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Radium
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tion in the esophagus. The writer has in mind particularly one case in
which the esophageal obstruction was by post-mortem shown to be due
to a carcinoma of the lesser curvature of the stomach, with extensive
infiltration of the glands about the cardiac orifice and some infiltration
of the cardia; yet the site of the obstruction in the esophagus, as determined
both by sounds and by the roentgen studies, was two or three
inches higher than the infiltrated area, and it had all the earmarks of a
spastic hindrance. We therefore make routine use of antispasmodic
medication, both in the study and the treatment of esophageal lesions
thought to be malignant. One of the most important technical problems
to be overcome in radium treatment of esophageal cancer is the
delivery of an adequate dose of homogenous radiation into the depths
of the tissues. The investigations of Fricdrich. supplemented and corrected
by Schmitz working in Friedrich's laboratory, show how rapidly
the efficiency of radiation from a radium capsule diminishes at a short
distance from the applicator; so that unless one does considerable damage
through overdosage to the tissues actually in contact with the radium
applicator, he will not deliver an efficient dose into the depths of the
lesion, say only two centimeters beneath the mucous membrane, and certainly
nothing like an efficient dosage along the normal lines of extension.
If the lumen of the stricture suffered sufficient dilation to permit
from S to 15 mm. of uibher tissue wrapped around the radium in its
usual metal container, the added distance from the radiant source to
mucosa would greatly improve the depth dosage, though much prolonging
the time of application. Yet„ one hesitates to dilate a malignant
stricture at all. and in the light of our present knowledge he surely will
not do so any more than is absolutely required for introducing some form
of radium applicator, fearing that the instrumentation may do more
harm than the radiation does good. The radiologist is thus by circumstance-;
limited to an unequally distributed, non-homogeneous radiation.
if he depends upon radium alone: therefore the natural tendency to supplement
the radium application by external applications of radium by
packs applied at some distance from the skin, or by deep roentgen irradiation,
or by both.
Another serious problem is an accurate visualization of the lesion.
as interpreted from the x-ray and clinical findings. Some have recommended
the routine study of these patients by means of the csophagoscope.
but such instrumentation is extremely distressing to some patients
and. for various reasons, quite impossible in others.
It is not easy to make an accurate map of the infiltration or ulceration
in any given case, and yet an error of estimation amounting to only
a centimeter or so makes a great difference in the result. The above
considerations emphasize the obvious need of the greatest possible accuracy
in the mental picture formed of the lesion under attack, the need
of abundant filtration and a maximum of distance from radiant source
to lesion, none of which ideals are capable of satisfactory realization.
at least in the present state of our attainments.
Radiim Methods
Various methods have been devised and employed by all of us in
the attempt accurately and efficiently to place the radium.
I. Radium-bearing Sound Guided by a Thread. By the wellknown
technique, a thread several feet in length is employed. Fight or
ten inches of this stout but very fine thread is enclosed in an ordinary