milligram hours in the rectum the following day. She would not allow me to treat her thereafter. The pain left her within fortyeight hours, and the paregoric was discontinued. The odor diminished within ninety-six hours to such an extent that her family could be in her room, which previously was impossible. She lived about six weeks from the time I first saw her.

CASE IV. Mrs. S., aet. sixty, came to me with the diagnosis of cancer. She had refused operation, and desired to have the radium treatment. On examination a very large cauliflower-like growth was found in the vault of the vagina. The cervix uteri could not be detected. This patient had been very stout, lost much weight, was very weak, in constant pain, and complained of a foul acrid discharge. After three applications of twenty-five milligrams of radium element for 2400 milligram hours at each treatment, at intervals of three weeks, the vaginal growth, pain and discharge had disappeared.

CASE V. Mrs. S., housewife, aet. fifty-one, was referred to me for a hysterectomy, on account of continuous hemorrhage for over a year. All treatments resorted to had been without avail. The patient lost 30 pounds in weight, was practically exsanguinated, and edematous. Hemoglobin index 40; red blood count 3,600,000; albumin and casts in the urine. She was a grave surgical risk. I could not discover any growth.

The use of radium was suggested and accepted. Twenty-five milligrams of radium element were placed in the uterus for 100 milligram hours daily for six days; after two weeks, a similar series of treatments were given. The hemorrhage ceased on the fourth day after the first treatment, but reappeared sixteen months later. The radium was again used as before, 100 milligram hours for three days, when the hemorrhage ceased. Four months have elapsed since the second treatment was given without further loss of blood.

CASE VI. Mrs. X., aet. fifty-six. Panhysterectomy two and one-half years previously. Complete recovery, and well for two years after. For the last six months she has had a bloody discharge from the vagina. She kept this condition from her family until the constant pain and bad odor compelled her to seek relief. A digital examination of the vagina proved impossible on account of the presence of a cauliflower-like growth. There was a profuse, bloody, purulent discharge of a vile odor. The pain was constant, loss of flesh pronounced and she was very weak. Twenty-five milligrams of radium element were used in the vagina for 2100 milligram hours. At the end of two weeks she returned for a second treatment. At this time the pain was gone, the odor much lessened, and it was possible to examine the vagina. Two more treatments of the same quantity of radium were employed at the same intervals. When she returned after the fourth treatment, all symptoms had disappeared and the vaginal growth was gone.

A synopsis of these cases shows that pain was relieved; that odor was markedly controlled; that hemorrhage had ceased; and that

there was a change in or a disappearance of the local pathological tissues. Two patients died in coma two months after the treatment. Four are alive and hopeful. In Case V, the uterine hemorrhage was not of cancerous origin, but the condition was a terminal one. I am sure the patient would have died had it not been for the use of radium.

These few cases are not sufficient to draw definite conclusions. But nearly every worker with radium makes the same statements concerning its value in the relief of pain, hemorrhage and odor, but without emphasis in relation to its use in this particular field. In calling your attention to these cases, I cannot but feel that the results I have observed are more than merely accidental.

In using radium in these cases I believe it is possible to produce a toxemia which may prove fatal. I have seen the end hastened in this way. I would suggest two precautions when applying radium locally; first, a patient with a low leukocyte count should not be given prolonged applications of radium; and, second, when radium is used, it should be accompanied by the liberal administration of alkalies.

Finally, I wish to emphasize as my conviction, that no case of this type is so desperate, and no postoperative condition so hopeless, that radium should not be used with an expectation of the alleviation of the distressing symptoms.

511 BROADWAY.

DISCUSSION.

DR. ROLAND E. SKEEL, Cleveland, Ohio.-I am glad indeed Dr. Moriarta has called our attention to the radium treatment of inoperable carcinoma. We have been using radium only about a year, and while we have but few definite ideas to put forth at this time there are two or three things that can be said to be proven. We have used a larger dosage than Dr. Moriarta, he using a smaller quantity over a longer period of time. He gives about the same number of milligram hours as we do but the results are quite different according to the period of time over which it is applied, although the total number of milligram hours is the same.

As to the local application of radium in carcinoma of the cervix, we no longer perform the radical operation for this disease unless the case is seen very early, practically only if we find it by accident, if it is not a clinically demonstrable carcinoma, if it is proven to be such only by the use of the microscope; then we feel that it is a case for radical operation, but in patients with large cauliflower excrescences or huge excavations, even though the uterus is freely movable, our results have been so disastrous so far as recurrence goes that we resort to a palliative operation only, plus the later use of radium, and

the palliative operation chosen is the Percy cauterization without preliminary curetting. As soon as the sloughing produced by the heat has stopped and the vault of the vagina is clean, radium is used. In one of our patients, a woman thirty years of age, this method was used, the primary operation having been performed five months ago. The uterus was as large as two closed fists and the whole vault of the vagina was excavated by the Percy method, followed by the use of radium two months later. My impression is that at this time we gave her 3000 milligram-hours of radium after the method of Schauta, 50 mg. for twelve hours every second day. I examined her only a day or two before coming to this meeting and found the entire cervix gone, the vault of the vagina smooth with a dimple showing the location of the uterine canal. She has had no hemorrhage, not even a menstrual flow, and most remarkable the body of the uterus is no larger than my thumb, a really startling result from the application of this combination of surgery by heat followed by radium.

While I am glad the essayist brought up the subject of radium in inoperable cases of cancer, I would have been gratified had he spoken of its postoperative use in every case of carcinoma of the cervix. There are portions of the body in which it does not seem to work so well, but both as a palliative measure in inoperable cancer of the cervix and after operation as a safeguard against recurrence, it seems to be of great value.

Our one year's experience with radium in approximately twentyfive cases shows some results that on the surface seem unbelievable, and makes it certain that it is a therapeutic agent well worthy of serious investigation.

There is one more matter I wish to call attention to. That dangerous toxemia may result from the prolonged application in advanced cases cannot be doubted. One patient in whom 50 mg. of radium was buried in the wound for twenty-four hours went into a quiet sleep lasting for a week and then died. There seems not to be so much danger from its use in large doses over a short period of time as there is from smaller doses continued longer. Three of these patients I have seen go to sleep without pain, remain more or less stupid for some days, and then die quietly; to be sure they were hopeless from any standpoint and were much better off dead, but one does not wish to be regarded as a public executioner even though he secures euthanasia. I do not wish to be understood as saying that an ordinary dosage of radium in the average case is associated with any danger, but that its prolonged use in patients already toxic may cause death as above described is my conviction from my short experience with it.

DR. SIGMAR STARK, Cincinnati, Ohio.-The previous speaker has really covered the ground I wished to dwell upon, but I would like to say a few words with reference to the small quantity of radium that the doctor uses in the treatment of his malignant cases. Fifty milligrams to my mind is the smallest amount you should employ. When a person undertakes to treat a case of carcinoma of the cervix, or carcinoma of the vault of the vagina, he ought to use from 50 to

100 mg., and it ought to be used for a short period of time, possibly ten to twelve hours, at intervals of from two to four days depending upon the resistance of the patient. If you do it in that manner, you will not get serious toxic symptoms. Furthermore from the use of small quantities of radium over a prolonged period you accomplish exactly what was described by the essayist. You destroy the carcinomatous material in loco through a short distance, and consequently cure it symptomatically, but you actually stimulate the growth of the tumor at a distance.

From my experience, the field of usefulness of moderate doses of radium in gynecology is principally in the treatment of benign tumors and those miserable cases we all have to contend withthose cases of idiopathic menorrhagia for which we have done everything imaginable to stop the hemorrhage, cases in which we could not find any pathological condition to account for the bleeding. I want to say to you, if you will properly use a small quantity of radium in such cases you will invariably stop the bleeding without prematurely bringing on the menopause, which is the case when you employ the x-ray for the same purpose.

If I am permitted time, I would like to recite two cases that came under my observation last spring. One was the case of a woman who came from Sewanee, Tennessee. She had a uterine cavity which measured 6 inches in depth and was bleeding almost three weeks out of four. She was supposed to have a fibroid tumor and sent to me for the purpose of operation. I could not make out a fibroid nodule, but considered the case one of subinvolution which was associated with a complete perineal laceration. I curetted her, and introduced into the uterine cavity forty milligrams plus radium element for a period of twenty-two hours. She left the hospital four or five days after the introduction of the radium, went home, and came back recently, and examination disclosed the fact that the uterus was shriveled up and the uterine cavity measured less than 22 inches. There has been no bleeding since.

The other case was a young woman, twenty-five years of age, eager to have children, with no appreciable change in the uterus. There was absolutely no evidence of a pathological condition, but that woman was a sufferer from menorrhagia for several years for which she had been curetted several times. I curetted her in June, and introduced 35 mg. of radium element, leaving it in situ for eight hours. Her physician Dr. Lurie, of Cincinnati, told me recently that she missed her July menstruation but menstruated four to five days in moderate quantity and without pain in August and September.

DR. FRANCIS REDER, St. Louis, Missouri.-I would like to report a case in connection with this discussion. It was one of recurrent sarcoma of the left side of the neck operated on about four months previous to the recurrence showing itself. The tumor was about the size of a goose egg. The first operation was a very extensive one, and under the conditions I did not care to undertake a second one. The patient was anxious to take the radium treatment. In this I encouraged him. He consulted a physician who possessed $14,000 worth of radium. It was interesting to note how the tumor became

reduced under the radium treatment. The bleeding, which was very free, sometimes bordering on an actual hemorrhage, ceased. The pain, which was at times very severe and acute, disappeared. It was very noticeable, too, how the patient was reduced as far as the soft structures are concerned. Two months after the application of radium the patient died.

DR. HUMISTON.-What was the cause of death?

DR. REDER. Simply exhaustion.

DR. MORIARTA (closing).-I had no thought of considering the broad use of radium in my paper; simply wished to suggest its possible value in controlling desperate symptoms in hopeless cases. The radium treatment gave the patients comfort and relief.

Dr. Skeel has raised the point in relation to the relative value of radium applications; that is, whether it makes any difference if the same milligram hours are the result of the use of a small amount of radium for a long time, or a large amount for a short time. This point is of interest, though difficult to determine. The one who works with a small quantity of radium naturally cannot decide what a large quantity might do; and those men who have a large quantity, of course think it unwise to work with a small quantity. One of the speakers has suggested that a small amount is objectionable because it has not the power of deep penetration, and may stimulate some part, instead of annihilating the growth. It is an accepted theory that the gamma rays do not penetrate more than 5 cm. However, the discussion of these points was not my purpose. It is unfortunate that workers with a small amount of radium cannot develop technical information as to its value. Clinically, however, they are forming a number of valuable conclusions.

It goes without saying, as one speaker has emphasized, that surgery is the most valuable remedy we have in all localized malignant conditions. Experience has also taught, I am sure, that radium is a valuable aid to surgery and should be used in connection with it, particularly in breast cases. I believe it should be buried in the operative wound, and later, after the wound has healed, used externally. I believe, when used in this way, it is a very valuable prophylactic measure, although with limited data, I have no way of substantiating this conclusion. I am sure, however, that time will show its value in these conditions.

The question of toxemia in the local use of radium is interesting. The patients whom I have seen and thought died with radium toxemia, died in coma, suggesting uremia, though the secretion of urine was up to normal in quantity and specific gravity.