RADIUM IN SURGERY AND DERMA TOLOGY.* M. L. RAVITCH, Louisville. I wish that I had not written the editorial on radium in our State JOURNAL for May. Had I not written it I might have worked up imaginary effect and reported wonderful results of radium therapy and would have shown our profession that our lack of real medicinal remedies can be replaced by this cure-all metal. It is really pitiful to see our despair when it comes to therapeutics. We are ever ready t oabandon our favorite remedies for imagin ary new ones. How did the therapy of radium start? Because Becquerel, in carrying a small piece of radium in his vest pocket, observed about a fortnight later a severe inflammation of adjacent skin, the first demonstration of radium's caustic and destructive action was brought forward. Since then its applications and uses have been numerous. It was used for everything from corns to consumption with the alleged wonderful results.-if we could believe all the reports and articles written. I do not doubt that among the numerous experimenters we have a few earnest investigators who carefully, painstakingly and scientifically observed the action and effect of radium. Great things may be expected from these earnest observers, and I am glad to notice that the most enthusiastic investigators such as Louis Wickman and Degrais in France, and Abbe in this country have not lost their enthusiasm, though they have modified their claims and become more conservative in regard to therapy of radium. Wickham, the master of all of them, in his latest publication admits that radium does not cure deep-seated malignant tumors, that it is only a useful agent as far as to relieve pain, and insists that "operable cancers should be operated upon without delay. This should be an absolutely fixed rule." In the radium institute of London, the second of its importance in Europe, where hundreds of patients have been treated, none of them have been reported as cured. Apparent cures are mentioned in benign forms of cancers, 30 per cent. of cases, while in malignant forms the reports are not very favorable. The same statistics can almost be duplicated in the Vienna hospital, and in the Samaritan hospital in Heidelburg. Surgery, medicine and particularly dermatology, have expected great therapeutical properties from this precious metal, but all *Read before the Kentucky State Medical Association, ar Newport, September 22-25, 1914. these three branches had to fall back on their oft-tried and partly successful methods and agents. Looking over the literature of radium therapy, we find that its use and applications can be limited to few diseases. The most successful results were obtained in treating skin cancers, as the majority of enthusiastic followers of radium lay claim; but skin cancers are of such minor importance, that with perfect technique the knife, electro-cautery, suitable caustic and karatolytic agent will do just as good work in a shorter time and with less expense. As to the cosmetic effect, on which the radium followers lay particular stress, 1 get just as fine cosmetic effect from the use of the electro-cautery. Supplemental use of Xray, if occasion demands, is, at times, advisable but in very few cases. On account of its destructive action on the tissues, particularly of cancerous nature, radium has been used in the following suecessive line: mycosis fungoides, lymphadenomas, tubercular adenitis, sarcomas, epitheliomas, angiomas, naevi, lupus vulgaris and erythematosus, rhinophemas, keloids, scars and acne rosea. I named only these few diseases because the majority of experimenters claim that they have obtained success in these particular diseases from radium treatment; while in many other diseases, in which radium has been used, the results seem to be purely imaginary. I will take up the few diseases that were mentioned above. Of the use of radium in skin cancer I have already spoken. In superficial skin cancers it was used with some success, but in deep-seated malignant growth no good results, but only disappointments were obtained. True, some enthusiastic followers of radium. such as Exner, were able to trace histologically the retrogression of carcinomatous nodules in the mamma, larynx, pharynx and nasal passages, but even such an occurrence was rather rare. Isolated instances of apparent cures of malignant cancers are, at times, heard of, but to my mind. there was never a complete eradication of the ultimate ramification of the disease. though there might have been an apparent retrogression of the primary site of the tumor. Tubercular adenitis does not respond to radium even if it is employed for a long duration. Surgery is more efficient and practical. Lately massive doses of X-ray have been applied with great success. In keloids and scars (particularly on the neck) some claim for radium better cometic results than from an operation. Operation, it is claimed by radium followers causes formation of larger scars on the site of the ones that were removed. But it should be remem bered that the removal of keloids and scars should be entrusted to surgeons who devote themselves to plastic surgery. Radium therapy, if it does give good cosmetic results must be used for a very long period. Such treatment is rather prohibitive on account of the time and the great expense involved. X-ray in such cases is quicker more active and less expensive. Angiomas should be divided into two groups: small ones or naevi vasculosi and bloody tumors which are liable to great loss of blood. In very extensive angiomas we should use the method "feu croise," i.e., to place the tumor between two blades (clamp like) pointing towards each other. It should be remembered that angiomas in adults do not yield to treatment as easily as in children. While angiomas seem to yield to radium treatment, it must not be forgotten that sometimes Kromayer's lamp, electrolysis, hot air and even the knife give splendid results; but where angiomas are too extensive and the danger of bleeding is imminent, radium is useful, but here again we meet with its chief drawback, the length of time required for treatment. Pigmentary naevi do not yield to radium treatment as well as angiomas do. It is a tedious and unsatisfactory procedure. In lupus vulgaris radium is rather useless on account of the length of time it takes; it requires at least one hundred hours to make any perceptible impression upon the disease. Electric or Paquelin cautery is far superior. Finsen light was found far more useful in lupus, particularly in the manifold lupoid nodules. In lupus verrucosus the action of radium was found to be too weak. No results were obtained in lupus erythematosus. On the other hand, in lupus of the mucous membranes, radium was found to be an excellent remedy. I do not believe that radium can be of any use in mycosus fungoides, the disease being too extensive in area and too formidable for the practical use of radium. The rectal surgeons have tried to apply this remedy in pruritus ani, while gynecologists used it in pruritus vulva, but the dermatologists, who mostly handle the above diseases, have found X-ray far superior. Some radium enthusiasts claim that radium has given them beautiful results in acne rosea and rhinophyma, but if these statements were true, our late Mr. Pierpont Morgan, who suffered from rhinophyma, would have cornered all the radium out-put in the world. In pappillomas and warts the influence of radium was supposed to be very good, but who, in this wide world, would dare to apply such a precious metal to such a common thing as a wart. While radium was principally and extensively used in dermatology and surgery, yet it must not be forgotten that it has also been tried in general medicine. Radium emanations in all forms and devices have been used in faulty metabolism, in certain forms of arthritis and other conditions, but it seems to me that its use in such cases have been more of a commercial exploitation than of a scientific basis. Stored emanations of radium in glass tubes, metal rods impregnated with radium emanations, waters charged with radium emanations and other devices of canned radium have been brought forward, but all such things smack of fakery. In speaking of radium we must not forget to mention mesothorium. But Fred Soddy was right when he said that 'five minutes application of radium is equivalent to ten years. application of mesothorium." What is, then, the present status of radium in thereapeuties? We have no real status as long as we do not understand fully the emanations and radiations of radio-active bodies. As I said in my editorial on radium: "a variety of theories have been offered to explain. its peculiar properties. Some scientists declare that radium is a source of earth-heat and that it is probably of the same substance as that of the sun, since it is known to emit certain gases of the same vapor as given out by the sun. Much of the speculation among the therapeutic values of radium have been found unwarranted by actual demonstration, but that it will some day be found a very useful agent, can not be disputed. Surgery, if justifiable, offers at present the best and surest method of handling malignant cases." DISCUSSION. Curran Pope, Louisville: I expect that there has never occurred a more interesting story in all the world of science, and science has its fairy tales, than the fairy tale of radium. It was one. of those scientific toys at the start that appealed in a singular manner to the emotional side of the individual. Like everything of that kind, like tuberculin and like the X-ray, it was going to revolutionize the world, to eliminate pathology and enable the physician to control the secrets of life. To those of us who have no tendency toward philosophie thinking, such an attitude as regards radium absolutely presaged the "pride that goeth before destruction," and so it has been with radium. If radium had lived up to onetenth of its reputation at the start, it would be to-day one of the most marvelous of the various radiations that we have at the present time to use in medicine. Radium depends largely for its therapeutic ef fect upon the use of gamma radiation, that radiation that is allowed to pass through aluminum. I believe where the radiations of radium are filtered by aluminum we get the gamma rays, and it is the gamma ray that possessed therapeutic value. The other two are too soft Their wave lengths are too long to be of value in anything save the most superficial of conditions. In other words, we may reasonably liken the Alpha ray to an exceedingly soft X-ray tube, a tube that nobody to-day would use. A Beta ray to a moderately soft tube and a gamma ray to a hard X-ray tube. The use of radium in superficial conditions has to my mind been practically relegated to the rear. No one would think to-day of using radium when the X-ray technic has been worked out to such an extent that we can almost with certainty depend upon the X-ray for superficial conditions or upon the actual cautery, as Dr. Ravitch has stated, but if we had a method by means of which the gamma ray of radium would have the penetrating power of the X-ray tube; that is to say, if we can by proper protection of the skin possess a gamma ray of radium that would penetrate deeply, we would then have a therapeutic method that would be of enormous value probably, in that even, combining the value of the hard radiation from the X-ray tube with the, therapeutic value of the hard or gamma from radium. There is every prospect at the present time that this hope will be fulfilled. Dessereaux has in a recent communication informed us of the use of a new X-ray tube, energized from a transformer, selecting only the crest of the transformer waves, by means of which he could get a special X-ray tube that formed rays that possessed the hard penetrating value of the Xray, and at the same time respond to all of the physical and other tests of the gamma ray of radium. If this is true, we are then really having an era opened up to us of radium therapeutics in a cheap way. Radium is to-day the most expensive mineral, so expensive in fact that no one but institutions that are richly endowed or hospitals that are richly endowed can afford to have what might be reasonably termed a decent radium outfit. It would be a wealthy individual that would want to carry sufficient radium to carry en proper radium therapeutics, but if we can for a few hundred dollars make a tube that will possess all these values, then we will have made a step forward, and one which promises greatly for the future. There is no question but what radium has some value, but it is extremely circumscribed; whereas the tube, such as Dessereaux is working upon, and which he presented to the Congress offers a wide field for application, and with it I believe he makes the claim of a very powerful deep-seated effect. In fact, the field to-day of deep therapy that is being offered by the tube of another investigator, which is a very remarkable discovery, ought to be credited to an American electrical engineer, working at Syracuse in the general electric laboratories, a new tube that enables us to practically control the radiations for deep therapy. James O. Jenkins, Newport: It is almost presumptuous on my part to say anthing on radium after such an elegant paper as Dr. Ravitch has presented to us. I have only used a small portion of radium, not sufficient in quantity to do any good excepting in superficial conditions. I believe it will cure superficial cancers. It will cure epitheliomas if confined to the lips and face, and I do not think I have had any failure from its use. I believe, as the essayist and Dr. Pope have just remarked, that there was a great deal of psychic influence in the adoption of the remedy in the beginning, but its value as a therapeutic agent from all the information I can gather and from my experience is that it is successful in the cure of some cases of malignant disease. The great trouble about the remedy is its expense. A small quantity is of very little use, and a large quantity will exhaust the financial resources of the Kentucky doctor unless he is more affluent than most of us. Less than a gram cannot be expected to accomplish much good in a deep-seated condition, In Europe and also in America where a quantity of it has been secured, and a proper technic developed, and the proper filters used, something has been accomplished in deep-seated conditions. Dr. Freude, of Strassburg, has effected a permanent cure in carcinoma of the rectum. Eight months afterward there developed a nodule along the lumbar spine. He made a section of the abdomen and rayed the nodules effectively causing their disappearance and a cure the case having been surgically inoperable. Others have reported numerous cures from the use of radium. It seems to possess value in deep seated cases. Beck. of New York, has used the X-ray to the exposed neoplasm. The adoption of filters to eliminate undesirable rays is one of the technical steps in using radium. That requires calculation as to the patient and calculation as to the variety of ray you are using, the length of exposure, and the estimation of radium rays at your disposal. With all this, radium does not possess that ready adaptability to general practice that other well-known and tried remedies do. The X-ray is efficient and is within our means, it is not expensive, and can be applied in a small hospital. The reason why so many surgeons have given up the use of radium is because of its expense, as well as its lack of adaptability. The very small hospital or the men who are away from large cities or towns are deprived of the use of the remedy. It is costly to the patient: therefore, it is not economical, and taking it altogether the difference between the availability of use of radium and other well-known remedies that we have at hand is not in favor of radium. Later, perhaps it may be placed upon a more available basis. In that case I believe the remedy is a good one. M. L. Ravitch, (Closing): I wish to thank the gentlemen who have discussed by paper. Their views are in accord with my own. I agree with Dr. Pope that the rays of radium are not identical with those of the X-ray, and those who are working with radium and the X-ray know that. The nature of the burns either with the X-ray or radium prove it. I have not been so successful as Dr. Jenkins has in the treatment of epitheliomas of the lip or face. He made mention of undesirable rays, but we do not know anything about which rays are undesirable or desirable. Until we find the true nature of different rays, at present it is all speculation. Four or five years ago radium enthusiasts thought the Beta rays were less irritating and the most useful. Last year Abbe and Carroll found the gamma rays were the most useful ones and the least injurious, while the Beta rays were not so effective and useful. PERIODIC EXAMINATION OF SUPPOS- By EUGENE LYMAN FISH, New York. This principle of periodic inspection of the human mechanism, which appeared so radical a few years ago, has now become widely accepted as almost axiomatic. Two of the largest life insurance companies in the world have extended this privilege of periodic health examination to their policy holders. A number of the smaller, but not less conservatively managed companies, have done likewise, apparently well convinced that the saving from reduced mortality will more than cover the expense of carrying on the work, and afford a business justification for these measures, fundamentally designed to improve the vitality and well-being of policy holders. Employers of labor are also extending these privileges to their employes, with the same purpose in view, viz.: improving their vitality and well-being, the business warrant for the expenditure lying in the increased productiveness of the working force, and the better quality of the work turned out. In many communities general inspection of school children is now practiced but not yet with sufficient thoroughness. Banks, trust companies, department stores, widely diversified industries, and individuals acting in their own behalf, are moving in this matter. This remarkable growth of sentiment *Read before the Kentucky State Medical Association, at Newport, September 22-25, 1914. has taken place largely within the past two years. In fact, this practical, effective, and far-reaching influence for human betterment, has spread with a rapidity seldom attained by movements for racial improvement. The explanation lies, not only in the fact that it appeals to common sense, but that it contributes to the welfare of all concerned,-employer, corporation, employe, and society in general. It is likewise a most powerful influence for adjusting the practice of medicine to modern requirements, and for increasing the scope and value of the physician's work, as it constitutes him a custodian of individual and public health, rather than a mere emergency man, who is too often called in too late to render the most effective service. Apart from a few nervous neurologists, and well-meaning, but utterly misinformed representatives of organized labor, there is no sentiment in opposition to the plan. The nervous neurologist suggests that a man who is in the early stages of a chronic malady, and drifting along without medical supervision, because he has no symptoms and is unaware of his true condition, should be allowed to drift until the malady reaches a stage when it announces its presence, possibly by uremic convulsions or cerebral hemorrhage. According to such view, it is better for a man to receive his warning when it is too late, lest his mind be disturbed by receiving it too early; lest his health be injured by in telligent medical supervision, designed to check the progress of his malady, or lest his of his pet indulgences or injurious habits. and mind be disturbed by depriving him of some thus warding off even the early stages of dis ease. Such views are not, of course, widely held by neurologists, and, I believe, there is a reaction against the over-emphasis of mental suggestion and purely psychic factors in the causation of disease, which is well expressed in the writings of Lugaro. We must recognize body poisons, as well as mind poisons, and beware, while we are "psych-analyzing" for submerged elements in the sub-conscious stream, that we are not overlooking sub-infection from a gall-bladder, or intestine, a blind dental abscess, a seminal vesiculitis, a visceral ptosis, or some other material focus of disease. As for the labor sentiment against periodic examinations, it is not widespread, but simply reflects a fear that the "weak brother" will be discriminated against, and also evidences a total misapprehension of the spirit and the motive underlying these activities. It is not the weeding out of the sick or of the unfit that is contemplated in this movement, but the raising of the general level of fitness and well being. The frankly sick have for years been weeding themselves out, while under this new system sickness is not only prevented, but the unfit are given an opportunity to improve their condition,-in many cases, given the kind of employment to which they are adapted, if they cannot be physically adapted to the work they are doing. I do not know of a single instance in which a corporation taking the service of the Life Extension Institute has discharged an employe because of the results of his examination, but I can say, most positively, that in every establishment that has taken such service there have been numerous instances of help extended to employes in bettering their condition. Leaves of absence have been granted, and efforts have been made to give employment better adapted to the individual, and those found impaired have been counselled with and urged to take the proper measures for the improvement of their condition. For example, in a number of cases of hernia, operation for radical cure was arranged by the employer. Most of us are more or less unfit. In one group of four hundred and fifty people examined, only eight were found who did not require some kind of advice regarding their physical condition or their manner of living. I am not going to consume your time by any extended argument in favor of the principle of the periodic health examination, but rest the case with a quotation from Victor C. Vaughan's splendid presidential address before the American Medical Association in, June last: "If preventive medicine is to bestow on man its richest service, the time must come when every citizen will submit himself to a thorough medical examination, once a year or oftener. "Science must discover the facts, and medicine must make the application for either cure or prevention." Coming down to the practical details and suggestions relating to the actual work, I invite your attention to the following special aspects of this question: 1. Ideals, standards and methods. 2. Evidence derived from actual experi ence. 3. The practicing physician's opportunities and responsibilities. A volume could, of course, be written under each one of these captions, and I can attempt to cover only the most important points. IDEALS, STANDARDS AND METHODS. In planning these periodic health examinations, our ideal should be to uncover the workings of human body, and to secure a complete picture of the mechanism, and of the conditions under which it exists. The total value of a man equals heredity plus environment, plus physical condition, plus what he does. Plus or minus in any of these factors counts. In this photograph, as it were, of the individual as a whole, there may appear many features that we cannot, in the light of present knowledge, correctly interpret; our effort should be, nevertheless, to secure this picture; thought we may not be able to advise, we can, at least, study, and thus, entirely apart from the immediate value of these examinations to the individual, enormously increase their general value to science, and to mankind. With the picture before us, we must then attempt a thorough valuation of the individual as a "going concern." It is not enough that we seek for pathological conditions; the working plan must be constructive, as well as protective. When we keep a man out of a sick bed, we have done a good thing, but we may not have added one jot or tittle to his average efficiency or well-being. Our aim should be to take the measure of the man, to ascertain how far below his best possible condition he may be, not only with regard to working capacity, but with regard to the capacity for living a well-rounded and useful and happy existence. A man may not be afflicted with tuberculosis, heart disease, or any other grewsome malady, and yet be but a pale reflection of what he might be, with his physical handicaps removed, with his life adjusted according to the rules of personal hygiene, even as they are known now, in the rudimentary state of that science. With these ideals in view, we should endeavor to square with them the standards for carrying on the work. These standards, of course, must be modified, according to the available facilities and the limitations of expense, but it is most important that all who are doing this work should seek for certain fundamental things, and observe certain standard methods. Dr. Schereschewsky, of the United States Public Health Service, who has been conducting the examinations of the employes of the cloak and suit trade of the City of New York, in cooperation with the Joint Board of Sanitary Control, has suggested that the Government establish a standard examination blank. While this may not be practicable, in view of the fact that the conditions and requirements are so varied in different industries, and walks of life, it is certainly possible to observe a reasonable degree of uniformity. Take the blood. pressure for example: This is a most important feature, and should be included in any physical examination, however, brief and cursory. Both the systolic and diastolic blood pressure should be taken by the auscultatory method. The technic of this method is so simple that it can readily be acquired by a layman in a few minutes, and a competent phy |