THE USE AND ABUSE OF RADIUM NEEDLES .sx By PROFESSOR F. L. Hopwood and Miss F. E. SMALLMAN , St. Bartholomew's Hospital , London .sx ( Read , December 5 , 1929 .sx ) ALTHOUGH post-graduate courses of instruction , books , papers in scientific and medical journals , etc. , inform the medical profession concerning the essentials of radium therapy , there is , as yet , comparatively little public information available on the economic and administrative aspects of a hospital radium service .sx The need for this kind of information is very apparent at the present time , when the acquisition of radium for the treatment of malignant disease is under consideration by many groups of hospital authorities .sx Under these circumstances we have thought it would be of interest to publish the results of an analysis of some of the records which we , as radium custodians , have kept for several years at St. Bartholomew's Hospital .sx As an account of the organisation and equipment of the Radium Department of the Hospital has already been given , we shall here confine ourselves to the task of furnishing data for the guidance of those who have to answer the following questions :sx Q.1. How many patients can be treated in a year with a given quantity of radium ?sx What efficiency of use can be expected ?sx Q.3. What is the best distribution of radium that can be made among the several types of container ?sx Q.4. What is the average " life " of a radium container and its risk of loss or damage ?sx It is obvious that the answers to most of these questions will vary both with the type of case to be treated and with the technique adopted .sx The statistics which follow relate mainly to treatment by radium puncture , although a large number of patients was also treated by the methods of surface application .sx Use of Radium Needles .sx In Table I a summary is given of the number and types of case which were treated in two years when using approximately 500 milligrammes of radium element as salt in 230 containers chiefly needles .sx Table II gives the efficiency of use during the same period , i.e. , the actual number of milligramme-hours of treatment expressed as a percentage of the maximum possible number of milligramme-hours of treatment .sx This method of expressing the extent to which the radium is employed , although probably the best from the administrative point of view , is liable to be misinterpreted , unless due consideration is given both to the type of case treated and to the form of radium container used .sx For instance , Table I shows that 36 per cent of the cases treated were out-patients and therefore only in attendance for a few hours daily .sx Some of these cases needed special applicators unsuitable for surgical use for in-patients .sx Both factors short duration of treatment and employment of containers .sx having a restricted use tend to reduce the efficiency as recorded .sx Similarly , long needles ( 6 cm .sx ) , while capable of rendering conspicuous service in breast cases , have great limitations for other sites , and are impracticable for tongue cases .sx Consequently , it is desirable not to have too great a proportion of these , although a limited number will show a relatively high percentage efficiency ( see Table III) .sx Tubes of 50 milligrammes of radium element content are also restricted in their use .sx Another and decisive factor which controls the extent to which the radium supplies are used , is the number of beds available for cases undergoing radium treatment .sx Speaking broadly , needles of 1 milligramme and 2 milligrammes content in radium element have been found to be the types best adapted to the purposes of a general hospital .sx For such a hospital , in the opinion of the writers , an average yearly efficiency of use exceeding 50 per cent should be regarded as very satisfactory .sx Abuse of Radium Needles .sx Turning now to the debit side of the account , Fig. 1 shows the kind of damage which radium needles may experience , and Table IV the number of damages incurred during a period of two years .sx After making every allowance for the fact that most of the damages included in Table IV are of a trivial nature , the sum total is still very striking .sx and justifies further analysis .sx The result of such analysis is shown in Tables V and VI .sx Table V brings out quite clearly several facts , which might have been anticipated , namely , ( a ) that long needles are much more vulnerable than shorter ones , ( b ) that there is a marked gain in mechanical strength through using 0.6 mm .sx of platinum walls instead of 0.5 mm .sx , and ( c ) needles used for surface application are less liable to damage than those inserted into malignant .sx growths .sx The progressive deterioration of needles over a period of five years can be gathered from Table VI .sx Thus 25 per cent of the needles of length 6 cm .sx are responsible for 45 per cent of the damages and 15 per cent of the 4.5 cm .sx needles for nearly 30 per cent of the damages , in their respective classes .sx The policy of classifying a needle as " damaged " for every trivial injury , and setting it aside for immediate repair , has been thoroughly justified by results .sx During the five-year period under review , only two needles have had to be replaced through being damaged beyond repair .sx The weakest spot of a needle is the eyelet , and the worst type appears to be that shown in Fig. 2A .sx Lately a new type of eyelet has been introduced into our service ( Fig. 2B) .sx This is stronger than previous types and possesses the great advantage of permitting the thread to be attached longitudinally to the needle .sx The latter can be readily withdrawn from tissue without the eyelet acting as the barb of a fish hook .sx The needle is threaded quite simply by means of the device C shown in the figure .sx Leaks and losses .sx In our experience , leakage of emanation from damaged needles is a comparatively rare occurrence if the needles have been gold soldered .sx Leakage is such a nuisance , however , when it does occur , that it pays the custodian to carry out routine tests for its detection and to reseal at once a needle having this defect .sx No matter how efficient the organisation of a radium service may be , in the course of years the intensive use of radium is likely to be accompanied by the temporary or permanent loss of some containers .sx When a loss is suspected .sx it is advisable immediately to stop the dispatch of refuse or articles for the laundry from all departments of the hospital , and to institute a visual and electroscopic search .sx In this connection it should be noted that containers which have accidentally passed through an incinerator may have lost most of their emanation through the melting of the solder used as a seal .sx No reliance should therefore be placed on negative findings by an electroscope in this case .sx We ourselves have recovered from an incinerator , containers which produced .sx no readily appreciable effect on an electroscope even at distances of less than .sx six inches , although no radium salt had been lost .sx The records of nearly ten years show a permanent loss of four needles with .sx a total content of four milligrammes .sx Of these one needle is known to be .sx buried with a patient , and three are untraced .sx In conclusion , we would express the hope that other institutions will .sx follow our example by publishing details of their radium service .sx Only in this way can satisfactory answers be given to the questions set out earlier in this paper .sx THE ASSOCIATION OF RADIUM AND X RAYS IN THE TREATMENT .sx OF MALIGNANT DISEASE .sx By J. E. A. LYNHAM , M.D. , M.R.C.P. , D.M.R.E. .sx ( Read December 5 , 1929 .sx ) MY subject is the association of radium and X rays in the treatment of malignant disease .sx Radiotherapy is still a new science , and whilst general principles give rise to controversy , there are of necessity many variations in technique being practised in different countries , by different schools and by different workers .sx In a science which is in a state of evolution , there is much to be gained by meeting together and comparing experiences and impressions , and I therefore make no apology for putting before you certain views which may meet with criticism , adverse or favourable .sx I have listened with very great interest to the opinions of other speakers , but I must say it has been my practice to refer all operable cases of carcinoma to the surgeon .sx I have had the somewhat unusual experience of approaching radiology by way of radium .sx I began to study it seriously in 1911 .sx A few other workers , including Dr. Finzi , had already become established in that particular branch .sx But everyone will admit that our treatment then was empirical ; we were feeling our way , with much care and anxiety , in a glare of criticism where failures were attributed to faults , and success almost invariably led to a challenge of our diagnosis .sx Nevertheless , even in those early days , dealing only with advanced cases beyond the hope of relief from surgery , there were successes sufficient to win over the most hostile critics , sufficient to call into the field a multitude of other workers , and ultimately to establish the general acceptance of radium as one of our great helps in the treatment of malignant disease .sx Our applicators at first were relatively crude , but I witnessed , and had a share in , the gradual evolution in design which led ultimately to the construction of the needles now so widely used in the surgical application of radium .sx But whilst some of us were entirely devoted to radium as a specific agent , others , working at X rays , were producing results which were obviously analogous , if not so dramatic .sx They worked with 12 or 16 inch coils , unsatisfactory interrupters , thoroughly unreliable gas tubes , and inaccurate measuring devices .sx They met with every sort of opposition and criticism yet they had the courage and persistence to keep on ; and they too produced results .sx It was obvious , even before the physicists came to our aid , that clinically , X rays and gamma rays were of the same order .sx Here was shown a series of photographs of cases of carcinoma of the breast :sx Treated by radium .sx Treated by X rays .sx Treated by X rays and radium .sx If you go to any large clinic in the country , in spite of the variations in the methods of the operator , you will find results perhaps comparable with these .sx It takes more time and trouble perhaps to achieve such results by X rays .sx Radium undoubtedly , in a number of cases gives a local result more quickly than will X rays , but the results following X rays , when achieved , appear to have been equally good .sx And the deduction is obvious where possible use radium for its local effect , but let the case be followed up by careful , systematic X-ray applications .sx The methods are not different , but supplementary .sx Almost every new recruit to the army of radium workers passes through a phase of enthusiastic optimism when it is found that as a result of predetermined treatment a series of tumours can be made to disappear ; and I was no exception to the rule .sx But , as the years went on , many cases which had shown apparent cure or startling improvement , came back with extension of their disease , and certain of these failed to respond to further treatment , and died .sx Several conclusions were forced upon us :sx Our lasting successes occurred only where the disease was localised ; and were then comparable with the successes that followed surgical removal with this difference , that our cases were surgically inoperable when treatment was begun .sx That in certain cases isolated secondary growths appeared , even after the healing of the primary .sx These would frequently respond to further irradiation .sx That in cases where the disease had become generalised , we could not produce even local improvement .sx That when recurrences developed in cases which had done well previously , but now failed to respond , their appearance at the surface was frequently accompanied by extension of the disease elsewhere ; in other words , unknown to all concerned the disease which had been latent for a time , had suddenly become active .sx Here were shown radiographs of the pelvis in advanced carcinomatosis secondary to .sx Carcinoma of the breast .sx Carcinoma of the stomach .sx Carcinoma of the prostate .sx