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RADIUM TREATMENT OF CANCER OF THE CERVIX.
1406
Special Articles. RADIUM TREATMENT OF CANCER OF THE CERVIX. BY HELEN CHAMBERS, C.B.E., M.D. LOND., FULL-TIME INVESTIGATOR FOR THE MEDICAL RESEARCH COUNCIL.
It is an astonishing fact that in this country we much less advanced in the treatment of uterine Radium has cancer than certain foreign countries. only been used in England on scientific lines for the treatment of this disease since 1921, and in very few clinics only. Comparatively few of our hospitals carry out radium therapy at all for these cases; many possess no radium, and some which possess it have not enough to treat uterine cancer effectively. This is a deplorable state of affairs which urgently
are
needs THE recent report issued by the Ministry of Health1 on the results of treatment of cancer of the uterus is a matter of serious concern to all who are responsible for the treatment of patients suffering from this disease. The report is a statistical inquiry based on an analysis of the existing literature prior to March, 1926. It deals with the results of treatment of not less than 80,000 cases of uterine cancer and compares the results obtained by surgery with those obtained by radiology. Cancer of the body of the uterus is considered separately from cancer of the cervix, because the problems associated with the disease at these two sites are widely different. Radium treatment of cancer of the cervix has been in extensive use in foreign countries since 1913 and a vast literature has accumulated, dealing with over 5000 cases. During the period under review surgical technique has reached its limits, for the methods of operation have been standardised for many years. Radiological technique, on the other hand, has been largely in the experimental stage, and although great advances in technical methods have been made, the limits of these developments have not by any means been reached. The technical methods adopted in the radiological treatment of the cases under review have therefore on the whole been more elementary than those of surgery ; but, nevertheless, the results of radium compare very favourably. When the general results of these two methods of treatment of operable cancer of the cervix are compared they are found to be closely alike; there is, however, an important factor weighing against the surgical method, the relatively high operation mortality of 17 per cent. Compared with this radium has an immediate less than 1 per cent. When only mortality of inoperable cases, which are completely hopeless from the point of view of the surgeon, are considered, roughly 12-6 per cent. can be saved, for prolonged periods at any rate, by radium. This figure is based
rectifying.
The use of radium for the treatment of cancer of the cervix requires a skilled gynaecologist with an intimate knowledge of the disease and its pathology, and of the physical and biological properties of radium. Without this equipment it is impossible to treat the zone involved by the cancer with an effective dose of radiation. In this disease the use of radium has passed the experimental stage, although it is still in the transition period of a new form of treatment. The technique will doubtless be subject to great improvements as experience and knowledge increase. Certain known facts, however, largely determine the results. The object of this paper is to emphasise some of these essential points of technique.
General Method of Treatment. There is as yet no general agreement as to the best means of treating cancer of the cervix with radium. Many different methods are in use and they vary in the quantity of radium used, the dosage, and the method of distribution. When the earliest cases were treated very little was known about the range of action of radium tubes and applicators or their biological effects. The methods of treatment were largely empirical, and all treatment other than surgery was looked upon as a palliative measure. The clinician using radium in the early days only treated cases which were completely hopeless from the surgeon’s point of view, and looked upon a poor result as the inevitable and unavoidable consequence of the disease. The usual method was to insert a single tube applicator into the cervical canal or against the growth for a varying time, often for 24 hours. In the great majority of cases the extent of the growth was far wider than the range of action of the applicator, and in practice this treatment did little more than treat the surface of the disease. Temporary benefit, nevertheless, often followed. The case was then watched until definite signs of extension were evident, 1 on a five-year period. and the same treatment was then given again some These conclusions are a summary of the evidence two or three months later. It was usual to repeat produced by many different clinics, and they therefore the treatment as long as the patient was well enough have the special value that they are not subject to attend the out-patient clinic, usually for six or to the bias of any individual observer. When the nine months, and occasionally for several years. evidence is examined in detail the results are, of It is sincerely to be hoped that this method of treatcourse, found to vary widely with different clinicians ; ment will never again be carried out in England; they also vary with different countries, for some have there is complete proof that it invariably fails. It is advanced in technical methods much more than like cauterising the surface of a carcinoma and others. These facts mean that we have to advise hoping for success. patients suffering from cancer of the cervix (except In contrast with this treatment is the method perhaps in the very few cases* where the disease adopted when an attempt is made to cure the disease. has only reached its earliest stage), that if they obtain The range of action of the radium tubes and applicators modern radium treatment their prospect of life will and the approximate dose required to produce a be as good as if they submit to operation, and the lethal effect on cancer cells are known within limits. immediate risk of radium treatment is practically nil. The treatment is planned soon after the patient is Needless to say, no woman will submit to a severe first seen and the whole course of radiation carried surgical operation when she knows that this is true. out within a few weeks. The radiation is arranged But the soundness of this outlook clearly depends so that an effective dose reaches as widely as possible upon what is meant by modern radium treatment. in the region involved by the disease. If the growth We have no right to advise against competent recurs the treatment is recognised as having failed. surgery, even with its comparatively high death-rate, The conditions are now much less favourable for unless there is a reasonable prospect that the further treatment, as the growth has extended, to alternative radium treatment will be carried out a wider zone and the cancer cells may have acquired with all the skill and knowledge that science now tolerance to the radiation. If further treatment is possesses. The experience of the last 12 years has decided upon, it is clearly useless to give the same conclusively shown that radium therapy is a treatment again ; either a heavier dose of radiation specialised art which completely fails to save life must be given or the treatment must be applied unless the essential technical conditions for success to a different zone. For the benefit of subsequent are understood. cases the reason for the failure must be carefully * There are no data yet available for cases such as these sought, and the original technique critically examined to see if it can be improved. As a matter of fact, treated with radium.
I
1407 more radium applicators are placed near to each are now given that usually impossible to repeat the original treat- other, the adjoining tissue receives radiation from ment, and it is comparatively rare for the growth to them all, and the dose is then the sum total which recur at the zone treated. Any recurrence is usually reaches a given spot from every source of radiation. at the edges or beyond. Recurrence at the original This dose depends upon the amount of radium, its site generally means faulty distribution of the radium distribution inside the applicator, the distance it is away, the filtration, and the absorption of the or inadequate dosage.
such heavy doses of radiation it is
The success of radium treatment in cancer of the cervix depends upon the fact that for many months the disease is a local one. It involves a region which is accessible, and one to which a heavy dose of radiation can be safely applied if special precautions are taken. When the disease has spread widely to the deeper structures of the pelvis it is doubtful whether any form of radiological treatment can prevent the cancer cells from growing. It is a common but erroneous idea that it is possible to sterilise the whole of the pelvis. As a matter of fact, the dose of radiation required to kill cancer cells is so heavy that if it were applied to any large region of the body the patient would die. The treatment with heavy doses has therefore, to be limited to a comparatively small
tissues. effective action when
intervening m
raUIUIlJ.
2 shows the range of central tube containing 50 mg.
Fig. a
ele-
ment is placed in the uterine cavity, and three flat applicators, each containing 25 mg. of radium ele-
FIG. 2.
ment, are placed in the vaginal vault
for 48 hours. The size and shape of the cone vary with field. The most serious objection to radium therapy is the condition of that it fails to treat pelvic lymphatic glands. They the cervix, for are only involved, however, in about 37 per cent. of the size of this these cases at the time of death, and as the majority determines the of patients are first seen a year or 18 months earlier, plane in which it is reasonable to suppose that the greater number the flat appliof patients when first seen have no gland involvement cators can be at all. This is supported by the fact that many placed. It is at e obvious cases are alive and well ten years after radium once this treatment. The truth can only be determined by that statistics on a large number of cases. Clinicians state method of disthat they often find glands involved at operation, tribution offers Shows the zone of effective radiation but this is not convincing to a pathologist. It is a a much better when cross firing is obtained between common error, even after microscopic examination, prospect of an intra-uterine applicator and flat applicators in the vaginal vault. to mistake enlarged glands of long standing inflamma- treating carcinoma of the tion for glands involved with growth. cervix successfully than does the use of a single tube Distribution of the Radium. applicator. The distances of effective action from the The range of the effective action of radium tubes sources of radiation are based on experimental bioand applicators is so limited that the position in logical tests. I am indebted to Prof. Russ for adding the dotted lines to these diagrams, and to the Cancer wmcn tney are Research Committee, of the London Association of in relaplaced FIG. 1. tion to the the Medical Women’s Federation for allowing me to 2 growth and to reproduce them from their first report. each other One of the most important points is that the wider determines the this cone is made at its base, the greater will be the results. Fig. 1 prospect of saving the patient’s life ; it is therefore shows approxi- necessary to stretch the vault of the vagina to its mately the widest capacity. Clinicians find it far easier to insert effective range a small applicator than a large one, and they often of a tube appli- pack radium tubes closely to the cervix, with the cator contain- result that they obtain a more intense but smaller ing 50 mg. of cone of radiation, and the outlying parts of the growth radium element are ineffectively irradiated. The results are correplaced in the spondingly poor. At the Fondation Curie (Regaud), cavity of the although a somewhat different method is used, this uterus for 48 point is recognised. Two radium applicators are hours. This is attached to a spring which keeps them as far apart roughly an in the vault of the vagina as the space will allow. ellipsoid; its It is impossible in this paper to go into details of length, size, and the many other methods of distribution of the radium shape depend which are now employed at different clinics. A method upon the length very similar to that shown in Fig. 2 has been used in of the appli- Stockholm (Forssell Heyman) for the last 15 years, cator and on and a similar method has been used in Japan (Ikeda) the amount and since 1914 ; the results are some of the best on record. Shows the zone of effective radiation when distribution of This method has only been used in England since a single applicator containing radium tubes is inserted into the cavity of thethe radium. 1925 at two London clinics, and, as far as I know, uterus. The size in- it is not in use at the present time anywhere else in creases with this country. The largest number of cases treated longer exposures, but only to a very small extent. by this method and recorded in our own literature When this ellipsoid is compared with the zone usually have been treated under the auspices of the Cancer involved by a carcinoma, it is evident that a single Research Committee of the London Association of tube, however placed, can only rarely, if ever, treat the Medical Women’s Federation. They report 3 the whole region affected. Single tube applicators 117 cases with no death directly due to the treatment. have now been universally discarded in modern Fifty per cent. of their cases treated more than a year methods of technique. ago are stated to be free from signs and symptoms It is therefore essential to use multiple sources of cancer ; the percentage operability of these cases of radiation at the site of the growth. When two or was not more than 15 per cent. These results are too
I
1408 recent to justify conclusions as to the ultimate value of the method, but as far as they go they agree with the foreign reports and compare very favourably with the results at those clinics which report 70 per cent. of cases as having died within a year of the patients first being seen.
Dosaye. The question of dosage is as important as the method of distribution. All clinics recognise that their early work was done with inadequate doses. Radium was known to be dangerous and the At the clinician naturally used it with caution. present time it is possible to rely on wide clinical experience and scientific technique, and there is no longer any excuse for using small doses which It is customary to are known to be ineffective. describe the dosage in terms of milligramme element hours. Although this is a convenient method it gives no real information unless the amount of radium and the position in which it is placed and the time during which the treatment is carried out are stated. It is impossible to add together all the doses given over a period of several months, as is often done, and look upon this figure as truly representing the dose. The most suitable dose of radium needed to cause the death of all the cancer cells, and the time in which this should be given, is still a matter for research. Most authorities are agreed that 7000 m.e. hours can be given safely without serious after consequences. The time varies in different clinics ; some give the whole treatment in five or six days, others spread it over two or three weeks. There are a few cases on record which are alive and well ten years after treatment with 3000 m.e. hours, but it is almost certain that the clinics which reduce their routine dosage to this amount also reduce the percentage of their successful results. The object of the treatment is to give, as far as possible, a uniform radiation to the whole region involved by the disease and only to give just enough to prevent the cancer cells from living. If this is achieved the connective and epithelial tissues which ultimately replace the growth are not seriously
damaged..
General Technique. In this very short account of an intricate subject it is impossible to consider many important details. For example, the failure to pack off a radium applicator and to appreciate its range of most intense action may result in the normal bladder or rectal mucous membrane receiving an intense exposure ; long-standing and distressing symptoms and fistula If the bacterial infection which is so may result. commonly associated with this type of case is not treated, the insertion of the radium tubes may set up an acute pelvic abscess. Many of the immediate deaths are due to this. A uterus involved with soft friable growth with an orifice difficult to find can easily be punctured by inserting radium. All these risks, which are very real, become practically negligible in the hands of a competent clinician trained in this very specialised field of work.
providing
are entirely without the facilities for it. With extended knowledge it is to be hoped that this state of affairs will very soon be
hospitals
rectified.
References.—1. Cancer of the Uterus, J. E. Lane-Claypon, Reports on Public Health and Medical Subjects, No. 40, 1927. 2. The Radium Treatment of Cancer of the Uterus, Cancer Research Committee of the London Association of the Medical H. K. Lewis and Co., Ltd., 1926. Women’s Federation. 3. British Empire Cancer Campaign, Annual Report, 1927.
SCOTLAND. (FROM OUR OWN CORRESPONDENT.) SCOTTISH HOSPITAL POLICY. FUTURE relations between voluntary hospitals ami local authorities in Scotland are none too easy to define, but their course has been made clearer by Sir John Gilmour’s replies to a recent deputation from the Scottish Regional Committee of the British Hospitals Association. In introducing the deputa" tion, Colonel J. A. Roxburgh said that there was an estimated shortage of 3600 hospital beds in Scotland, and while the voluntary hospitals wanted to cooperate with the public authorities, they felt it necessary to have a lead from the Government on the- methods of cooperation, especially in view of the proposals for Poor-law reform. Colonel D. J. Mackintosh, for the deputation, then asked the following questions :-
(1) Is it proposed to establish hospital service in Scotland ? (2) If the answer is in the affirmative, would the statutory hospital service cover the whole field of medicine and would it work in competition with the voluntary hospitals ? (3) Who is to provide the necessary additional beds after the present building programmes of the voluntary hospitals
a unified -
completed ? (4) Will the voluntary hospitals and the public authorities work in cooperation round the voluntary hospitals as are
centres ? (5) Is it
hospitals, (6) Is
hospital
proposed to give financial aid to the voluntary recommended by the Mackenzie Committee ? there any need to establish a statutory general as
service ?
public disaster. Colonel Mackintosh were crippled in any way, but if the voluntary system was to be maintained in Scotland, a definite policy should now be declared so that there should be no competition and rivalry with the statutory authorities. Sir John Gilmour, in reply, assured him that the Government would do nothing inimical to the voluntary hospitals, whose position it would be very unwise It would be
a
said, if the voluntary hospitals
to disturb. He could not say what would be the future of the Poor-law system, but he thought that in any scheme it would be necessary to have larger units. Cooperative arrangements should centre round the voluntary hospitals, and he thought that the Poorlaw institutions should be brought up to their standard. Whilst the Government was anxious to avoid doing anything to harm the voluntary system, he could not promise financial assistance as the Treasury were finding it very hard to meet existing commitConclusion. ments. It was exceedingly difficult to enunciate a It has been conclusively proved that for the large common policy for the whole country, but already in majority of patients suffering from cancer of the Scotland some advance on cooperative lines had been cervix modern radium treatment can completely made in such places as Stirling, Falkirk, Aberdeen,. replace surgery and give equally good and long- and Glasgow. He suggested that the voluntary standing results ; the immediate risk of the radium hospitals should appoint a small committee to act treatment is practically nil. The lives of many women, !, as a link between the regional committees and his quite hopeless from the surgeon’s point of view, have I department. This might be very helpful in solving been saved for ten years and more. The treatment I regional difficulties. can often relieve distressing symptoms even when it The Position Considered. does not save life ; there is some evidence that it can fistula formation. the Probably hospitals will be disappointed with prevent The success of this treatment entirely depends the Secretary of State for Scotland’s reply to their upon the use of a scientific technique, and it requires six questions. But it is obvious that the answer to those questions depends on two main factorsa skilled gynaecologist specially trained in the work. Without this radium is often dangerous and is prac- namely, (1) public opinion about the proper use of the Poor-law hospitals, and (2) the necessity for a tically always useless as a means of saving life. Very few women in this country can obtain this large increase of beds in the voluntary hospitals if modern radium treatment, and many of our leading they are to meet the ever-increasing demand for .
.
Special Articles. RADIUM TREATMENT OF CANCER OF THE CERVIX. BY HELEN CHAMBERS, C.B.E., M.D. LOND., FULL-TIME INVESTIGATOR FOR THE MEDICAL RESEARCH COUNCIL.
It is an astonishing fact that in this country we much less advanced in the treatment of uterine Radium has cancer than certain foreign countries. only been used in England on scientific lines for the treatment of this disease since 1921, and in very few clinics only. Comparatively few of our hospitals carry out radium therapy at all for these cases; many possess no radium, and some which possess it have not enough to treat uterine cancer effectively. This is a deplorable state of affairs which urgently
are
needs THE recent report issued by the Ministry of Health1 on the results of treatment of cancer of the uterus is a matter of serious concern to all who are responsible for the treatment of patients suffering from this disease. The report is a statistical inquiry based on an analysis of the existing literature prior to March, 1926. It deals with the results of treatment of not less than 80,000 cases of uterine cancer and compares the results obtained by surgery with those obtained by radiology. Cancer of the body of the uterus is considered separately from cancer of the cervix, because the problems associated with the disease at these two sites are widely different. Radium treatment of cancer of the cervix has been in extensive use in foreign countries since 1913 and a vast literature has accumulated, dealing with over 5000 cases. During the period under review surgical technique has reached its limits, for the methods of operation have been standardised for many years. Radiological technique, on the other hand, has been largely in the experimental stage, and although great advances in technical methods have been made, the limits of these developments have not by any means been reached. The technical methods adopted in the radiological treatment of the cases under review have therefore on the whole been more elementary than those of surgery ; but, nevertheless, the results of radium compare very favourably. When the general results of these two methods of treatment of operable cancer of the cervix are compared they are found to be closely alike; there is, however, an important factor weighing against the surgical method, the relatively high operation mortality of 17 per cent. Compared with this radium has an immediate less than 1 per cent. When only mortality of inoperable cases, which are completely hopeless from the point of view of the surgeon, are considered, roughly 12-6 per cent. can be saved, for prolonged periods at any rate, by radium. This figure is based
rectifying.
The use of radium for the treatment of cancer of the cervix requires a skilled gynaecologist with an intimate knowledge of the disease and its pathology, and of the physical and biological properties of radium. Without this equipment it is impossible to treat the zone involved by the cancer with an effective dose of radiation. In this disease the use of radium has passed the experimental stage, although it is still in the transition period of a new form of treatment. The technique will doubtless be subject to great improvements as experience and knowledge increase. Certain known facts, however, largely determine the results. The object of this paper is to emphasise some of these essential points of technique.
General Method of Treatment. There is as yet no general agreement as to the best means of treating cancer of the cervix with radium. Many different methods are in use and they vary in the quantity of radium used, the dosage, and the method of distribution. When the earliest cases were treated very little was known about the range of action of radium tubes and applicators or their biological effects. The methods of treatment were largely empirical, and all treatment other than surgery was looked upon as a palliative measure. The clinician using radium in the early days only treated cases which were completely hopeless from the surgeon’s point of view, and looked upon a poor result as the inevitable and unavoidable consequence of the disease. The usual method was to insert a single tube applicator into the cervical canal or against the growth for a varying time, often for 24 hours. In the great majority of cases the extent of the growth was far wider than the range of action of the applicator, and in practice this treatment did little more than treat the surface of the disease. Temporary benefit, nevertheless, often followed. The case was then watched until definite signs of extension were evident, 1 on a five-year period. and the same treatment was then given again some These conclusions are a summary of the evidence two or three months later. It was usual to repeat produced by many different clinics, and they therefore the treatment as long as the patient was well enough have the special value that they are not subject to attend the out-patient clinic, usually for six or to the bias of any individual observer. When the nine months, and occasionally for several years. evidence is examined in detail the results are, of It is sincerely to be hoped that this method of treatcourse, found to vary widely with different clinicians ; ment will never again be carried out in England; they also vary with different countries, for some have there is complete proof that it invariably fails. It is advanced in technical methods much more than like cauterising the surface of a carcinoma and others. These facts mean that we have to advise hoping for success. patients suffering from cancer of the cervix (except In contrast with this treatment is the method perhaps in the very few cases* where the disease adopted when an attempt is made to cure the disease. has only reached its earliest stage), that if they obtain The range of action of the radium tubes and applicators modern radium treatment their prospect of life will and the approximate dose required to produce a be as good as if they submit to operation, and the lethal effect on cancer cells are known within limits. immediate risk of radium treatment is practically nil. The treatment is planned soon after the patient is Needless to say, no woman will submit to a severe first seen and the whole course of radiation carried surgical operation when she knows that this is true. out within a few weeks. The radiation is arranged But the soundness of this outlook clearly depends so that an effective dose reaches as widely as possible upon what is meant by modern radium treatment. in the region involved by the disease. If the growth We have no right to advise against competent recurs the treatment is recognised as having failed. surgery, even with its comparatively high death-rate, The conditions are now much less favourable for unless there is a reasonable prospect that the further treatment, as the growth has extended, to alternative radium treatment will be carried out a wider zone and the cancer cells may have acquired with all the skill and knowledge that science now tolerance to the radiation. If further treatment is possesses. The experience of the last 12 years has decided upon, it is clearly useless to give the same conclusively shown that radium therapy is a treatment again ; either a heavier dose of radiation specialised art which completely fails to save life must be given or the treatment must be applied unless the essential technical conditions for success to a different zone. For the benefit of subsequent are understood. cases the reason for the failure must be carefully * There are no data yet available for cases such as these sought, and the original technique critically examined to see if it can be improved. As a matter of fact, treated with radium.
I
1407 more radium applicators are placed near to each are now given that usually impossible to repeat the original treat- other, the adjoining tissue receives radiation from ment, and it is comparatively rare for the growth to them all, and the dose is then the sum total which recur at the zone treated. Any recurrence is usually reaches a given spot from every source of radiation. at the edges or beyond. Recurrence at the original This dose depends upon the amount of radium, its site generally means faulty distribution of the radium distribution inside the applicator, the distance it is away, the filtration, and the absorption of the or inadequate dosage.
such heavy doses of radiation it is
The success of radium treatment in cancer of the cervix depends upon the fact that for many months the disease is a local one. It involves a region which is accessible, and one to which a heavy dose of radiation can be safely applied if special precautions are taken. When the disease has spread widely to the deeper structures of the pelvis it is doubtful whether any form of radiological treatment can prevent the cancer cells from growing. It is a common but erroneous idea that it is possible to sterilise the whole of the pelvis. As a matter of fact, the dose of radiation required to kill cancer cells is so heavy that if it were applied to any large region of the body the patient would die. The treatment with heavy doses has therefore, to be limited to a comparatively small
tissues. effective action when
intervening m
raUIUIlJ.
2 shows the range of central tube containing 50 mg.
Fig. a
ele-
ment is placed in the uterine cavity, and three flat applicators, each containing 25 mg. of radium ele-
FIG. 2.
ment, are placed in the vaginal vault
for 48 hours. The size and shape of the cone vary with field. The most serious objection to radium therapy is the condition of that it fails to treat pelvic lymphatic glands. They the cervix, for are only involved, however, in about 37 per cent. of the size of this these cases at the time of death, and as the majority determines the of patients are first seen a year or 18 months earlier, plane in which it is reasonable to suppose that the greater number the flat appliof patients when first seen have no gland involvement cators can be at all. This is supported by the fact that many placed. It is at e obvious cases are alive and well ten years after radium once this treatment. The truth can only be determined by that statistics on a large number of cases. Clinicians state method of disthat they often find glands involved at operation, tribution offers Shows the zone of effective radiation but this is not convincing to a pathologist. It is a a much better when cross firing is obtained between common error, even after microscopic examination, prospect of an intra-uterine applicator and flat applicators in the vaginal vault. to mistake enlarged glands of long standing inflamma- treating carcinoma of the tion for glands involved with growth. cervix successfully than does the use of a single tube Distribution of the Radium. applicator. The distances of effective action from the The range of the effective action of radium tubes sources of radiation are based on experimental bioand applicators is so limited that the position in logical tests. I am indebted to Prof. Russ for adding the dotted lines to these diagrams, and to the Cancer wmcn tney are Research Committee, of the London Association of in relaplaced FIG. 1. tion to the the Medical Women’s Federation for allowing me to 2 growth and to reproduce them from their first report. each other One of the most important points is that the wider determines the this cone is made at its base, the greater will be the results. Fig. 1 prospect of saving the patient’s life ; it is therefore shows approxi- necessary to stretch the vault of the vagina to its mately the widest capacity. Clinicians find it far easier to insert effective range a small applicator than a large one, and they often of a tube appli- pack radium tubes closely to the cervix, with the cator contain- result that they obtain a more intense but smaller ing 50 mg. of cone of radiation, and the outlying parts of the growth radium element are ineffectively irradiated. The results are correplaced in the spondingly poor. At the Fondation Curie (Regaud), cavity of the although a somewhat different method is used, this uterus for 48 point is recognised. Two radium applicators are hours. This is attached to a spring which keeps them as far apart roughly an in the vault of the vagina as the space will allow. ellipsoid; its It is impossible in this paper to go into details of length, size, and the many other methods of distribution of the radium shape depend which are now employed at different clinics. A method upon the length very similar to that shown in Fig. 2 has been used in of the appli- Stockholm (Forssell Heyman) for the last 15 years, cator and on and a similar method has been used in Japan (Ikeda) the amount and since 1914 ; the results are some of the best on record. Shows the zone of effective radiation when distribution of This method has only been used in England since a single applicator containing radium tubes is inserted into the cavity of thethe radium. 1925 at two London clinics, and, as far as I know, uterus. The size in- it is not in use at the present time anywhere else in creases with this country. The largest number of cases treated longer exposures, but only to a very small extent. by this method and recorded in our own literature When this ellipsoid is compared with the zone usually have been treated under the auspices of the Cancer involved by a carcinoma, it is evident that a single Research Committee of the London Association of tube, however placed, can only rarely, if ever, treat the Medical Women’s Federation. They report 3 the whole region affected. Single tube applicators 117 cases with no death directly due to the treatment. have now been universally discarded in modern Fifty per cent. of their cases treated more than a year methods of technique. ago are stated to be free from signs and symptoms It is therefore essential to use multiple sources of cancer ; the percentage operability of these cases of radiation at the site of the growth. When two or was not more than 15 per cent. These results are too
I
1408 recent to justify conclusions as to the ultimate value of the method, but as far as they go they agree with the foreign reports and compare very favourably with the results at those clinics which report 70 per cent. of cases as having died within a year of the patients first being seen.
Dosaye. The question of dosage is as important as the method of distribution. All clinics recognise that their early work was done with inadequate doses. Radium was known to be dangerous and the At the clinician naturally used it with caution. present time it is possible to rely on wide clinical experience and scientific technique, and there is no longer any excuse for using small doses which It is customary to are known to be ineffective. describe the dosage in terms of milligramme element hours. Although this is a convenient method it gives no real information unless the amount of radium and the position in which it is placed and the time during which the treatment is carried out are stated. It is impossible to add together all the doses given over a period of several months, as is often done, and look upon this figure as truly representing the dose. The most suitable dose of radium needed to cause the death of all the cancer cells, and the time in which this should be given, is still a matter for research. Most authorities are agreed that 7000 m.e. hours can be given safely without serious after consequences. The time varies in different clinics ; some give the whole treatment in five or six days, others spread it over two or three weeks. There are a few cases on record which are alive and well ten years after treatment with 3000 m.e. hours, but it is almost certain that the clinics which reduce their routine dosage to this amount also reduce the percentage of their successful results. The object of the treatment is to give, as far as possible, a uniform radiation to the whole region involved by the disease and only to give just enough to prevent the cancer cells from living. If this is achieved the connective and epithelial tissues which ultimately replace the growth are not seriously
damaged..
General Technique. In this very short account of an intricate subject it is impossible to consider many important details. For example, the failure to pack off a radium applicator and to appreciate its range of most intense action may result in the normal bladder or rectal mucous membrane receiving an intense exposure ; long-standing and distressing symptoms and fistula If the bacterial infection which is so may result. commonly associated with this type of case is not treated, the insertion of the radium tubes may set up an acute pelvic abscess. Many of the immediate deaths are due to this. A uterus involved with soft friable growth with an orifice difficult to find can easily be punctured by inserting radium. All these risks, which are very real, become practically negligible in the hands of a competent clinician trained in this very specialised field of work.
providing
are entirely without the facilities for it. With extended knowledge it is to be hoped that this state of affairs will very soon be
hospitals
rectified.
References.—1. Cancer of the Uterus, J. E. Lane-Claypon, Reports on Public Health and Medical Subjects, No. 40, 1927. 2. The Radium Treatment of Cancer of the Uterus, Cancer Research Committee of the London Association of the Medical H. K. Lewis and Co., Ltd., 1926. Women’s Federation. 3. British Empire Cancer Campaign, Annual Report, 1927.
SCOTLAND. (FROM OUR OWN CORRESPONDENT.) SCOTTISH HOSPITAL POLICY. FUTURE relations between voluntary hospitals ami local authorities in Scotland are none too easy to define, but their course has been made clearer by Sir John Gilmour’s replies to a recent deputation from the Scottish Regional Committee of the British Hospitals Association. In introducing the deputa" tion, Colonel J. A. Roxburgh said that there was an estimated shortage of 3600 hospital beds in Scotland, and while the voluntary hospitals wanted to cooperate with the public authorities, they felt it necessary to have a lead from the Government on the- methods of cooperation, especially in view of the proposals for Poor-law reform. Colonel D. J. Mackintosh, for the deputation, then asked the following questions :-
(1) Is it proposed to establish hospital service in Scotland ? (2) If the answer is in the affirmative, would the statutory hospital service cover the whole field of medicine and would it work in competition with the voluntary hospitals ? (3) Who is to provide the necessary additional beds after the present building programmes of the voluntary hospitals
a unified -
completed ? (4) Will the voluntary hospitals and the public authorities work in cooperation round the voluntary hospitals as are
centres ? (5) Is it
hospitals, (6) Is
hospital
proposed to give financial aid to the voluntary recommended by the Mackenzie Committee ? there any need to establish a statutory general as
service ?
public disaster. Colonel Mackintosh were crippled in any way, but if the voluntary system was to be maintained in Scotland, a definite policy should now be declared so that there should be no competition and rivalry with the statutory authorities. Sir John Gilmour, in reply, assured him that the Government would do nothing inimical to the voluntary hospitals, whose position it would be very unwise It would be
a
said, if the voluntary hospitals
to disturb. He could not say what would be the future of the Poor-law system, but he thought that in any scheme it would be necessary to have larger units. Cooperative arrangements should centre round the voluntary hospitals, and he thought that the Poorlaw institutions should be brought up to their standard. Whilst the Government was anxious to avoid doing anything to harm the voluntary system, he could not promise financial assistance as the Treasury were finding it very hard to meet existing commitConclusion. ments. It was exceedingly difficult to enunciate a It has been conclusively proved that for the large common policy for the whole country, but already in majority of patients suffering from cancer of the Scotland some advance on cooperative lines had been cervix modern radium treatment can completely made in such places as Stirling, Falkirk, Aberdeen,. replace surgery and give equally good and long- and Glasgow. He suggested that the voluntary standing results ; the immediate risk of the radium hospitals should appoint a small committee to act treatment is practically nil. The lives of many women, !, as a link between the regional committees and his quite hopeless from the surgeon’s point of view, have I department. This might be very helpful in solving been saved for ten years and more. The treatment I regional difficulties. can often relieve distressing symptoms even when it The Position Considered. does not save life ; there is some evidence that it can fistula formation. the Probably hospitals will be disappointed with prevent The success of this treatment entirely depends the Secretary of State for Scotland’s reply to their upon the use of a scientific technique, and it requires six questions. But it is obvious that the answer to those questions depends on two main factorsa skilled gynaecologist specially trained in the work. Without this radium is often dangerous and is prac- namely, (1) public opinion about the proper use of the Poor-law hospitals, and (2) the necessity for a tically always useless as a means of saving life. Very few women in this country can obtain this large increase of beds in the voluntary hospitals if modern radium treatment, and many of our leading they are to meet the ever-increasing demand for .
.