Three forms of radium application are employed in the treatment of cancer of the cervix: (1) direct application of screened radon to the accessible growth; (2) implantation of radon seeds into the local growth or lateral extension, and (3) heavy cross-firing through the pelvis from several portals over the

Radio-active Substances: Their Therapeutic Uses and Applications

THE therapeutic application of radium has always been so closely associated with the idea of malignancy that the great majority are hardly aware that it is equally applicable to many benign conditions. In the treatment of lesions of the nose and its accessory sinuses, it has been found that in a variety of newgrowths which are clinically non-malignant, but in many instances highly resistant to all the surgeon's efforts toward extirpation, radium has provided a means of cure, or, at the least, marked amelioration, when every other previously known therapeutic agent had proved utterly impotent. There is comparatively little in the literature concerning the radium treatment of rhinologic lesions, yet it is daily becoming more indispensable to those who devote themselves to surgery of the nose and the structures intimately connected with it. This is probably because, despite the great advance in every form of radium application, the majority of rhinologists still feel that the work has not yet passed beyond the experimental stage, and that any results they may be able to report must be regarded as more or less inconclusive. It has apparently been tried in a wide variety of nasal conditions, and in all some measure of success has been reported, but in many instances it is likely that the treatment was applied by those who had neither the fundamental knowledge nor the experience to give their patients the full benefit they might have derived from the therapy, and, as is always the case under such circumstances, the therapeutic agent has received the blame that should rightly have been laid upon the shoulders of the therapist who wrongly used it. Thus two years ago we find Laura A. Lane listing a considerable number of benign conditions about the nose to which radium may be considered applicable, in which are included even hay fever and syphilitic lesions. There do not, however, seem to be any reliable reports in literature, or any testimony which has been presented before special societies, to warrant our becoming enthusiastic over the employment of radium in such conditions, and one cannot but feel that the indiscriminate use of radium, whether or not extended experimental evidence is in favor of its employment in any particular systemic state, will only tend to discredit the therapy, and make conservative medical men cautious about employing it in those diseases which thorough study and extensive clinical demonstration have proved are amenable to its influence. Fibromas of the Nasopharynx:—A technically benign condition occurring in the nasopharynx, which is, however, often fatal because of its inducing suffocation when it attains a large size, or because it extends to the skull and produces pressure upon the brain. This type of fibroma makes its appearance in adolescence or early adult life.

A Method for the Study of Scattered and Secondary Radiation in X-Ray and Radium Laboratories

THE question of the exposure to radiation of workers with X-rays or radium is generally recognized as very important. It is known that the effect of radiation is cumulative, to a certain extent. The amount received at any given time may be small, but the more or less continuous exposure to such small quantities may presumably in time produce a very serious effect. This radiation does not, in general, come mainly from the primary source,—the X-ray tube or radium applicator. It is the scattered and secondary radiation from walls, floors, and other solid objects which must be guarded against, because it is less obvious, and from such radiation it is harder to shield oneself. It would be very desirable to know (1) how much radiation an individual can receive without harmful effects, and (2) how much any given individual is receiving. In order to ascertain these points, it is necessary to devise a method of measuring quantitatively the amount of radiation being received by any worker. When this is done, the first question can be answered by a study of the condition of many X-ray and radium technicians who have been exposed for a considerable time. The usual method of investigating the scattered and secondary radiation in a given place is to expose dental films for some days or weeks. If a film shows considerable darkening in a short time, it is evident that there is an undesirable amount of radiation. Pfahler (1) examined films carried by several hundred workers in different parts of the country, and evaluated the method. It is qualitative, or, at best, roughly quantitative, in the absence of a means for measuring accurately the darkening of the film and comparing it with standards. An attempt to get quantitative results has been made by Mutscheller (2) using an ionization method. Such a method has the advantage that the measurements are quickly and easily made. But the electroscope must be calibrated to read in terms of the chosen unit, which is not simple. Moreover, the readings are not continuous nor additive, and the amount of radiation received must be calculated from a number of isolated measurements. The radiation to be measured, however, is apt to vary considerably from time to time, and an accurate measurement of one hour's or even one week's output may give false ideas as to the quantity received over a long period of time. Furthermore, measurements in one or several definite parts of a room do not adequately represent the exposure of the technician. An X-ray film, worn or carried by the worker, gives a cumulative record of the radiation it receives. If this record can be translated, it is preferable to one consisting of intermittent measurements. Repeated tests of this sort will give accurate information regarding the radiation received by any one worker.

INTRAGASTRIC RADIUM TREATMENT OF CARCINOMA OF THE STOMACH

The frequency and low operability of cancer of the stomach make improved methods of irradiation desirable. The application of radium immediately to the growth has definite advantages over external roentgen-ray therapy alone. Pinch 1 has applied radium to the interior of the carcinomatous stomach by having the patient swallow a radium tube on a string. The position is observed by the roentgenoscope, and the radium may be moved by pulling on the string. From this, he has obtained definite palliative results, in slowing the rate of growth, checking hemorrhage, and relieving pain. With radium applied in this way, the surface of the tumor bears the brunt of the exposure. Adjacent sensitive organs are protected by the rapid decrease in the intensity of irradiation, with distance. This permits heavy caustic irradiation, sufficient to influence highly resistant scirrhous carcinomas and adenocarcinomas. Roentgen-ray treatment could not be carried to this intensity because of

RADIUM APPLICATOR FOR TREATMENT OF LESIONS ABOUT THE HEAD, FACE AND NECK

Great difficulty has been experienced with methods of applying radium to the face, head and neck. This applicator, while very simple in construction, is adjustable to any angle by bending the copper wire, and when once adjusted remains in perfect contact with the lesion, allowing the patient to move his head in any direction. Another important consideration is distance without the use of blocks or gauze. This method eliminates the handling of radium, as it can be placed in the rubber tube with forceps and removed in the same manner. It consists of a leather head-band, copper wire and universal ball joint made to be used with one-fourth inch rubber tubing, in which the radium is placed. The applicator is manufactured by the Akron Surgical Instrument Company, Indianapolis.

Radio-active Substances and Their Therapeutic Uses and Applications

V. French Methods of Application THOUGH all French radium therapists are very punctilious in acknowledging that it was Abbe, of New York, who first applied radium to cancer of the uterine cervix, the practical demonstration of the peculiar adaptability of this element to the treatment of this particular lesion was the work of the French themselves, and even to-day it is to them that we must look for leadership in this most important branch of radium application. For this reason, the technical methods employed by the gynecologists and radiologists of France are of the utmost interest to all who are devoting any considerable part of their attention to this branch of therapy, and a careful review of these methods is essential to an intelligent understanding of the progress which has been made in the treatment of cervical malignancy. The earliest workers were Wickam, Degrais, Dominici, Rubens-Duval and Cheron, all of whom met with considerable success in combating the ravages of this deplorably prevalent neoplasm by means of the newly discovered element. Dominici, in particular, was able to employ the penetrating gamma rays—segregated by powerful filtration—with excellent effect, and as early as 1909 demonstrated the selective action of these rays upon the malignant cells of cervical cancer, while at the same time he was able to show their relative harmlessness to the cells of healthy tissue. As Mallet recently put it: “Because of its frequent occurrence and its easy accessibility, cancer of the cervix uteri has offered a peculiar suitability for the researches of curietherapists. Moreover, the fact that the conditions obtaining in this area are favorable for application of radium to the center of the neoplasm, as well as the histologic sensitivity of the lesion, have contributed not a little to the early success which attended this particular application of radium treatment.” Régaud, the associate of Madame Curie, is perhaps the best known user of radium treatment in France to-day, so it is natural that we, on this side of the Atlantic, should consider his technic as the most important offered by the country where our knowledge of this treatment had its origin. In the opinion of this authority the use of a large number of centers of radio-activity is a primary requisite to the efficacy of the therapy. These centers may be located in the cervical canal, in the vagina, in the rectum, in the parametrium—by means of implantation, or upon the external surface, where radio-activity may be brought into play by X-ray or flat radium applicators. But in practically all cases, the most useful sites for the location of radio-active centers are the uterus and the vagina. If the cervical canal is open and permeable without dilatation to an applicator of small caliber, this container should always be so fashioned as to occupy the entire length of the canal.

Radio-active Substances and Their Therapeutic Uses and Applications

Histologic Effects of Radiation (continued)1 AS IT was in France that the element radium was first recognized, and in France also that its therapeutic properties originally became known, just so it is to that country especially that we look for the most minute and exacting observations upon the successive steps which have marked the advance of radium therapy. This is especially true of that branch of radium technic which has to do with the treatment of cancer of the cervix uteri, for in France, more than anywhere else, this particular therapy has reached its highest usefulness, and it is to the workers there that we who speak the English tongue, both here and on the other side of the Atlantic, are constantly turning for instruction, inspiration and leadership. As far back as 1908 we find Dominici and Barcat, those pioneers in the therapeutic application of radium, discussing the histologic effects which the gamma rays produce upon carcinomatous tissues, and the relation which these bear to those previously noted when the gamma rays were applied to epitheliomatous neoplasms. In studying the histologic sequence of the regressive process, it was noted that the portions of the tissue which had been subjected to radium assumed a character essentially different from that displayed by tissues which had not been so exposed. This differentiation was especially noticeable in the alteration and variation in the direction of the connective tissue bundles. It was also pointed out by Degrais and Bellot that when the epitheliomatous cells are exposed to radium there takes place hypertrophy of the nucleus, degeneration of the protoplasm, and a certain amount of keratinization, which—after an interval of perhaps three weeks—advances until the entire epitheliomatous mass has been converted into keratinized débris. All the formed elements will have broken up and disintegrated, and there will be evident an infiltration with young fibroblasts and connective tissue cells, lymphocytes and polymorphonuclears, which appear to be carrying on a phagocytic function; while cicatrization is taking place at the expense of the cancerous growth's hyperplastic and regenerated stroma. Following the radium applications it will be seen that the cancer cells gradually shrink and lose their staining properties, but this atrophy does not correspond to the metamorphosis of these same definitely formed elements, but to their destruction, which is evidenced by keratinization or absorption. Thus the cancer cells seem to disappear either by progressive absorption of their protoplasm and nuclei, brought about by the leukocytic infiltration, or by a sort of granulardegeneration.

PracticalversusTheoretical Application of High Voltage X-rays and Radium

IN the practice of medicine, as in other arts and sciences, to some it is given to lead, to others to follow; to some is the opportunity given to map out the theoretical, technical and scientific aspects of the problem, while to others of us falls the lot of artfully adapting the dictum of theory and fact to the solution of the problems at hand, confirming such teachings or proving them impractical. The writer's energies have been directed wholly to the practical uses of radiation therapy, an effort trying, and at times discouraging, when confronted with the facts, theories and dreams which have so tended to confuse as well as clarify the situation. To unravel, assort and logically arrange these facts and theories is an Herculean task; to fit them in and demonstrate them practically is an impossibility. Hence those minds with the inherited tendency to think for themselves may be pardoned when they wander from the path laid out for them and presume to speak from their own limited experience and in language shocking to the ultra- or pseudo-scientist. When the lightning-like flashes of high-voltage electricity began to leap across our horizon a few years ago, and seemed to give promise of illuminating the darkest recesses of radiation knowledge, my mind wandered back to the year 1904, when, in the rural section of southern Louisiana, I saw my twelve-revolving-plate static machine speeding under the power of a snorting gasoline engine, and wondered if that power which shot those sparks across an air gap of 12 to 16 inches, was not the same force—only made greater and bigger and stronger in the resurrection. Such, it seems, was and is the case. And my second thought was: Does the bigness, the greatness and strength of this force solve our problems, or will there develop the greater problem of controlling, measuring and directing its energies? Again, it seems, our thought was prophetic, for it appears now we are all agreed that the methods of measuring and directing radiation intensities have done more to advance radiation therapy than has the manufacture of high-voltage X-ray machines. In the practical application of X-rays we accomplished just as satisfactory results years ago when operating with medium voltage as we have in more recent years with the higher voltages. This is but a practical proof of the scientific fact that biologic action is more proportionate to the quantity than to the quality of radiation. The practical problem has been to determine the relative quantity of radiation delivered to, and produced in, the tissues and the effects produced by these quantities on the different pathologies. The methods of measuring radiation, now familiar to us all, have partly solved this problem, and have, further, demonstrated that a given quantity can be delivered more accurately, more constantly, and more easily with high than with low voltage. This, to our mind, constitutes the one and only advantage of high voltage.

Radio-Active Substances and Their Therapeutic Uses and Applications

MALIGNANCY of the prostate in some respects offers more difficulties to the physician who attempts to cope with it than does any other growth of this character elsewhere located. There are several reasons for this. Obviously, its sequestered situation makes it less easy of access than neoplasms nearer the surface, but aside from this, several other factors combine to render the control of the malignancy in this gland an especially difficult problem. Very often the disease will be far advanced before there is the slightest indication of its presence, and even when symptoms do appear they are those common to a number of disturbances in the urogenital tract, and not sufficiently characteristic of prostatic cancer to immediately suggest the possible existence of that lesion. Thus much valuable time is likely to be lost, and when the diagnosis is finally made the patient is all too frequently beyond the aid of any treatment. Early metastasis is especially characteristic of prostatic neoplasms. Extension to the bladder is very common, because, as one of wide experience with these growths has recently pointed out, the gland lying between the dense fascia of Denonvillier and the firm, though somewhat more yielding, fascia forming the base of the bladder, offers the invading growth practically no room for expansion except by metastasis. Moreover, the contraction of the vesical sphincter after each micturition exerts a frequently recurring pressure upon the growth that would seem especially likely to induce early invasion of the bladder, and very probably contributes not a little to the encouragement of early metastasis. If it is purposed to employ radium treatment, measures should always be taken to ascertain whether or not metastasis has occurred. Glandular involvement is commonly detected easily, but as cancer of the prostate is likely to extend to the lumbosacral region and to the chest, only thorough examination by roentgenography will serve to give definite information as to whether or not the malignancy is still localized in the prostatic region. If secondary foci are found it should be realized that treatment by radium offers little beyond palliation. The pain in the back and extremities which is so often a distressing feature of cases where the sacral region is involved, may frequently be much lessened or even entirely abolished following radium applications. More than 60 per cent of the patients reported by Deming as suffering from pain in the back were entirely relieved of this symptom after radium treatment. Bumpus, however, takes quite an opposite view of the advantages of radium under such conditions.

A review of a number of cases treated by radium in the year 1924

1. Rodent ulcers respond favourably to treatment by radium. One application is usually sufficient, and the cosmetic results are very good. 2. The combined applications of radium and X-Rays are more beneficial than one or other of them alone in the treatment of uterine and oral carcinoma, when a rapid intensive local effect is required as well as a diffuse effect to destroy metastases. 3. For prophylactic post operative irradiation “Deep Therapy” is preferable to radium, because X-Rays are more diffuse in their action, and a more homogeneous depth dose can be obtained with them than with the amount of radium which is ordinarily available.

Radio-active Substances and Their Therapeutic Uses and Applications

The Employment of Buried Radium Emanation THOUGH dosage and the proper distribution of the sources of radiation are important in any method of employing this therapy, in none are they of so great moment as when the method of buried emanation is under consideration. It is at once apparent that ideal conditions cannot obtain in all cases, or, to be exact, in any case, for the particular tissue or tumor which is to be treated will invariably present individual characteristics and peculiarities which cannot be absolutely subordinated to any fixed rules. All living things are subject to individual variations, and in the application of radium, an active substance, to human tissue, a living organism, we are confronted with a twofold problem. We have already (in a previously published paper of this series) explained the method of preparing radium emanation tubes or “seeds.” The problem confronting the clinician is the number of these tubes which he shall employ in a given case, and the several locations within the area of tissue to be irradiated where these tubes can be disposed to the greatest advantage. Where the greatest attention has been given to this particular form of radium therapy it has been found that complete retrogression of a tumor growth can be accomplished in the great majority of cases by a single treatment, and that such a result—if it can be accomplished—assures greater likelihood of halting the disease process at an early stage, as it gives no opportunity for further extension having its rise in remnants of diseased tissue, the destruction of which was not completely accomplished. Thus the selection of dosage and location for the initial treatment becomes a matter of paramount importance. The object to be attained is to destroy the neoplasm or pathologic area completely, but at the same time to reduce the caustic action to the lowest possible minimum, while avoiding the production of extensive necrosis. Necrosis Due to Embedded “Seeds” It would be desirable, but is—because of the limitations of our present knowledge—unfortunately impossible, to eliminate all necrosis about the tubes used in deep implantations of radium emanation. At the Memorial Hospital, for example, no tube is used which contains more than 3. millicuries or less than 0.1, and it has been observed clinically, and substantiated by careful experimentation upon animals, that any of these tubes imbedded for periods varying within two months, will unfailingly produce an area of necrosis one centimeter in diameter,—this necrosis being due to the intense beta and soft gamma radiation which takes place in the immediate vicinity of the tube.

The dangers resulting from apparently trivial gynecologic procedures

I was brought up in a school of fundamentalists where it was taught, and strictly adhered to, that no intrauterine manipulation, applications or operations should be done unless the patient was under anesthesia. It was held that unless the patient was under anesthesia the vagina could not be sufficiently sterilized to permit intrauterine approach without danger of infecting the interior of the uterus. It was also held that adnexal infection contraindicated intrauterine manipulation and that in the majority of cases the exact condition of the adnexa could not be determined unless the patient was anesthetized. (Note.—This, of course, did not include those cases in which the abdomen was to be opened on account of adnexal disease.) To vary from these teachings was heresy. The modernistic teachings of office diagnostic curettage, the office application of the Rubin test, and its poor relations; the office introduction of stem pessaries; the intrauterine application of radium in the unanesthetized patient and like procedures caused my fundamental soul many pangs. While I did not accept these modernistic teachings in toto, I could accept them provided they were purged with the saving grace of anesthesia. It is the unfortunate experience with some of these apparently trivial procedures that I wish to recount. About a year ago I reported to this society the history of four women who had had stem pessaries introduced into their uteri, in a doctor's office. All four suffered evil results, the worst required a complete clearning out of the pelvis to get rid of the pathology. This report was not unique except that the women were all related and that they followed one after the other in spite of the experience of those that had gone before. The literature is so filled with reports of major and minor evil results of the stem pessary that it would be a work of supererogation to report it here. The few cases which I have to report were done in a hospital operating room under rigid operating room technic, the patient anesthetized and the pelvis examined under anesthesia.

Myeloid leucemia, complicated by pregnancy, treated with topical applications of radium: Dr. John O. Bower and Dr. J. H. Clark presented a paper entitled Report of two cases (See page 207, February issue.)

Myeloid leucemia, complicated by pregnancy, treated with topical applications of radium: Dr. John O. Bower and Dr. J. H. Clark presented a paper entitled Report of two cases (See page 207, February issue.)

Two cases of myeloid leucemia complicated with pregnancy: Treated with topical applications of radium

Two cases of myeloid leucemia complicated with pregnancy: Treated with topical applications of radium

Correspondence

To the Editor—This morning (Nov. 3, 1923) a patient presented himself with a mass the size of an egg in the submental area and apparently somewhat fixed to the lower jaw. In March, seven months ago, a small ulcer on the lower lip was subjected to radium treatment and has healed, leaving a slight, umbilicated scar. The lesion, whatever its nature, had been present three months. It occupied the mucocutaneous border of the middle third of the left lower lip. It had apparently begun as a smoker's burn in a patient with bad teeth. These cases are increasing in number. That is, the lesion on the lip heals, or apparently heals, after the application of roentgen rays or radium, and then, a few months or years later, glands appear in the neck, which, when removed, prove to be metastatic carcinoma. I would appreciate an opportunity to present to the larger audience of the readers of The Journal the following facts: Some years ago I made one report on the operative treatment and results of cancer of the lip, and there is in preparation a second report on a larger number of cases. The conclusions of the first report are confirmed by the restudy of both old and new material, and the ultimate results up to date. If the lesion on the lip can be excised with a V-shaped piece and the wound closed without a plastic operation, there has never been a local recurrence, irrespective of the pathologic condition, whether the lesion was benign or malignant. This operation can be done under procain within one-half hour, and the patient should not lose more than a few hours from work. The cost of such a minor operation in material and in time of patient and operator is small as compared with that of any other treatment, and it is my opinion that the results are the best. The piece excised from the lower lip is subjected to microscopic study, and if the sections show cancer, the glands of the neck are removed (this can also be done under procain). When these glands show no evidence of metastasis, the percentage of cures has been 100. When the glands have shown metastasis, the percentage of cures in the first report was 50, and in the second report will be somewhat larger. Now that the community is educated to seek advice early, the moment the lesion is observed on the lower lip, I am able to divide the cases observed and reported by me into die following classes: 1. The lesion on the mucocutaneous border of the lower lip is small, of short duration—a few days up to two weeks; it is of the type of a burn, a fever blister, a vesicle, keratosis or a wart. The patient smokes or chews; the teeth may be ragged and dirty. The majority of these lesions heal by removal of the causes—tobacco and ragged, dirty teeth—and instructing the patient to keep the teeth clean and the lip lesion covered with petrolatum. 2. The lesion is of longer duration, but still distinctly benign—leukoplakia, or the chronic chapped lips of the smoker.

Experimental Methods for Testing Leakage of Emanation from Radium Tubes and Applicators

Experimental Methods for Testing Leakage of Emanation from Radium Tubes and Applicators

Points to be Considered in the Application of Radium

In considering the basic and the contributing factors that one must correlate in order to utilize the radiations from radium or radon to the best therapeutic advantage, it occurred to me that I might visualize, with some semblance of order, the various facts that I found assisted materially in the building up of what might be termed radiological judgment for the individual case. I realize, of course, that actual experience is the best if not the only teacher; nevertheless, I feel that constant visualization of all the points charted (their relation to each other, etc.) has been of considerable help in arriving at the main issue— the dose. For operators who have established a fixed standard (erythema dose, etc.) such a chart is, perhaps, of no value. My experience, however, teaches otherwise. To attempt a complete explanation of all the points involved would require considerable time and space, a thing I shall not attempt here. My object in offering the chart at this time is, then, to bring about an open discussion from which I hope to further improve or discard the idea. Personally, I believe it will assist the beginner, in that it will at least impress upon him the fact that the application of radium is an art requiring wide general information, together with special knowledge of the disease he intends to radiate.

Carcinoma of the uterus

Our own standpoint at the present moment may be summarized as follows: 1.1. In any cases of abnormality in uterine function within the child-bearing period, meticulous care to determine the cause of the abnormality.2.2. In the case of any abnormal discharge after the menopause, immediate vaginal hysterectomy followed by the application of radium.3.3. Radium and x-ray therapy in the treatment of all cases of carcinoma of the cervix, final judgment as to the abandonment of surgery in these cases being reserved.4.4. Individualization of each patient; that is, certain cases of carcinoma of the fundus which are apparently inoperable may become operable after a period of rest and the application of selected therapeutic measures.5.5. Extensive correlation of the experience of individual observers is essential to the establishment of a correct basis of judgment as to the relative merits of surgery, radium and of the x-ray in the treatment of carcinoma of the uterus—whether of the fundus or of the cervix.

Radium and X-ray Treatment of Advanced Carcinoma of the Breast Prior to Amputation

FOUR cases of inoperable carcinoma of the breast will be discussed from the standpoint of the initial response, the gross and microscopic tissue changes, and the treatment. Two of the cases were massive inoperable carcinoma of the breast, the third was an operable primary growth with metastasis to the right and left axillary glands, and the fourth an easily operable primary growth with metastasis to axillary glands, and associated carcinoma of the fundus of the uterus, questionably operable. Report of Cases Case 1 (A406833). A woman, aged 48 years, came to the Clinic October 5, 1922, with a large pendulous right breast, massively infiltrated with carcinoma, especially in the upper half. The skin was attached but not discolored. Many axillary and supraclavicular glands were involved on the same side. The general condition of the patient was good. However, chronic rheumatic endocarditis, aortic and mitral regurgitation, and chronic myocarditis, with marked dilatation and hypertrophy were noted. The surgical risk was 2+. Between October 11 and 17, the surface of the skin overlying the primary tumor, and the right axillary region were exposed to 22,428 mg. hours of radium. Topical applications of radium were applied continuously, two to four applications at a time, until twenty-eight areas were exposed. October 19, following an interval of two days, twenty alloy steel points containing radium sulphate were buried in the tumor and allowed to remain in position for twenty hours. October 23, 24 and 25, the left half of the chest, right and left supraclavicular and left axillary spaces anteriorly, and the posterior chest cavity divided into two equal areas, were all exposed to moderate voltage X-ray treatment. December 6 the patient was in good general condition. The primary mass was markedly reduced in size. The breast was much smaller and softer; the axillary glandular enlargement was not palpable. A radical amputation of the right breast was performed December 8, 1922. The patient's convalescence and the healing of the wound were uneventful. The pathologist reported two carcinomatous nodules, 4 cm. and 3 cm. in diameter, marked fibrosis and degeneration, and glandular involvement. Between December 20 and 23, and between January 23 and 26, 1923, the anterior and posterior wall of the chest and the right and left supraclavicular and axillary spaces were exposed to moderate voltage X-ray treatment. The patient was in good general health; no palpable nodes were found.2 Case 2 (A424868). A woman, aged 47 years, came to the Clinic May 5, 1923, with inoperable carcinoma of the upper half and central part of the right breast. The axillary and supraclavicular glands on the same side were markedly enlarged. The right arm had been moderately swollen for two months. There was chronic mastitis of the left breast with a discharge occasionally.