Deep roentgen-ray and radium therapy in malignant disease of the genitourinary tract

NEW

SERIES,

FEBRUARl’,

VOL. II

No.

192-

DEEP ROENTGENHRAY AND RADIUM

THERAPY

2

IN

MALIGNANT DISEASE OF THE GENITOURINARY TRACT* HUGH

H. YOUNG,

M.D.,

F.A.C.S.,

AND CHARLES

RALTIMORE,

LTHOUGH the literature on this subject is quite extensive, no recent articIes have appeared deaIing in a comprehensive wa>A with the various advances that have been made in the use of deep roentgen-ray and radium therapy in the fieId of

A. WATERS,

M.D.

hiD.

based, the therapeutic effects, the technique to be empIoyed and the resuIts that may be expected. We reaIize that the instruments described wiI1 in a11 probability be repIaced by others more perfect in the near future, but much progress has reaIIy been made in the standardization of instruments, tech-

5 cm.

FIG.

I.

Glasser’s isodoses chart with porta of entry 20 by 20 cm. Note that at a distance of 10 cm. below face the absorption is about 42 per cent.

SUP

uroIogy. W’e h ave attempted to present nique and results. We shall, therefore, here a compIete discussion of the subject, attempt to set out here as brieff y as po.ssibIe the scientific principIes upon which it is the present status of this new field of therapy. * From the James Buchanan Brady Urologica Institute, Johns Hopkins HospitaI. 101

102

American Journal of Surgery

Young and Waters-G.-U.

Radiotherapy

FEBRUARY,192,

Oem

FIG. 2. Glasser’s

isodoses

chart with portal of entry IO X 15 cm. Note that at a distance surface the absorption is about 36 per cent.

FIG. 3. Bachem Ziehn iontoquantimeter. (For a compkte and fuI1 description of this instrument, see Albert Bachem’s “Principles of X-ray and Radium Dosage,” Chicago, 1923, p. 78.)

of IO cm. below

FIG. 4. Bachem Ziehn eIectroscope. (For a fuII description, see Albert Bachem’s “Principles of X-ray and Radium Dosage,” p. 74.)

FIGS. 5 and 6. Two views of the Seeman spectroscope. A good description of this instrument Hirsch’s “PrincipIes and Practice of Roentgen Therapy,” N. Y., 1925, p. 137.

wiII be found in

NewseriesVOL.II. NO. z DEEP

Young and Waters-G.-U.

ROENTGEN-RAY

THERAPY

Not unti1 the work of Kroenig and Friedrichl and the subsequent work of GIasser, Korner, Bender and Huth couId deep roentgen-ray therapy be administered with comparative safety. Many other investigators have contributed invaIuabIe information upon the subject-Dessauer, HoIfeIder, Siemen, Duane, SoIomon, Wood, FaiIIa, Glasser, Wintz, Bachem, Seitz, Fuerstenaue, Gauss, and many others. Any method that is adopted to give roentgen-ray treatments must be subjected to repeated tests. Up to the advent of the so-caIIed deep radiation, the dosage was expressed in terms of the degree of skin erythema, and whiIe this stiI1 hoIds true to a certain degree, it aIone is not the important guide to the correct dosage. To arrive at the correct dosage, two physical factors of the roentgen-ray tube and machines must be determined, nameIy, quaIity and quantity. We shaI1 not discuss v

FIG. 8. Anatomica

American

JOW~I

OT

surgery 103

For our measurements we empIoy .ed the iontoquantimeter of Bachem Ziehn, t:he

-

cross-section

FIG. 7. Friedrich’s water phantom for measuring absorption at different Ievels of water.

Bachem Ziehn electroscope man spectrograph.

the

and the See-

and contour chart of the human trunk through the kidney, which we have empIoyed in estimating our doses.

the physics of these important factors, as the numerous textbooks and articIes deaIing with this phase of radiation therapy cIearIy espIain these points. 1Die Physikalischen der StrahIentherapie.

Radiotherapy

und BioIogischen

Grundlagen

ISODOSES

CHARTS

Isodoses charts (GIasser), shown in Figures I and 2, represent the amount of radiation absorbed in the tissues at various IeveIs. With the instruments above described, nameIy, the iontoquantimeter

104

American journalofsurgeryYoung and Waters-G.-U.

Radiotherapy

FEBRUARY, 192,

blaider

_ re

FIG. g. Anatomical

cross-section

and contour

FIG. IO. Obstetrica caIipers which are used in conjunction with Iead strips for outIining shape of body in the region to be treated.

(Fig. 3), ‘the eIectroscope (Fig. 4) and the spectroscope (Figs. 5 and 6), the

chart of the human trunk through the bladder.

quaIity and quantity of roentgen radiation can be accurateIy determined at different IeveIs of the body. For our measurements, we have empIoyed a water phantom (Fig. 7). Knowing the voItage generated and passed through the tube, the unknown factors, hardness and quantity, can readiIy be computed. These conditions are then put down in the form of charts, as shown in Figures I and 2. These charts show the intensities at various centimeter IeveIs in the body, using various types of radiation, different size portaIs of entry and fiIters of varying thickness. Technique of Application. After ascertaining the above-mentioned factors and in order to give accurateIy a series of deep roentgen-ray treatments, one must go a step further and appIy the isodoses charts to the patients to be treated. For this purpose, contour and crosssection charts of the body must be used (Figs. 8 and 9). With the assistance of caIipers, ffexible Iead strips (Fig. IO) and centimeter-ruIed charts, the Iocation and extent of the Iesion must be determined and outIined on these charts.

New

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No.

2

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American Journal O( SWWY

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103

FIG. I 1. Shows the isodoses curves drawn onto the cross-section anatomical charts. We have indicated by bIack dots the areas where the dosage is to be computed. Comparing these superimposed charts with the original cross-section drawings, one can easily obtain a cIear idea of the areas treated. The radiation is directed through the front in this chart.

ti

i i ii

i t

rllllltiliiiillliliiiliiiiiliiiiiiii 12. Shows the isodoses curves drawn onto the same cross-section charts when the treatments are given over the sacrum. One can easily see at a gIance that the anterior bIadder waI1 now only receives about 22 per cent, whereas when treated through the front it received over 75 per cent.

FIG.

106

A m&can

II

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III

III

of Surgery

Young and Waters-G.-U.

Radiotherapy

,,

-_ I II1 ,,I,,

I

FEBRUARY, 192,

,

I

I

I

Young and Waters-G.-U.

New Series VOL. II, No. 2

Using this method, we have attempted to give tumors of the bIadder, carcinoma of the prostate, renaI neoplasm, and testicuIar tumors with abdomina1 metastasis a depth dose of 130 per cent. In Figures II, 12, I 3 and 14 are shown a combination of isodoses charts, superimposed upon anatomica cross-section charts through the bIadder on centimeter-ruled sheets. One can see at a gIance that by giving a fuII erythema dose over the front, a depth dose at IO cm. of about 42 per cent is obtained. By giving the same technique through the back and both sides it is possibIe to give 135 per cent to a given spot. TABLE TIIE

AMOUNT

OF

INFILTRATING

RADIATION

A GIVEN

PAPILLARY

IN

CARCINOMA

A

CASE OF

OF

THE

AN

Radiotherapy

American

TABLE THE

AMOUNT

OF

RADIATION RENAL

PortaIs of Entry

I

JOUXUII of SWW

IO7

B GIVEN

IN

THE

CASE

OF

A

NEOPLASU

Treated Areas in Different Sections of Tumors :__----.----;-

EmpIoying: 200 kv. (peak), 4 ma., I mm. Cu and mm. AI. F.S.D. 50 cm. Time Factors: 135 minutes with 20 X 20 cm. size of fieId. 140 minutes with IO X 15 cm. size of fieId.

Table B shows a simiIar method for recording the amount of radiation given in Treated Areas in Different Sections renaI neopIasms. PortaIs of Entry o!Tumo%~.~_ TabIes c, D, E and F show the method by which the deep roentgen-ray treatments are recorded from day to day in a case of 20 X zo cm. front.. , . .’ 78i 601 601 421 49 28 bIadder tumor. Note that the time factors, 20 X 20 cm. back.. .I 221 30, 301 42’ 371 65 voltage, fiItration, etc., are put down each z X 15 cm. right side. _. _. I 17m81 22 I?: _ZZ day in order to avoid any possibIe error IO X 15 cm. left side. . .T. .) 17’ 25; 13 2o/ 30 _..~301~‘__~ by giving too many treatments. TotaI ..,. . . . . . _, :. 1341130 13I’r261rzgjr35 Complications. One of the most serious Employing: 20 kv. (peak), 4 ma., I mm. Cu and compIications in deep roentgen-ray therapy I mm. AI. F.s.D.~~o cm. is a burn, but by empIoying the above Time Factors: 135 minutes with 20 X 20 cm. size of technique we have been very successfu1 field. 140 minutes with IO X 15 cm. size of in giving this Iarge dosage without profield. ducing a marked burn with necrosis. Table A shows the amount of radiation Notwithstanding that with the abovegiven in a case of carcinoma of the bIadder described method a burn of the skin wiI1 through four port& of entry, the size of not be produced, in a certain number of which is indicated. As shown here, the instances IocaI and systemic reactions, amount of radiation deIivered in the spot which at times reach Iarge proportions, indicated by Star I is 73 per cent through wiI1 Occur. the anterior, 23. per cent through the It is a weII-known fact that when a posterior, 20 per cent through the right patient is exposed to a series of roentgenside, and 20 per cent through the Ieft side, ray treatments a cumuIative effect is prototaling 137 per cent. Similar figures are duced, and this shouId be cIoseIy watched indicated for other spots indicated by the for by the uroIogist and roentgenoIogist. six stars shown on the cross-section chart. It has seemed to us that the cumulative By means of this chart one knows at the effect of roentgen rays upon a patient end of treatment exactIy how much dosage occurs in direct proportion to his debihhas been given to a given spot. Every effort tation. Thus, an oId man with a papiIIary is made to deliver between 130 and 140 carcinoma of the bIadder, greatIy per cent. debihtated from Iong-continued suffering, BLADDER

METHOD

F.

_____

___~_._

Remarks_._____

posterior

Carcinoma

DEEP

c

1N A

OF

wall

the

Johns

inVOIving

PIdd.est ___ right

HopkinD orfflos.

229

RECORDED

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ARE

ureteral

TUMOR

TREATMENTS BLADDER

_-_---_~,.___~

CASE

ROENTGEN-RAY

TABLE

bladder

DAY

Y.

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N.

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THE

Dr. aUgh Ii. Young,

Buffalo,

Xrha. T.

DAY

WHICH

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ureteral

orifice.

N02%L_

ARE

Hor&iins Hosoital.

60

TUMOR

TREATMENTS BLADDER

involving

Address

CASE

ROENTGEN-RAY

TABLE

bladder

DAY

THE DEEP

posteiior

N.

DAY

WHICH

FROM

BY

Buffalo,

Mrs.

METHOD

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Name

THE

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E

A

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TABLE

IN

_

DEEP

D.T.

BLADDER

D.T.

TUMOR

TREATMENTS

ARE

I

D.T.

RECORDED TO

THE

posterior

DAY

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METHOD

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wall

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TUMOR

TREATMENTS BLADDER

involving

CASE

ROEXTGEN-RAY

‘rAAuLE

bladder

DAY

DEEP

orifice.

RECORDED

I IO

American

Journal

of Surgery

Young and Waters-G.-U.

Radiotherapy

FEBRUARY, 191,

requires more carefuI watching during the course of his deep roentgen-ray therapy than wouId a younger and stronger man.

recta1 burning and tenesmus. Repeated examinations of the bIood shouId be made to determine the effect upon the white

Among the earIiest symptoms of radiation intoxication may be mentioned diarrhea, nausea, vomiting, prostration,

bIood corpuscIe count, in particuIar, though counts of the red bIood ceIIs .and hemogIobin estimations should aIso be made.

New Series VOL. II, No. z

Young and Waters-G.-U.

The number of white blood ceIIs is reduced much more rapidIy foIIowing radiation than is that of the red ceIIs. It is rareIy safe to treat a patient further when his white count has faIlen beIow 4000.

The necessity for carefu1 and cIose cooperation of the uroIogist with the roentgenologist is, therefore, obvious. Many of the i&effects couId be avoided if the roentgen-ray treatments were more cIoseIy observed by the roentgenoIogist and the uroIogist and not Ieft so IargeIy to mere technicians. Despite the disturbing reactions that are not whoIIy avoidabIe, the reIief afforded to two symptoms of bIadder carcinoma, nameIy, root pains and hematuria, justify the treatment. It is rare that, even when no other benefit is obtainabIe, these two distressing symptoms fai1 of rehef with roentgen-ray therapy. Roentgen-ray Treatment of Renal Neoplasm. The results in deep roentgen-ray therapy are based on the treatment of 20 cases, divided as foIIows: hypernephroma without metastasis, I5 cases; hypernephroma with metastasis, 5 cases. After radica1 operation for hypernephroma, we have given a dose of 130 per cent around the perirenal fat, adjacent glands and through the Iower mediastinum. It has been our experience that metastases from hypernephroma more frequentIy occur in the chest than any other pIace; yet in some of our cases we have found metastasis in the bones, especiaIIy near the entrance of the nutrient vesse1. The humeri seem to be particularly prone to this type of metastasis. In severa cases in which radical remova was thought impossibIe or inadvisabIe, we radiated the kidney region first with the hope that by shrinking or partIy destroying the tumor, radica1 remova might be possibIe Later, with the resuIt that in every instance at Ieast a great diminution in the size of the tumor was noted. One patient Iived two years. There were no symptoms of a recurrence,

Radiotherapy

American Journal of Surgay

I I I

and no paIpabIe mass was to be made out. Pain, probabIy due to pressure, is often greatIy benefited in this group of cases. Bladder tumors. So far we have treated 130 cases of bladder tumors with deep roentgen-radiation. These cases are divided as foIIows: papiIIomas, benign and maiignant; non-infiltrating papiIIary carcinomas, and infiltrating carcinomas, superficial and deep. By a combination of fulguration with the intravesical application of radium to the surface of tumors, on the one hand, and by destruction of the carcinoma with the cautery after suprapubic incision, on the other hand, about 75 per cent of tumors can be destroyed. This Ieaves about 25 per cent of hopeless tumors that occupy positions that render them inoperabIe or involve such extensive areas of the bladder waI1 that neither surgery nor intravesicai radium treatments offer any chance of success. It is quite cIear that there still remain many cases unsuitabIe for fuIguration, for intravesica1 radium treatments, for resection or for treatment with radium needIes. By the combination of radium with roentgen-ray treatment, as above outIined, many of these tumors can be destroyed with a minimum amount of damage to the bIadder, and in many instances with but IittIe or no irritation of the bladder mucosa. When the growth is an infiItrating carcinoma, but stiI1 opersbIe, we beIieve that radical resection shouId be carried out, since it offers the greatest chance of complete cure. Twenty-five per cent of the SiItrating growths in our series occupy a position that renders them inoperable, or they are so extensive that radicai remova is impossible. In this group, when it is possible to apply radium directIy to the growth, both radium and deep roentgen-ray treatments should be given a tria1, for in a certain number of the cases favorabIe resuIts can be obtained by this method alone. But in cases in which this procedure does not yieId the resuIts hoped for or in cases in

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American Journal of Surgery

Young and Waters-G.-U.

Radiotherapy

FEBRUARY, 192,

FIG. 17. E. W. C., aged seventy-three.

This patient came to the hospital in May, 1923, complaining of frequency and bIeeding. Cystoscopic examination reveaIed a Iarge papiIIary carcinoma as shown in drawing A. He was given a 130 per cent dose of roentgen rays aIong with 800 mg.-hr. radium intravesicaIIy. The tumor promptly responded to radiation and in ten days’ time was found to be made up of four separate tumors, as shown in drawing B, which had superfkiaIIy fused. Drawing c shows the condition of the tumor when the patient was discharged, with the understanding that he was to report for observation in one month. This patient ako has a tumor transpIant in the posterior urethra, as shown in the iIIustration. The patient did not return for examination, but was still alive in May, 1926, three years after treatment.

FIG. 18. P. G., B.U.I.

12003, aged sixty-two years, married, admitted December 13, 1923, compIaining of hematuria of six months’ duration. Prostate was indurated on the right side. Cystoscope showed Iarge, globular, uIcerated, infiItrating carcinoma of right haIf of trigone, invoIving prostatic orifice. Patient was treated by radium appIications through the bIadder and through the rectum, 1400 mg.-hr. He aIso received deep roentgen-ray therapy. UItimate resuIt: tumor compIeteIy disappeared and aIso infiItration of prostate. Cystoscopy showed no tumor present. Two years Iater patient died of metastases.

which one feeIs that the growth is sufficient Iocalized to warrant impIantations

Iy

of

radium needIes, the bIadder shouId be suprapubicaIIy opened and screened radium needIes shouId be impIanted throughout the tumor. Within the past few years, diathermy has been used in a number of clinics. Our experience with this form of therapy is too recent to warrant any definite concIusions. FinalIy, the great tendency to recurrence of tumors of the bIadder, foIIowing their apparent destruction, either by fuIguration, radiation or deep roentgen-ray treatment, makes it imperative that patients return at frequent intervaIs for cystoscopic examinations. In a number of our cases, in which recurrences uItimately resuIted in death, compIete cures might we11 have been obtained had these individuaIs returned reguIarIy for observation and treatment before the recurrences had become too extensive. In a few cases, where the patients have returned for observation, when found, have recurrences, the responded we11 to radium aIone. This is especiaIIy true of the non-infiItrating papiIEven in cases that are Iary carcinomas. incurabIe, regardIess of the therapy deep roent,gen-ray treatment empIoyed,

New Series

VOL. Il. No. 2

Young and Waters--G.-U.

is an cxcehent pahiative measure, in that it tends to control hemorrhages and to decrease nerve root pains. IIIustrative cases are appended (see I 7-20). The histories have been Figs. stated briefly in the Iegends. As indicated in these legends, in a11 these cases the results of combined radium and deep roentgen-ray therapy have been compIete remova of the tumor mass. In some cases there has resulted apparent cure, the

FIG. rg.

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113

enIargement, and to obtain relief from obstruction and other symptoms by means of deep roentgen-ray therapy and radium treatment. A very few encouraging reports have been made. Young reported a case of prostatic hypertrophy in a man with very severe calfd;ac disease where use of radium and deep roent.gen-ray therapy caused shrinkage of the gland to such smal1 dimensions that it was possible, by means of the punch operation, to remove the

FIG. 20.

FIG. 19. Mrs.

I. M. F., B.U.I. 1x984, aged sixty years, married, admitted September rg, 1923, with history of frematuria for three years. Cystoscopy showed Iarge, infiltrating, papiIIary carcinoma of right half of bIadder, involving region of right ureter. On vaginal examination marked infibration of the vagina was made out. Patient was treated by intravesicaI appIications of radium and received goo mg.-hr. She aIso received deep roentgen-ray therapy, 130 per cent. The resuIt of this treatment was compIete disappearance of the tumor, and infiItration and induration between vagina and bIadder disappeared. SubsequentIy suprapubic cystostomy was done for ulcer of bladder; scrapings were removed. Microscopic examination showed no carcinoma. Report by Ietter aImost three years Iater states that patient is entireIy we11 and that urination is normaI. FIG. 20. B. U. I. I 1966. L. T. H., aged sixty-one years. Cystoscopic examination in December, 1923, reveaIs the above findings, namely, a large papiIIary, infiItrating carcinoma invoIving the right side of the bIadder and right ureter with induration into the vagina. This patient was given 700 mg.-hr. of radium through the urethra, IOO mg.-hr. per vagina and 130 per cent deep roentgen dose without producing any change in the tumor whatsoever. ‘Vl’hilethis case is aImost identical with that shown in Figure 19, both women, both practically the same age, tumors of the same type, Iocation and size, one was cured and the other not affected.

patient being still ahve; in others the tumor has been destroyed, but the presence of uIcer makes it impossible to say whether this is due simpIy to treatment or indicates persistence of the maIignant disease. In al1 cases, however, marked benefit has resuhed from the treatment. Benign Prostatic Hvpertr0ph.y. There are many cases in which operative treatment of prostatic hypertrophy is attended with so much risk that many attempts hax~e been made to cause shrinkage of the

obstruction and reIieve the frequency of urination. In other cases the treatment has been compIeteIy unsatisfactory in our hands, and the consensus of opinion now is that roentgen-ray therapy is of IittIe or no value in prostatic hypertrophy. Hematuria is often wonderfuhy affected, and not infrequentIy one appIication of radium to the urethra or one exposure to deep roentgen rays 41 cause cessation of the bIeeding. Carcinoma oj the Prostate. As stated

I 14

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eLsewhere, the pIan foIIowed in the treatment of carcinoma of the prostate has been as foIIows: I, radica1 operation when there was a chance of a cure; 2, appIication of radium to the prostate through perinea1 or suprapubic wounds in cases where the chance of cure by this method seemed possibIe; 3, appIication of radium through the rectum to prostate, semina1 vesicIes and peIvic gIands; through the urethra to the periurethral prostate; 4, through the bIadder, by means of an appIicator passed through the urethra, the beak containing radium being heId firmIy against the trigone so as to radiate the region invoIved above the prostate; 5, conservative perineal prostatectomy, if the previous method (4) did not reIieve obstruction or pain or hemorrhage. For a11 types of cases deep roentgen-ray therapy has been empIoyed, appIied through portaIs 20 X 20 cm. in front, in back, and 15 j< 15 cm. through the region of the right and Ieft sides. SimiIar therapy is aIso appIied to the spine where there is evidence of metastases or where pain suggests metastases. The resuIts of these combined methods have been remarkabIy satisfactory in many cases, even where the disease was so extensive, and the symptoms of obstruction, hematuria and pain so pronounced that they seemed hopeIess. By the use of radium and roentgen ray very great enIargement of carcinomatous infiItration of the prostate and vesicIes diminishes so greatIy that examination a few months Iater wiI1 often revea1 a condition not at a11 suggesting carcinoma. In fact, we have not infrequentIy seen the prostate return to practicaIIy normaI size and consistence. The cessation of hemorrhage is often immediate and deep-seated pain of a very severe character Iocated in the spine, hips, thighs and Iegs, and due to metastases in the spine and peIvis, generaIIy disappears aImost compIeteIy. We have records of 122 cases in which deep roentgen-ray therapy was empIoyed, and whiIe we have very few cases in which cures can be cIaimed, we have a great number in which the

Radiotherapy

FEBRUARY, 1917

patient was reIieved of severe symptoms, and in many instances passed the remainder of his days in comparative comfort. Sarcoma of the Prostate. In two cases sarcoma of the prostate, characterized by huge retrovesica1 tumor masses, has disappeared compIeteIy with a combination of IocaI appIications of radium through the rectum and urethra, and deep roentgenray therapy. One of these cases has been foIlowed for seven years, and the other three years. Th e resuIts obtained are, indeed, quite remarkable. Tumors of the Testicle. In our series of cases treated with deep roentgen-ray therapy, there are 12 which were diagnosed as foIIows: carcinoma, I ; sarcoma, I; teratoma, IO. Of these 12 cases, 4 showed demonstrabIe roentgen-ray evidences of metastasis in the Iungs. AI1 of these are dead. Tw.o had metastasis in the gIands, inguina1 and aortic, at the time of operation. Both patients received a fuI1 course of deep roentgen-ray therapy and are Iiving at this time, one two years, the other one year after operation. The remaining six patients in which roentgenograms showed no metastases a.re stiI1 Iiving and free of metast.asis, one for six years. In a11 of these cases, with but one exception, deep roentgen-ray therapy was administered over the abdominal and thoracic aortic gIands, the exception being the first case treated in which the oIder ten-inch type of therapy was empIoyed. As soon as the patient has suffIcientIy recovered from the effects of theoperation, radiation is started. A depth dose of 130 per cent is given, and is repeated every three months. In one case four series of treatments were given during a period of fifteen months. Repeated observation as to the condition of the bIood must be made in order to prevent the deveIopment of an apIastic anemia, for which Iittle can be done. Carcinoma of the Penis. In this group are 9 cases: 7 without demonstrabIe metastases at the time treatment was Instituted; 2 with metastases.

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I 15

In perirena1 and retroperitonea1 tumors, which are generaIIy of a sarcomatous character, the use of radium and deep roentgen-ray therapy is often of great value. We know of one case in which an extensive mass, which had been seen at operation and found to he a huge retroperitonea1 perirena1 tumor, was treated by roentgen-ray therapy with complete cure. Th e patrent ’ has now been folIowed for ten years. Other cases of this RADIUM THERAPY type in which roentgen-ray therapy has (In conjunction with roentgen rays or been successfu1 are to be found in the Iiteraalone) ture. Roentgen-ray therapy may be tried in the huge tumors of infancy and chiIdThe Kidney and Ureter. As remarked elsewhere, rahica1 operative therapy is the hood, but so far the results obtained method of choice. The tumor shouId be have not been satisfactory, as these tumors removed as thoroughIy as possibIe and in seem not to be affected by either raditim the case of kidney tumors, the perirena1 fat, or roentgen ray. Bhdder. Radium particuIarIy has been adjacent gIands and sometimes the adrena very effective in the treatment of bladder gland shouId be extirpated. Where the tumor extends into the ureter, this shouId tumors and is of great assistance in both be removed to an extent sufEcient to be benign and maIignant growths. Paschkis was apparentIy the first to construct a certain that the operation is compIete. After such radica1 procedure our statiscvstoscopic radium appIicator, the descriptron of which he pubIished in 191 I. This tics seem to prove that deep therapy, either with roentgen rays or radium, is instrument was first brought to our notice indicated, even though the operation has in a pubIication by Thomas in 1913. It apparentIy been successfu1 in removing consisted of a straight cystoscope around the entire growth and no metastases are which there was a sheath having a curved shown on roentgen-ray fiIms. beak provided with a screw top in which Where it is found at operation that it is the radium was conceaIed. No provision impossibIe to remove a11 of the maIignant was made for hoIding this instrument in tissue, the insertion of radium needIes, any fixed position in the bIadder. Since the emanation points, or masses of radium first brief report no other record is to be eIement shouId be considered. If the veins found of the use of this instrument, by the of the pedicIe are deepIy invoIved, if the inventor or others. vena cava contains tumor growths or if In 1913 Pasteau and Degrais reported the carcinomatous infiltration is so cIose (to the 1913 Congress of Medicine in to the great vesseIs that the use of radium London) cases of cancer of the prostate and might be dangerous for fear of causing bIadder in which truIy striking resuIts had necrosis and hemorrhage, radium shouId been obtained by simpIy introducing not be used. radium through a Coud6 gum catheter into With due care, radium may be inserted the bIadder or prostatic urethra for an into the carcinomatous infiItration in the hour. On our return from the Congress we region of the vascuIar pedicIe with com- procured IOO miXgrams of radium and parative safety, and we have empIoyed introduced it in the way they had done. it in severa cases. We must admit, how- We soon found that it was impossibIe to ever, that the resuIts obtained have not appIy the radium with any accuracy, and been satisfactory. we then set about to devise a cystoscopic

AI1 of these cases were vigorousIy treated with radium appIied IocaIIy to the growth, and deep roentgen radiation, 130 per cent, given to the deep inguina1 gIands and base of the penis. The resuIts in this group have been very discouraging, and a11the patients are dead. One Iived one year and then died of metastasis in the abdominal gIands.

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instrument using our No. 13 straight cystoscope which we had empIoyed for severa years in our cystoscopic rongeur. With our simpIe cystoscopic applicator and the paraIleIogram instrument, a11 forms of vesica1 tumors can be treated with massive doses of radium under direction of the cystoscope, through the unopened bIadder and generaIIy very effectively. The most important and entireIy new idea in the employment of the instrument is the use of the cIamp by means of which the radium is heId directIy against the desired part of the tumor during the period of treatment, usuaIIy for an hour.

FIG. 21. New radium appkator mems. of radium each. which at;achabIe shaft (B). ’

with mav*

enIarged be used

cap aIso

We soon found it desirabIe to make applications of radium per rectum, and while the simpIe cystoscopic applicator with the obturator in pIace of the cystoscope may be empIoyed for this purpose, we soon found it advantageous to have a smaIIer instrument not carrying a cystoscope (Fig. 21). Where the vesica1 tumor is Iocated on the base of the bIadder we usuaIIy make appIications of radium to the region of the tumor through the rectum. The Iine of Iymphatic extension is aIso treated. The radium treatment is usuaIIy combined with fuIguration and in this way more rapid destruction of the tumor is brought about. Since the pubIication of the report on this radium cystoscopic apphcator, descriptions of other instruments have appeared in the journaIs, severa of which are aImost identica1 with our instrument No. I. The designers, however, have not seen the importance of fixing the instrument by a cIamp to the tabIe, thus omitting

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the part of the procedure which we consider most important. Hinman presented an appIicator which could be used with the posterior cystourethroscope. Barringer, Buerger and others presented simiIar instruments for appIying radium upon and introducing it into the substance of vesica1 tumors with needles. In 1915, KeIIy and his associates began to empIoy radium in the treatment of bIadder tumors through his air endoscope, and in 1917 we treated a woman with a Iarge carcinoma of the trigone, through our urethroscope, implanting radium emanations with very effective resuIts. In 1922

(A),

for

made to contain needIing through

four needIes containing rz.3 the perineum by means of

NeiII presented an exceIIent instrument for introducing the emanation of radium in glass “seeds” into tumors of the bIadder through the KeIIy cystoscope, and more recent1.y Muir has devised an ingenious radium emanation introducer which is provided with a slot which greatIy faciIitates the introduction of the emanation seeds. Radium has aIso been appIied to bIadder tumors through suprapubic wounds. By this method masses of radium have been pIaced against the tumor, smaIler amounts have been introduced in the form of needIes, and seeds with emanation have been Ieft buried in the tumor mass. It was soon found that very smaII doses wouId have to be empIoyed to avoid deep necrosis and painfu1 uIcerations. In one of our patients in which six glass points of emanation, each containing 234 mc. of radium, were buried in a sessiIe carcinoma of the vesica1 neck, an extremeIy painfu1 uIcer was produced and suprapubic excision was required in

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which can be SatisfactoriIy reached, exceIorder to reIieve the patient of the intoIerIent resuIts have been obtained by resecabIe pain. We now never use unscreened tion, far better than those obtained by any points of greater strength than I milhother method of treatment. By these gram or I miIIicurie, and gIass seeds of 44 various methods of therapy the resuIts milIicurie are probabIy preferable. They now obtained in benign and maIignant shouId be inserted so that they compIeteIy occupy the tumor, in dosage sufficient to tumors of the bIadder are infiniteIy more satisfactory than they were when surgical atlow I miIIigram for every cubic centiexcision was the onIy method empIoyed, meter of tissue. Where a suprapubic operation is done, for then not onIy the benign but the invariabIy tumors aImost we usuaIlv remove the tumor mass as maIignant compIetely as possible, either with the recurred. In benign papiIIomas, by means of fuIguration, diathermy, radium appIicaelectrocautery or by means of diathermy, tions and roentgen ray, practicaIIy every and then insert the radium into the base, case can be uItimateIy cured. It is true incIuding also the norma area immediately that benign recurrences in a11 parts of the surrounding the tumor. In a recent study of our resuIts made by bIadder frequentIy occur and require intermittent treatment. In maIignant cases, Scott and McKay of the Brady UroIogical where the disease is papiIIomatous, a Institute staff, 434 cases were anaIyzed. In papiIIomas, where the bIadder waI1 fairIy Iarge proportion of cures can be was not infiItrated, exceIIent resuIts have obtained without operation, by means of radium and roentgen ray pIus fuIguration. been obtained both inmaIignant and benign Prosmle. Cancer of the prostate can cases, by a combination of radium and easily be reached through the urethra, fuIguration; aImost al1 have been cured. rectum, perineum or bIadder. The first Where infiItration was present, the results have been far Iess satisfactory, but a few cases treated through the urethra were those of Pasteau and Degrais with the strikingIy good resuIts have been obtained by these methods and in others where cure radium carried in through a Coude gum has not been obtained, great symptomatic catheter, as above described. Since 1914 reIief for a Iong period has not rnfrequently we have treated some 500 cases with our metal radium applicator, at first with been obtained. In 28 cases in which suprapubic implantations of radium have been and afterwards without the cystoscopemade, there are apparentIy 4 cases in carrying sheath. The method empIoyed which the tumor has been compIeteIy has been simiIar to the one used in the destroyed or had not recurred, according treatment of bladder tumors with our to the Iast report. In 23 cases in which deep cystoscopic radium appIicator. The radium roentgen-ray therapy combined with some is pIaced in the desired spot under the other form of t,herapy has been empIoyed, direction of a gIoved finger in the rectum there are 6 in which the tumor has not and then held there by a cIamp to the recurred, according to the Iast report. table. The instrument which we now use Among these are severa in which realIy carries two smaI1 pIatinum tubes which remarkabIe disappearance of extensive contain IOO miIIigrams of radium eIement carcinoma of the anterior waI1 ofthe bIadder within a hoIIow beak composed of siIver is recorded. surrounded by gutta-percha. The aIpha, It is needIess to say that in the case of beta and secondary rays are thus almost inHtrating carcinoma, radica1 resection entireIy eliminated and by placing the shouId be carried out wherever possible; radium in a fresh spot each trme and nearer and in the treatment of those tumors appIying it again in the same area, we situated in the vertex of the hIadder, or in have found it possibIe to give as much as portions of the anterior or IateraI waIIs 2000 miIligram hours by rectum, without

I 18

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Surgery

producing Aeration. Not infrequentIy, irritation, edema, recta1 pain and spasm occur as a resuIt of treatment, but by carefu1 dissemination of the radium over the

Radiotherapy

FEBRUARY, ‘927

radium can be thus appIied just as freely and satisfactoriIy without the cystoscope as it can with the cystoscope in bIadder tumors. Being fixed m the proper posia

FIG. 22. I. W., B.U.I.

I 1338, mate, aged sixty-nine years. Admitted April 19, 1923. Two years before admission deveIoped frequency and urgency. One year before admission deveIoped “rheumatism” of Iumbar spine and both hips. Examination: prostate entarged, very hard, noduIar. Left seminal vesicIe involved. Wassermann reaction negative. Roentgenogram 43 I I showed very extensive metastases to IateraI bones of peIvis, and to spine; sacrum reIativeIy free, and atrophic. Many phIeboIiths in peIvis. Radium therapy given June 5, 1923, had had 800 mg.-hr. in rectum, 400 mg.-hr. in urethra, 400 mg.-hr. in bIadder (trigone). Treatment aImost every day. June 30: just concIuded first,course of tweIve deep roentgen-ray treatments of 33 minutes each in four days. JuIy g, 1923, considerabIy improved; urinary intervaIs three hours during night, five hours during day; no hematuria; recta1 irritation improved; no pain in sacra1 and Iumbar regions. August 18, 1923, no increase of urinary disturbances: great Dain in back and genita1 region. September, 1923, pain in back persisted, but reIieved by daiIy doses of codeine. .I

_

prostate and semina1 vesicIes, as shown in Figures 22-24, uIcerations are positiveIy avoided. Cases are aIso treated with the same instrument introduced through the urethra, at first near the apex, and then more deepIy so as to in&de the intravesica1 portion of the enIarged middIe Iobe. By passing the instrument into the bIadder it may be turned downward so as to Iie against the trigone and thus afford radium treatment to the region invoIved above the prostate, around the semina1 vesicIes and between them. By carefu1 manipuIation and attention to technica detai1 the

tion, the radium is directed against the desired point without the production of a burn in the rectum, where such precautions were not taken. In many cases remarkabIe disappearance of very extensive invoIvement and enIargement of prostate and seminal vesicIes is brought about. Where possibIe we carry out our radica1 operation-resection of prostate, vesicles and trigone. UnfortunateIy, in many of these cases metastases have aIready occurred, as shown in Figures 25 and 26, or the disease has progressed so far that a radicaI_cure

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is out of the question. In such unfavorabIe cases we use radium, as above outIined, and the cIinica1 improvement is often amazing in that hematuria, pain and

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American Journsl of surgCJry 1 19

void with comparative freedom. In some cases this result has lasted for several years ; in fact, unti1 the death of the patient. In many of these cases we have

FIG. 23. I. N. K., B.U.I. 10055, mak, aged fifty-nine years. Admitted October 27, 1921. Frequency and diff% c&y of urination for sixteen months, suffering from great pain in hip and groins. No hematuria. Recta1 examination: very extensive carcinoma of prostate and Ieft semina1 vesicIe. Frequency, night, four times and day, seven times. Catheterization: residual urine IOO C.C. Roentgenogram 3340 showed extensive metastases, osteoplastic type, in fifth lumbar sacrum and Sac bones. Treated by radium; considerabIe improvement in pain and frequency.

diffkxky of urination generaIIy disappear very considerably, if not compIeteIy. Many patients who were Ieading catheter Iives have been abIe to give up the catheter and

found deep roentgen-ray therapy of the greatest assistance. The pIan usuaIIy foIIowed is for the patient to receive, on with radium alternate days, treatment

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appIications by rectum, urethra and then by bladder, and on the other days deep roentgen-ray therapy, from fifteen to twenty treatments of twenty-five minutes’ duration being usually employed in the first series of deep roentgen-ray therapy. The number of radium treatments varies with the case, the extent of the invoIve-

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firmIy in the proper pIace by a clamp, and fastened to the tab1e. EIsewhere, we have given detailed cases in which this form of therapy has been the method used, with charts showing the app1ication of radium along with roentgen-ray therapy, from which our customary practice can be gleaned.

a

.

b FIG. 24. W. R. M., B.U.I. I 1467, maIe, aged sixty-three years. Admitted May 31, 1923. Diffkulty of urination for four years; hematuria recently. Great swelling of right leg. Prostate and vesicles enlarged, very hard, nodular and adherent. Roentgcnogram 44% showed localized destruction with new-bone formation of sacrum; other peIvic bones and spine free. Radium treatments, each with 200 mg.-hr., by rectum urethra and trigone. July 3: during past five weeks patient had had 2000 mg.-hr. by rectum, 800 mg.-hr. by urethra, 800 mg.-hr. by bladder. AIso received four deep roentgen-ray treatments, all of which were given through the front. Incontinence of urine had disappeared; voided at intervals without catheter. Prostate normal in size, shape and consistence. October 30. 1923, patient much better, rectal irritation gone, swelling of leg improved, some pain in right hip. Prostate and seminal vesicles no longer suggestive of cancer.

ment, and the reaction; but as a ruIe we are able to give from 1400 to 2ooomilIigram hours by rectum, 400 to 600 miIIigram hours by urethra and from 400 to Soo milligram hours through the trigone, with the simpIe radium app1icator carrying 200 miIIigrams (tandem) in its beak. Each treatment, as above described, is of one hour’s duration, the patient being fixed upon the table, the radium being held

In 1916 Barringer, following the work of Duoaine, brought out the use of radium needIes which he inserted into the prostate through the skin of the perineum with the assistance of a finger in the rectum. His needles contained from IO to 25 miIIigrams of element and are aIIowed to stay in pIace for eight hours or more. In many of our cases these needles have been employed in addition to the IocaI application through

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rectum, urethra and trigone, as aheady described. In some cases the needIes seem to be of distinct assistance, whiIe in others the results are distinctIy bad. It is now our practice to use them in onIy a smaI1 proportion of the cases. We have aIso introduced radium emanation through an open urethroscope into the substance

FIG. 25. E. W. M., B.U.I. 13767, maIe, aged sixty-nine years. Admitted Jury 29, ‘925. Frequency and difficulty of urination for two years. RecentIy had flad pain in back and sacra1 region, radiating down into Iegs. Urination every hour. Poorly nourished man. No enlarged glands. Rectal examination: markedIy enlarged, noduIar, irreguIar and very hard prostate, both semina1 vesicIes invoIved. Roentgenogram 6193 showed areas of osteopIastic bone metastases of second, third and fourth lumbar vertebrae, sacrum and right ilium. Treatment: radium. Condition improved.

of the prostate on each side and posteriorIy; I miIIigram each gIass tubes containing were empIoyed. In this way Iess IocaI necrosis and more widespread contact are possible, but here again our experience seems to indicate that the IocaI appIications with the Iarger amounts are preferable. Radium may aIso be appIied through an open perinea1 wound with or without

Radiotherapy

American Journal of Surgery

I21

operative attack upon the prostatic obstruction. If the patient is abIe to void rather freeIy, our method is to expose the prostate by means of our Iong urethra1 tractor and, after incision into the prostate and urethra, to insert pIatinum needIes containing I miIIigram each of radium through the prostate and adjacent portions

FIG. 26. W. S. A., B.U.I. 13625, male, aged seventyseven years. Admitted June 18, 1925. Frequency of urination for nine months, occasional catheterization necessary; frequency at time of admission, every haIf hour. Pain in penis; none eIsewhere. FeebIe oId man; glands negative. Recta1 examination: prostate enIarged, noduIar, very hard and adherent, both semina1 VesicIes invoIved. Urine bIoody. Roentgenogram 6108 showed two areas of metastases in right ilium, three or four in Ieft ilium, one in sacrum, and ischium. Suspicion of metastases of Iumbar vertebrae. Hypertrophic arthritis of second Iumbar vertebra. Radium treatment. Improved.

of the semina1 vesicIes and other surrounding tissues. We try to have I miIIigram in each cubic centimeter of tissue. The number of cases in which this- has been empIoyed is too smaI1 to give deductions of vaIue as to the efficacy of the treatment. Radium has aIso been introduced through open suprapubic wounds, into the prostatic urethra and adjacent portions of the prostate and semina1 vesicIes, through the bIadder mucosa. For these types we empIoy

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Young and Waters-G.-U.

needIes of I miNgram each, to which are attached threads for their removaL At the same time we usuaIIy introduce two needIes containing 123% miIIigrams of radium more deepIy into the IateraI Iobes ,of the prostate and two tubes containing IO miIIigrams each rather deepIy into the apex of the prostate and adjacent mem-

Radiotherapy

FEBRUARY.1927

have been remarkabIy satisfactory. As a ruIe we have empIoyed our method of IocaI appIication, as first described. Where obstruction to urination is compIete and unreIieved by radium treatment, we usuaIIy either carry out our conservative perinea1 prostatectomy or our punch operation to restore voIuntary urination.

FIG. 27. E. B., B.U.I. 13403, maIe, aged eighty-one years. Admitted ApriI 14, 1925. Frequency and di&culty of urination for seven years; dysuria. Nocturia ten times, diuria eight times. Sciatica, right side; waIked with sIight Iimp. Examination: head normaI, chest flaring, bones negative. Rectal: prostate enlarged, right Iobe indurated, but not stony hard or of third degree. VesicIes negative. Induration hardIy sufficient to suggest carcinoma, but sciatica suspicious. Roentgenogram 5945 showed marked osteopIastic type of bony change in peIvis suggesting carcinoma metastases. In view of roentgenoIogica1 findings, diagnosis of carcinoma made. Radium treatment givkn. Being dissatisfied with diagnosis, second roentgenogram, 5969, taken; this included right upper femur. Paget’s disease diagnosed. Comment: In reyiewing roentgenogram 5945, the bone picture certainIy suggests cancer, but the deformity in the right side of the peIvis and changes in the head and shaft of the femur shown in roentgenogram 5969 make the diagnosis of Paget’s disease unmistakabIe.

branous urethra. In some cases we have aIso empIoyed here two tubes of 100 milEgrams each in the urethra by means of a rubber catheter. In such cases the Iatter tubes are aIIowed to remain in pIace onIy about five or six hours, the needIes of 1244 miIIigrams are removed in about eight hours, the tubes of IO miIIigrams in about ten to tweIve hours, and the twenty I miIIigram needIes in about thirty-six to forty-eight hours. Treated in this way, the patients receive 2300 to 3000 miIIigram hours, generaIIy with IittIe or no necrosis. Some of the resuIts obtained by the intravesica1 method of introducing radium

Both of these procedures are remarkabIy satisfactory. In a report of IOO cases which were studied in this cIinic by Deming, surprisingIy good resuIts of Iong duration, with compIete remova of obstruction as Iong as the patient Iived, were recorded. The radica1 operaton is the idea1 method where the diagnosis can be made suff~cientIy earIy. Our technique comprises the radica1 excision of the prostate with its capsuIe, urethra, adjacent part of the hIadder, seminaI vesicIes and vasa deferentia. By means of the technique which we have described eIsewhere, radica1 cures have been obtained in about 60 per cent of

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the cases, where the cases have been fohowed over a period of five years. If practitioners couId be aroused to the importance of recta1 examinations, and be led to suspect marked induration even if the prostate produces Iittle or no obstruction, many more cases suitable for radical cure wouId come to hand. In concIusion, it may be said that the treatment of carcinoma of the prostate has become much more satisfactory in recent years, that it is possible to cure radicaIly- a certain portion of the cases which are seen suffrcientIy early, that in others by the use of radium and deep roentgen-ray therapy a remarkabIe amehoration of symptoms can be obtained, and in rare instances apparentIy compIete cures are thus effected. Radium and roentgen ra,v- have, therefore, contributed very splendidly to the progress of therapeutics in this heId. Sarcoma is much more rare than carcinoma of the prostate; in fact, we have seen 7 cases of sarcoma in this clinic, Ollll\; whereas there have been 700 cases of carcinoma. Sarcoma usuaIIy comes on insidiously and when first noted is in the form of a large gIobuIar, retrovesical mass bvhich obscures the seminal vesicIes and prostate and pushes the bladder forward. In some cases the prostate is of itselt only slightly involved. The disease arises in the tissues in and about the prostatovesicular junction. These tumors usuahy reach great size without invading or ulcerating the urethra, bladder or rectum. They are usually eIastic but sometimes are quite soft and occasionalIy are hard and nodular. In one recent case the ureters were obstructed, with complete anuria. Radium and roentgen-ray therapy is remarkabIy effecti\,e in these cases. We have now had 3 cases in which there has beenextraordinary disappearance of very large tumors, followed now for several years with apparent compIete cure. In one case we found it necessary to carrv out suprapubic cystotom\. with insertion of ureter catheters to relieve the obstructed ureters. Through

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the suprapubic wound we inserted radium points and Iarge masses of radium and have subsequently given applications through the rectum and urethra, with now almost complete disappearance of the tumor which was about five inches in diameter. Deep roentgen-ray therapy is a most valuable adjunct to the use of radium in these cases

FIG. 28. W. P. hf., B.U.I. 12631, mdc, agctl scventyFreqwncy eight years. Admitted August 22, rg24. and dilticulty of urination for ten yc-us, complete retention for three da,ys, pain on urination, no note of pain cIsewhere. No diffIcuIty of locomotion. Examination: prostate moderate1.v e&q&, smooth and elastic, seminal vcsicIes negative. C1ystoscop.v: K.U. 50 C.C., B.C. IOO C.C. Small, rounded median lobe. Urine acid, 1.013, alb. trace, W.B.C. +, Diagnosis: benign prostatic h? pertrophy. cocci +. Rocntgenogram $404 showed extensive ostcoplastuz deformities of spine and petvic bones. Xlarked deformity of pelvis. CI langes in bones similar to those caused by carcinoma mewstases, crcept that marked deformity seen here is typicaL of Pagtt’s disease and is not s-en in carcinoma.

and furnishes one of the most brilliant tieIds for the use of this therapy in urology. Urethra. Carcinoma of the bulbous urethra is rare and unfortunately very IittIe amenable to either surgica1 or roentgen-ray and radium therapy. We have seen very few cases and a11too far ad\,anced for any benefit.

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Carcinoma of the penduIous urethra usuaIIy aIso invoIves the penis, so that the surgica1 probIem consists of radicaI amputation and remova of the gIans in one

Radiotherapy

FEBRUARY,192,

tion, nor does it warrant the transpIantation of the urethra to the perineum. RemarkabIy good resuIts have been obtained by a procedure in which the

FIG. 29. A. H., B.U.I. 11901, maIe, aged fifty-three years. Admitted November IO, 1923, compIaining of pus in urine, of six years’ duration; nycturia twice. Pain in back. Recta1 examination: prostate slightIy enIarged, sIightIy adherent and sIightIy indurated. SeminaI vesicIes negative. Three enIarged glands on Ieft side, as shown in chart. Cystoscopy: R.U. 45 c.c.,B.C. 375 c.c.,slight hypertrophy of IateraI and median Iobes. Urinalysis: acid, 1.013, aIb. o, w.B.C. o, R.B.C. o, bacteria o. Roentgenogram 4765: peIvis and spine presented widespread areas of bone destruction and bone formation, typica of metastasis of prostatic carcinoma. Although uroIogica1 examination did not suggest cancer, in view of roentgenoIogica1 findings and pain in back, patient given deep roentgen-ray therapy, 132 min. over front and back with I mm. Cu + I mm. AI filter, 200 kv. with 4 ma. and 77 min. over sides; size of field 20 by 20 cm. over front and back, 15 by 15 cm. over sides. No treatment for prostate. February 26, 1924, patient had no symptoms whatever, pain gone. June 30, 1925, Ietter: condition continued improved; roentgenogram showed diminution of process in bones of pelvis. Comment: In view of the improvement of the patient after twenty months, in the absence prostatic findings, a diagnosis of metastasis of prostatic cancer was doubtfu1. Paget’s disease was considered, but ruIed out by the absence of bone Iesions eIsewhere. Lues was next considered, but the Wassermann reaction was negative. A positive diagnosis was, therefore, uncertain. We have at least 12 cases similar to this.

of

piece with the Iymph gIands Ieading from the origina growth to the groins. Our experience does not justify tota emascuIa-

urethra is brought out in front of the scrotum. Radium and roentgen-ray therapy have been strangeIy ineffective in carci-

NewseriesVOL. II, No.z

Young and Waters-G.-U.

noma of the penis. One would expect excehent resuIts in a region which is so easiIy attacked by this method of treatment, but it is generaIIy conceded that IittIe benefit has been obtained. Barringer has recentIy brought forth sIight hope by the recita1 of a few cases, but the resuIts obtained are stiI1 so unsatisfactory that a radica1 amputation of the penis, with remova of the Iymph gIands of the groin, shouId aIways be carried out, if possibIe. Testicle. Treatment of tumors of the testicIe by radium and roentgen ray has also been remarkabIy unsatisfactory. UndoubtedIy surgica1 remova shouId aIways be carried out. InvoIvement of the retroperitonea1 gIands seems to be most beneficiaIIy handIed by deep roentgen rays. WhiIe we stiI1 beIieve that radica1 remova of retroperitonea1 gIands shouId be carried out in a11 favorabIe cases, postoperative deep roentgen-ray therapy shouId not be omitted. Three of our cases, which have now been foIIowed for severa years, seem to show that this pIan may give exceIIent resuIts. CONCLUSIONS

In the above recita1 we have shown that there is no fieId in medicine in which radium and roentgen-ray therapy gives more satisfactory resu1t.s than in uroIogy.

Radiotherapy

American JournaI of Stlrgcry

125

Nowhere can radium be appIied to deepseated organs as accurateIy as by the cystoscopic and urethra1 and recta1 appIicators. Radium is vaIuabIe not onIy in maIignant but aIso in benign conditions. The roentgen ray is aIso of greatest assistance empIoyed in conjunction with and subsequent to the use of radium. By such combined methods of attack not onIy are many cures obtained, but even in unfavorabIe cases great betterment of symptoms usuaIIy foIIows. In the reIief of pain produced by metastasis to the spine and aIong the peIvic nerves the treatment with deep roentgen-ray therapy as above outIined gives reaIIy amazing resuIts. Our experience wouId seem to warrant the foIIowing concIusions: The best treatment for superficia1 papiIIary carcinoma, whether IocaIized or extensive, is a combination of deep roentgen-ray therapy with radium appIied directIy to the surface of the growth. Radium aIone has been very successfu1 in handIing this type of case, but frequentIy so much radiation is required that the destruction of the tumor is foIIowed by a severe radium ulceration. In our experience, the resuIts obtained by the combination of deep roentgen radiation with radium are better when the tumor has received 600 to 800 miIIigram hours of radium before the roentgen-ray treatment is started.