XTbe Bristol

flI>ebtco==Gbu'uiYjtcal Journal "

Scire est

nescire,

nisi id

me

Scire alius sciret."

JULY,

I924.

the therapeutic

of

uses

radium.

BY

A. E.

Hayward Pinch, F.R.C.S., of the Radium Institute. London.

Director

^

dEsire first

Paid Ch"

in

rns

to express my

inviting

me

appreciation

of the

compliment

to lecture before the Bristol Medico-

lrurgical Society, and to voice the very keen and heartfelt I experience in meeting once again my former *eachers and fellow-students. I spent six of the happiest

P^asure

^ears ?f my life

Sclent and

^eallghly 1 .

at the old Bristol Medical

and later

as

lasting

School, first

as

Medical Tutor, and made many very friendships, which I value more and more as

the years roll

on.

"^he subject

"

Radium Therapy," and of my address is is manifestly impossible to deal with it comprehensively

the time Slide* ?t

disposal, I propose to throw on the screen patients suffering from various conditions which arnenable to radium, to say something of the history of r

Vol ^Ll.

at my ,

.

^ No.

t

98

MR. A.

HAYWARD PINCH

E.

the cases, and to indicate

adopted

to

produce

briefly

the treatment which was

the results shown.

Radium treatment may be carried out either with radium salt or radon (radium emanation) apparatus, their therapeutic

properties being identical. At the Radium Institute itself radium salt apparatus is chiefly used; but when tubes or applicators are sent out of the Institute for employment in various parts of the British Isles the radon apparatus is supplied, the actual intrinsic value being so small that if mislaid or destroyed the pecuniary loss is but trifling. The tubes are charged with radium sulphate at least 90 per cent, pure, and there is

admixture with barium

no

or

any other

inert material.

applicators are made of three strengths : Full strength," containing 0.5 centigram radium element to each square centimetre; "half strength," containing 0.25 centigram radium element to each square centimetre; quarter strength," containing 0.125 centigram radium The flat surface

"

"

element to each square centimetre. The strength of all radon (radium

emanation) apparatus expressed in millicuries, a millicurie being the amount of radon in equilibrium with a milligram of radium elementWhen dealing with superficial or subcutaneous lesions the apparatus is employed either unscreened, or lightly

is

screened,

to cut out the soft and medium beta rays.

screens most

generally

Aluminium, Lead, Silver,

used for this purpose

0.01

0.1 mm. 0.2 mm.

In the treatment, of where a

and

0.02 mm.

The

are :?

thick.

thick. and

1.0 mm.

thick.

deeply-seated growths,

or

in cases

prolonged radiation of gamma type only is necessary* screen of lead 2.0 mm. in thickness is utilised, as such a

screen

a

practically

cuts off all beta radiation.

*

THE THERAPEUTIC USES OF RADIUM.

When

tubes

1,0 nimof

generally :n

0.3 and 0.5

silver,

,

^he patient

6n?e^y

or tumours screens

platinum

are

of

the most

place

and divers forms of disease. I.

j fri

mm.

before you a series of lantern the results obtained by radium treatment to

now

illustrating

many

buried in tissues

useful.

I proceed

slides

are

99

LICHENIFICATION

was

neurotic

a

OF NECK.

young married

subject,

a

nuisance to

woman

herself,

of a

thirty,

an

trial to her

her husband. ^Th anc* is most interesting, it affords history of the to the theory that the affection is supp?rt der?n^ ^he condition appeared about two weeks after thenia*1.'^s' shock from seeing ,?,a1:ient had sustained a curse

case

str

as

a

a

a

severe

neuro-

nervous

billed in a street accident. All remedies had failed the incessant and maddening irritation, and when eYe the Patient came to the Institute, the disease having then e_ S*x nionths, her mental condition was deplorable. She ?ne exposure of fifteen minutes' duration with h ,receivecl .strength applicators screened with 0.01 mm. of ai lniUm- The irritation rapidly subsided, and within thr Wee^s the skin was normal in character. Subsequently she e-i two recrudescences of the trouble. The first was ay cjet rrnined the shock of the loss of a relative on the Titanic, by ^ by an air-raid during the war. The same treatment 011 ?P eac^ occasion, with an equally successful to

r

?

"

"

tyasSec?nd

result

2.

PSORIASIS.

Th

f0r o.(2 Patient, a man of fifty, had suffered from the disease een years. He had received all kinds of treatment and oCca?. l0nahy experienced temporary benefit, but had never "been Radium Institute he had the trunk and upper exposures, each of five minutes' duraf 011 three successive half strength" days with S appropriate shape and number. No screening Was P lesions had cleared up within three \Veeks^ie an _

1SfCase

"

100

?

MR. A.

E.

LUPUS

HAYWARD PINCH

ERYTHEMATOSUS.

Patient a married woman of thirty-two. The disease had existed for seven years, and had proved most intractable, and resistant to all remedies, constitutional and local. The condition was of the bat's wing type, and very extensive, implicating the nose, both cheeks, and both lower eyelids. She was treated with half strength apparatus, screened with o.oi mm. aluminium, the exposure being of forty-five minutes' duration. Great improvement followed, enabling the patient almost completely to hide the disfigurement by a slight application of face powder, and permitting her to take part insocial functions. No cure of the condition was obtained, and exacerbations occur from time to time, but are always greatly benefited by the treatment above indicated. "

"

"

LUPUS VULGARIS.

4. Patient

a woman

"

of

fifty-six,

an

inmate of

one

of the London-

The disease had existed since childhood, was of a strongly ulcerative type, and had destroyed much of the nose and adjacent portions of the cheek. Scraping, cauterisation, X-rays and Fmsen light had all proved ineffective. Poor Law Infirmaries.

"

"

applicators unscreened, varying from one hour to one and a half hours duration, repeated at intervals of six weeks over a period of six months. Complete healing resulted, and the disease was She

was

treated with

half

the exposure

strength

arrested. Patient was afterwards fitted with an artificial nose, and remained free from further trouble until her death si* years later. 5.

SENILE

Two patients, a man of Each patient had a

two.

on a

KERATOMATA.

sixty-four and a woman of seventy'' large fiat oval pigmented keratoma

of the face. of one and exposure " "

conspicuous portion

a half hours' duration with a suitable sized half strength applicator unscreeneda effected a complete disappearance of the lesion, leaving smooth, supple and scarcely perceptible scar. There was n?

In each

case an

recurrence.

6.

KELOID ACNE.

Patient a man of forty-two. Not a coloured individualThe disease had existed for nine years, and implicated the right half of hairy margin of scalp at the neck. Three exposures of one and a half hours' duration with half strength applicators unscreened were given at intervals of two month5" Complete cure resulted. "

THE

THERAPEUTIC USES OF RADIUM.

KELOIDS.

7.

One case of ree, followed

IOI

in a young woman of twentyburn. The face and hands were ery severely affected. Patient was compelled to wear a thick ack veil when out of her home, and was scarcely able to use ^er hands. She was under treatment for two years. Half extensive upon

a

degree,

petrol

"

rength

"

Ployed,

applicators,

screened with 0.1

mm.

of

silver,

were

and exposures varying from twelve to eighteen ^ urs duration given at intervals of six weeks. Improvement as slow, but steadily progressive, the keloidal tissue became sorbed, and the skin gradually assumed its normal PPearances. At the present date scarcely any sign of the ?uble is appreciable on the face or hands. ^no^her case, a schoolgirl of fourteen was playing in some when some cotton wool which enveloped her neck upper part of the chest was accidentally ignited. Keloidal anges occurred in the scar, drawing the chin down to the rnum, and preventing the patient from closing her mouth. ^ similar line of treatment was adopted and an equally successful result obtained. i

grades,

^ is advisable

to treat

keloids at

early a stage as collagen have developed

Possible, and before the bundles of fu% organised connective tissue.

as

lnto

Sh?uld a

J

be

attention

Special

to the

edges of the lesion, as increase proceeds peri-arterial fibrosis, which is most active at the paid

Periphery. ^ is

interesting

to note that when once

a

keloid has

eceived an adequate radiation all tendency to further ?r?wth is checked, though it may require several exposures bring about a complete disappearance of the mass. 8.

^ )

Capillary

Ncvvi

("

ISLE VI.

Port Wine

"

Stains).

Considerable

^Ppearance face and

of

e

improvement may often be effected in the patients disfigured by "port wine stains of "

neck, but the rprocess is a tedious one and the ures have to be It is never very carefully calculated. ssible to restore the skin to its normal colour, but a very

?vn

102

MR. A.

definite

E.

HAYWARD PINCH

of the tint may

lightening the

enabling patient completely slight application of face powder. The best results from

thirty applicators

to

being given

on

sixty

are

usually

frequently

to hide the

obtained

minutes' duration with

screened with

o.i mm.

each of three successive

at intervals of two months.

be of

intensity

with

a

exposures of " half strength

by "

days,

exposures

and this series

The reaction

should

that

produces desquamation without any stopped when the discoloration salmon-pink tint.

The treatment is

vesication.

is reduced to

(b)

patch

of lead, three

repeated an

be obtained,

a

Cavernous Ncevi.

The slides exhibited show very clearly the remarkably satisfactory results of radium radiation in the treatment of these In

growths. one

case,

a

child of

size of

one

year,

a

large

oval

pendulous

small cocoanut, implicated the lower half of the right cheek and the right sub-maxillary region. Its weight was such as to drag the child's head down to the right shoulder, and it was growing rapidly. Under appropriate treatment the naevus steadily decreased in size, and two years

growth,

the

a

later it had completely disappeared, leaving only a very small flaccid area of skin over the right lower jaw. The second case, an infant of five weeks, was brought with a very extensive prominent cavernous naevus implicating the lobe of left ear and the left pre-auricular region. Fifteen months later no traces of the growth remained. The procedure adopted in both instances was cross-fire half strength irradiation with applicators screened with o.i mm. of lead, three exposures each of from twenty to fifty minutes' duration being given on three successive days, the series being repeated at intervals of six weeks. "

"

"

The treatment of

cavernous

undertaken at the earliest

naevi with radium should be

possible opportunity,

as

infants

prove much more susceptible than children approaching their 'teens, and if due care be taken no untoward result can occur.

THE THERAPEUTIC USES OF RADIUM.

105

RODENT ULCER.

9.

Three distinct types may be recognised :? (a) Lesions of the excavating type with thin overhanging edges and a soft gelatinous base, no rolled edge being present.

(^) Lesions of the hypertrophic and exuberant type, with slight superficial ulceration, and often limited by a distinct rolled edge.

(c) Lesions affecting

the

palpebral

mucosa,

outer and

inner canthi.

Ulcers a

of the first group are the most difficult to treat the absence of the rolled edge indicating that

isfactorily,

Patient's power of resistance

and that ls

no

protective

important

niargins

to the disease is deficient

reaction is

occurring.

to radiate some distance

beyond

cases

the visible

of the lesion, in order to deal with any outlaying columns of cells which will almost certainly be

nvasive Present in

those situations.

Repair ^Perfect,

in these

always slow, and sometimes a very strong tendency to they so that they should be subjected to inspection frequent intervals, even if an apparent cure has cases

and

is

exhibit

J~Currence, fairly een

In these

"

"

Produced.

^cers

of the second group usually do exceedingly well, the dose and exposure be correctly calculated one rnen1: ma^ suffice to bring about an apparent cure.

Th e

tendency many 1

^

111

ute in which the

any

^ th

t

to recurrence in these instances is but

patients

have remained

recurrence since their treatment

years ago. m ^IC treatment of this

^

the

slight,

cases are recorded in the case sheets of the Radium

most

striking,

particular

remarkable and

quite

eight,

free

ten

or

class of lesion

permanent

results of

MR- A.

104 radium of

an

therapy

are

extensive

E.

HAYWARD

obtained.

The

hypertrophic

PINCH

complete disappearance

ulcerated mass, and its

re-

placement by a smooth, soft, supple scar, differing but little surrounding skin, is often amazing, and might be regarded as incredible but for photographic evidence. In one of the slides shown an irregular hypertrophic ulcerated growth is seen to occupy the left side of nose and cheek and completely to occlude the eye. When the growth had from the

disappeared

under radium treatment the orbital fissure was

found to be narrowed from cicatricial contraction of the affected

eyelids,

Rodent

responds

but the eye

ulcer

affecting

quite healthy. palpebral mucosa

was

the

often

well to radium treatment, which may completely disease, and prevent its extension to the sclerotic

arrest the

and cornea,

Many

cases

and

subsequent

destruction of the

of this nature have been treated most

the movements of the

eyeball being

eyeball-

successfully*

unaffected and the vision

unimpared. Cases of rodent ulcer which have not

previously received

any active treatment with X-rays, ionization, C02 snow, etc., usually receive an unscreened exposure of from one and

according to the thickness of the lesion, with a full strength applicator. The reaction is generally fairly severe, producing a degenerative necrosis* and removal by ulceration of all the malignant tissue, and possibly of a small surrounding layer of normal tissue. The ulceration is followed by the formation of a limpe* shell" crust, underneath which repair occurs, leaving a smooth, soft, supple scar, particularly rich in elastic tissue a

half to two hours' duration, "

"

"

fibres.

great

In cases of very long standing, accompanied by destruction and invasion of the cartilaginous or bony tissues, unscreened exposures should not be given. irradiation of any kind is powerless to cure rodent

RadiuU1 ulceration

Figs,

i

and 2.

Rodent ulcer of the orbit before and after

lymphosarcoma

treatment

by

and 4. Figs. 3 and of the neck before and after treatment

radium.

by by

radium.

THE THERAPEUTIC USES OF RADIUM.

105

bone, and the same is almost equally true with respect to Cartilage. For this reason the affected portions of these lssues should, be removed

treatment

far

as

possible

as

before radium

A gamma radiation from heavilyScreened apparatus applied to the borders of the growth and deeper extensions will often serve to arrest the progress is commenced.

the disease, diminish the pain, and induce

degree of repair,

but it will not and cannot do 10.

Patient

some

more

slight

than this.

LYMPHADENOMA.

The disease had developed of the left cervical region w Principally affected, and in that situation they formed mass of firm, discrete, movable glands, oh c^n? the venous flow from the head and pressing upon the sympathetic ; the patient's face was congested and dusky, a there was some respiratory embarrassment from distrachea. hours' treatment was given with surface applicators w-

young girl of fifteen. rapidity. The glands

a

?reat

a^re

+?enormous

,

co

a

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