*Pusey: Jour. Amer. Med. Assn., 1907, xlix, 1215. 30 Pusey: Jour. Cutan. Dis., 1913, xxxi, 73.

Radium-At the time of writing, radium* is receiving more than its share of notoriety, both in the daily press and before the various medical societies, as a cure for cutaneous cancer. In fact, radium seems to be going through the same stages that the x-ray has-first, it has created wild enthusiasm, then deep disgust, and finally it has found its true place. The general trend of opinion is that radium must be used in large quantities and the application must be for a considerable period-that is to say, the present tendency is to use it in "massive doses" just as in the case of the Rontgen rays.

While the greater portion of the radium in the world is produced in America, it has been used much more abroad than at home; in fact, the majority of American dermatologists have been profoundly skeptical concerning its value, and this is hardly to be wondered at when one considers the undue enthusiasm with which it has been advocated by certain men on both sides of the Atlantic ocean.

Radium is usually employed in the form of the bromide. Its general action seems to be comparable to that of the x-rays, but rather more powerful. It is known that three classes of rays are given oflf by it, an<l these rays are called the alpha (a), beta (/J), and gamma iy>. The alpha rays possess but little power of penetration, and are somewhat (leviable by a magnet. They can be absorbed by an air cushion of three inches thickness, by glass, or thin aluminum. The beta rays have much more penetrative power, but are more easily deviated by the magnet, and are said to coincide with the cathode rays til" a C mokes' tube. Wickham thinks that they have curative properties of their own. The gamma rays penetrate deeply and do not respond to magnetic influence, and will easily pass through %2 mm. of lead. Radium also gives off an emanation that obeys the laws of gases, and that has become useful in the field of therapy.

*Lawrence: Radium Therapy, Melbourne, 1911. Wickham: Arch. f. Dermat. u. Syphil., 1912, cxi, 161. Wickham et Degrais: Radiumtherapie, 2d ed., Paris, 1912. Newcomet: Internat. Clinics, 23d ser., ii, 268. Williams and Ellsworth: Jour. Amer. Med. Assn., 1913, lx, 1694. Simpson: Jour. Amer. Med. Assn., 1913, lxi, 80.

When employed upon superficial cancers, all of the rays are usually employed, and no attempt is made to filter out the softest, which are presumably more irritating to the skin. Radium is usually kept in aluminum containers, or at least containers with aluminum windows, and these are brought in direct contact with the diseased tissue. As a general rule, an attempt is made to secure "cross-fire" action- -that is to say. radium is applied to several sides of the growth at the same time, so that the rays will cross each other, and this is deemed much more* effective than when applied at one point only. From 10 milligrams up are now applied at each point and left for from four to eight hours. It is, of course, essential to have radium that is very active, and many specimens are lacking in this respect, which fact undoubtedly explains the skepticism with which this remedy is viewed by many dermatologists and surgeons.

The rays of radium markedly resemble the x-rays in that they have an undoubtedly selective action for certain diseased cells, chief of which are the cancer cells. The author has seen instances in which an unsuspected focus in apparently healthy tissue was destroyed by the action of radium, leaving a tiny ulcer. The rays seem to kill the cancer cells, or at least to inhibit their growth, and not to inflame the normal tissue when carefully used. At the same time, it must be remembered that very serious burns can result from the use of radium, burns that are in every way comparable to x-ray burns, and hence the remedy must always be used with great care.

There can be no doubt that large quantities of radium, when used for a number of hours, can favorably influence the disappearance of cancer. There are probably only two styles of cancer of the skin in which it is justifiable to use it as a routine-the very early growths of the basal-celled variety that are situated where operation would be difficult and mutilating, and in inoperable growths. While a number of men in America are at present claiming brilliant results, and while Wickham and Degrais have at times accomplished won--ders, the attitude of the author is one of great skepticism, and for this there are the following reasons:

1. He, at the present time, has under his care three patients who have been treated with radium and pronounced cured, when in reality this was not true, in two instances at least the disease being made much worse.

2. The "cured" cases have not been followed for a sufficiently long space of time; it takes at least three years, in cancer of the skin, before one can regard a patient as definitely cured.

3. Because one cannot be absolutely certain as to the quality of the radium on the market.

As already pointed out, the only way to use radium is in "massive doses," and, inasmuch as the metal is extremely expensive-and inasmuch as at least $15,000 to $20,000 worth is necessary to even make a beginning, it is extremely improbable that this treatment can ever become very general. Personally, the author is very much inclined to agree with Bloodgood in his statement that radium as now used is holding back the correct therapy of cancer, and is a menace rather than an aid.

At the same time, it must be admitted that radium can do great good.

In conclusion, it must be stated that the last word has not been said regarding radium therapy. The author is inclined to believe that it is no better than a massive dose of x-ray, except in some few cases where the rays have failed, and even here radium is apt to prove useless. Its application is more convenient than that of the rays, but it is more difficult to gauge the dosage. We should keep an open mind on the subject at present.

Within the past year or two mesottiorium has been used by some clinicians as a substitute for radium, as it is much less expensive. It seems, however, not to be as effective, although opinions as to the degree of difference still vary, but all observers are agreed that in the course of four or five years it entirely loses its radioactivity. The same statements would seem to apply to thorium-x and radio-thorium, while the emanations from uranium are extremely feeble.

The proprietary remedy thoremedin has been carefully studied by Pusey,* who reports that its beneficial results were entirely due to the amount of sulphuric acid contained.

*Pusey: Jour. Aner. Med. Assn., 1912, lviii, 715.

Nitric Acid

Nitric acid has been very little used as a caustic in cases of skin cancer, although it is greatly used in such horny growths as warts. This lack of use is rather surprising, when one •considers that it is a deep-acting caustic, and that it can be speedily neutralized by an alkali. Possibly the reason is that the physicians fear the pain resulting from its application. At any rate, it is certain that the scar resulting from its use is not as good as that obtained from the action of many other caustics.

Sulphuric Acid

Sulphuric acid* has practically the same action as nitric acid, but, as a general rule, does not act so deeply; it is practically never used.

Acid Nitrate Of Mercury

The acid nitrate of mercury has been especially extolled by Sherwell (see page 182), and his results with it have been excellent. Of course, he uses it by first curetting away as much as possible of the new growth, and then allowing the acid to act for at least fifteen minutes, finally neutralizing with bicarbonate of soda, as has largely been described. Its action seems to be much deeper than that of either acid described above.

Chromic Acid

Chromic acid is but little used in dermatology, except in an attempt to destroy leukoplakia upon the tongue. The actual cautery can well replace this caustic.

Pyrogallic Acid

Pyrogallol is considerably used by some men, largely because it is supposed to have a selective action and to spare healthy tissue, while destroying the cancer cells. It is usually employed in a 10 percent strength, but the author agrees with Stelwagon* that this is entirely too weak, and that, to expect any results, a 25 percent strength must be used. The following prescription would be about correct:

R Pyrogalloli ................................................ 3ij

Vaselini,

Resinse cerati, aa partes sequalis ad......................... 5j

This mixture is spread upon gauze and kept closely applied to the cancer, changing the dressing twice daily. At the end of five to eight days a slough will form, which will shortly separate, or which may be loosened by means of a poultice. The part is then cleansed, and the treatment continued until the physician thinks that sufficient tissue is destroyed. As a general rule, this method has one commendation-the lack of pain caused.

*Pusey: Jour. Amer. Med. Assn., 1913, lx, 434. "Stelwagon: Diseases of the Skin, Phila., 1914.