Over 80 skin disorders were commonly treated with x-ray or radium therapies by 1922, as noted in Chapter 33, Part 1. We want to give readers an idea of what conditions were treated this way, and why such treatments could cause irradiation of breast tissue in specific cases. A good way to do this is by providing some relevant samples of treated conditions from Dr. George MacKee's excellent book, X-Rays and Radium in the Treatment of Diseases of the Skin, Third Edition, published in 1938. Dr. MacKee was then Professor of Clinical Dermatology and Director of the Department of Dermatology (skin and cancer unit) of the New York Post-Graduate Medical School and Hospital, Columbia University.
The samples will come from Chapters 28, 29, 30, and 31. These four chapters alone required 100 pages in MacKee's book, so it should be self-evident that we are not attempting to be comprehensive here. The co-author of Chapter 28 was Dr. George M. Lewis; the co-author of Chapters 30 and 31 was Dr. Fred Wise.Part 1. Diseases due to Fungi: Unplanned Breast-Irradiation
In their Chapter 28, "Diseases due to Fungi," MacKee and Lewis begin by listing ten skin conditions due to pathogenic fungi which are "more or less amenable to treatment with x-rays or radium" (p.441). We will mention only two of them, below.
Tinea Capitis (Ringworm of the Scalp)
The use of x-ray therapy for tinea capitis was first suggested in 1897, but early practice resulted in a discouraging frequency of permanent alopecia (baldness, loss of hair), "due to excessive dosage" (p.441). However, control of dosage was achieved and the practice was widely used. For example: "We and our associates have employed the combined method of dose estimation (Chapter XVII) in this work for over twenty years. The heads of over 3,000 children have been depilated without a single case of permanent alopecia" (p.455).
Dosage: The "Skin Unit" or "Erythema Dose"
On the subject of dosage: "Three hundred r (1 skin unit, unfiltered) is the epilating dose ... This is a safe dose, but it must not be exceeded except in cases where the toleration is known to be greater. In children under two years of age and in infants, the dose should be 225 r (3/4 skin unit)" (p.455). In those days, a "skin unit" (also called an "erythema dose") was defined as 300 Roentgens at about 60 KeV (p.455).
Beginners: Don't Try It !
MacKee and Lewis urge against use of this therapy by novices (p.455): "The beginner should not attempt the x-ray treatment of this disease until his apparatus and technic have been standardized and repeatedly checked, and he has had experience with the x-ray treatment of various cutaneous affections. He must be certain of his epilating or erythema dose which are the same and correspond with the skin unit (300 r at about 60 kv)," at which point MacKee and Lewis cite three earlier chapters in their book.
Breast Irradiation from the Procedure?
MacKee and Lewis make no comment about external scatter to the breasts. However, Modan and colleagues studied use of this method on 10,834 irradiated children in Israel (Modan 1989, in The Lancet). They claim that, using phantoms, they ascertained a dose of 1.6 rads to the breasts from such treatments.
Actinomycosis: A Leading Clinical Problem
According to another text, actinomycosis was the principal fungus disease of clinical importance. This other text, featured in our Chapter 36, is "Radiotherapy of Benign Disease" by Dr. Stephen B. Dewing (1965, p.28).
Dewing reports that "actinomycosis affects primarily the mouth, jaw, and neck regions. It also occurs in the chest and abdomen, as do the other fungus diseases." So direct breast irradiation must occur in treatment of some cases. MacKee and Lewis (p.484) provide a photo of a patient very disfigured by the affliction on her jaw, and report (p.483):
"From personal observation and a review of the literature, we are of the opinion that the x-rays or radium rays are not only indicated in this stubborn and serious disease but that such treatment is superior to any other." They provide a photo (p.485) of the same patient after two x-ray treatments, and the improvement is breathtaking.Part 2. Eczema, Including Eczema of the Nipple and Breast
In many parts of the literature, aside from MacKee, we encountered numerous reports of very successful therapy of "eczema" by x-rays. The definition of eczema" changes, and we will return to that topic in a moment."
According to MacKee, as early as 1900, x-ray therapy was recommended for treatment of chronic eczema (p.489). Moreover, "Very early the opinion was unanimous that in most instances the lesions of eczema disappeared rapidly under the influence of very small doses [of x-rays] and in practically all cases the itching was relieved quickly. At first it was thought that the clinical cure might be permanent but later it was found that recurrences were common" (p.489). And: "Modern writers are perhaps even more enthusiastic than were the earlier authors. The results are better today because of greater ability to select cases and because modern technic practically precludes injury. All modern text-books on dermatology and roentgen therapy call attention to the efficacy of irradiation in the treatment of eczema, especially the chronic types" (p.489).
What Is Eczema? MacKee's Reply (1938)
"To most dermatologists today the word eczema means an eruption that at some stage of its evolution is exudative, either clinically or histologically. It begins with erythema. If evolution is uninterrupted, this is followed by edema and often by vesiculation, erosion and exudation and, finally, by crusting and desquamation. The development may be slow or rapid; any one stage may be evanescent or prolonged; or the disease may end at any stage either spontaneously or because of therapy" (p.490).
If the cause of the skin eruption is an external factor, some dermatologists prefer to use the term "dermatitis" instead of eczema. Others use the term "eczema" whether the cause is external, internal, or a combination. Comments MacKee (p.490):
"There is, therefore, some confusion relative to the terms eczema and dermatitis, also as to the etiology of the various eruptions comprising the eczema group. Hence we hear of occupational eczema, contact dermatitis, dermatitis venenata, intertrigo, eczema intertrigo, eczematoid ringworm, parasitic eczema, eczema marginatum, dermatophytosis, etc." And MacKee follows this with a very sensible statement (p.491):
"Now as a matter of fact it makes little difference what we call a thing as long as we understand its nature and cause."
MacKee suggests (p.491) that dermatitis venenata "may be defined as a reaction of the skin caused by external contact with substances to which the skin or the patient has become sensitized or allergic." Just about any part of the body can be involved. According to MacKee (p.492):
"The x-rays are not indicated in the majority of cases of dermatitis venenata. If the case is properly diagnosed and the cause removed the eruption as a rule will disappear quickly; especially is this true of the acute types. At times, however, the diagnosis is exceedingly difficult; often quite impossible until after prolonged observation." He states that, although a few doses of 38 to 75 R at weekly intervals can hasten involution of acute eruptions and can reduce itching, "The detection and removal of the cause is the main requisite, otherwise the eruption is likely to persist or to recur repeatedly" (p.492).
MacKee points out (p.492) that years can elapse before identification of the offending agent. Meanwhile, "the erroneous belief that irradiation is of distinct service can occur if the offending agent sometimes decreases, by chance, soon after a patient receives an x-ray treatment for the problem.
Infectious Eczematoid Dermatitis
Infectious eczematoid dermatitis is defined by MacKee (p.494) as "a dermatitis secondary to a discharging ulcer, sinus, boil, abscess, etc." It spreads mainly by peripheral extension. MacKee himself "has seen eruptions begin at the margin of an ulcer and later involve most if not all of the body surface. In cases of this kind, when the symptoms are acute --- edema, erythema, exudation and burning pain --- x-rays have been of little benefit until the affection has become subacute." And: "In the less acute types, when the eruption is papular or squamous, with or without more or less exudation, and severe itching, x-rays may prove more efficacious than any form of treatment." But again, he points out that permanent cure is provided only by finding and removing the initiating cause.
Dermatophytosis Involving Armpits and Pendulous Breasts
"The term dermatophytosis, for convenience, may include any eruption of eczematoid appearance that is caused by fungi, and dermatophytide may include all eruptions caused by sensitization to fungus products" (MacKee, p.495). MacKee reports his experience that only some cases "do very well" under fractional x-ray treatment (p.496).
The armpits and the region under pendulous breasts are explicitly included by MacKee in a listing of areas which can become involved with this type of dermatitis (p.495).
Under this term, MacKee includes lichenification, lichenified eczema of nape of neck, and lichen simplex. There are two types of neurodermatitis: circumscribed and disseminated (MacKee, p.497).
Circumscribed lesions have sizes from that of a dime to that of a palm. There can be few or many. Although the neck is a common location, the lesions can be "scattered over the body" and may occur "on almost any part of the body" (p.497). According to MacKee, "Most authors agree that irradiation, either x-rays or radium, is usually very effective in the circumscribed types of neurodermatitis" (p.497).
The disseminated neurodermatitis is also known as atopic eczema or atopic dermatitis. It tends to pick the flexures and flexor surfaces, but it can be generalized over the body "and even almost universal" (MacKee, p.497). "There is usually a family history of hay fever and asthma and the patients are often sensitized to various substances." And: "The subjective symptom is itching which may be intense and which often precedes the appearance of the eruption."
Does radiation therapy help? MacKee reports with his usual candor (p.499):
"The effect of irradiation on this type of neurodermatitis is uncertain. The treatment practically always causes some relief, but it very frequently fails to cause complete disappearance of the eruption; especially is this true in children and adolescents. Even when the eruption does disappear recurrences are common. Nevertheless the x-rays are a valuable adjunct to general medical and conventional dermatological treatment. The fact that they will lessen the itching and directly or indirectly improve the eruption in the majority of cases of this stubborn affection, is all that is necessary to justify their use. Furthermore, there is always the possibility of complete relief which may even be permanent."
MacKee's Warning against More Than 1,500 Roentgens, Total
"As this affection [disseminated neurodermatitis] usually persists, intermittently, over a period of many years, x-rays are indicated, as a rule, only to help get the case under control during a severe exacerbation. The physician should guard against the accumulative effect of repeated courses of treatment by keeping adequate records. It is preferable to avoid a total of more than about 1,500 r on any part of the body during the life of the patient" (p.499).
Intertrigo Involving Armpits and Pendulous Breasts
Intertrigo is defined by MacKee (p.502) as "an inflammation of the skin situated in locations where there is moisture, warmth, friction and where it is difficult to keep the parts clean ... The usual sites are the crural region, the axillae, the anal region, and the breasts (under pendulous breasts). The eruption usually consists of redness, maceration, erosion, exudation and itching or burning."
MacKee thinks most cases will clear with hygiene and locally applied remedies. But if the problem persists in spite of such treatment, he suggests that "fractional irradiation may be beneficial" (p.502). And: "To irradiate the skin under the breasts it is necessary for the patient to elevate the breasts with the hands. All unaffected parts should be shielded." If MacKee's recommendation was followed, the dose to breast-tissue from that treatment could have been rendered small.
Eczema of the Nipple and Breast of Women
Radiotherapy for eczema of the nipple and breast is obviously a procedure where shielding is impossible for the breast-tissue lying beneath the afflicted area. We have seen several reports in the literature of this special eczema of the breast. MacKee says (p.505): "Here the first requisite is to be certain that the case is not one of Paget's disease. If eczema of the nipple and breast (omitting the possibility of Paget's disease), does not disappear as a result of one or two months' irradiation, it is inadvisable to continue the treatment for fear of injury to the underlying glands."
MacKee's Summary: "The Best Remedy We Have"
At the end of his chapter on eczema, MacKee sums up (p.508): "Considered as one of many remedies used in the treatment of eczema, omitting types of eczema for which there are specific remedies, and visualizing the disease in a very general way, it is the author's opinion that x-rays are the best remedy we have for eczema. In a general way it is our best antipruritic and our best resolvent agent for this purpose. However, too much must not be expected."
It is a common refrain in medicine: "The best we have is not as good as we wish." So, MacKee's opinion that "x-rays are the best remedy we have" was probably influential in the continued use of x-ray therapy for various eczemas.Part 3. Psoriasis, Including Treatment via Thymus Irradiation
Early in their chapter on psoriasis, MacKee and Wise comment as follows (p.510): "There is hardly a dermatologist or roentgenologist who has not written or spoken (medical society meetings) of the use of x-rays or radium in the treatment of psoriasis. Consequently the literature dealing with the subject is voluminous."
The statement heightens our concern about the possibly high breast-doses contributed from this source alone.
"Psoriasis may begin as a generalized eruption of discrete, rapidly evolving, lentil-sized or split-pea sized, red, conical, scaly papules. This is psoriasis guttata," they report. And (p.510): "The eruption may undergo spontaneous involution in a few weeks or months, but it is more likely to persist and evolve into the nummular, inveterate or other chronic types." And (pp.510-511): "At times, also, the eruption becomes universal, and it may then assume characteristics that compel a diagnosis of dermatitis exfoliativa. These unusual examples may occur spontaneously or they may be the result of improper treatment, either medicinal or by irradiation."
X-Ray Therapy: Often Effective, but Needing "Extreme Caution"
Mackee and Wise have high praise for x-ray therapy, provided it is appropriately used (p.511): "Before attempting to treat psoriasis with x-rays or radium the reader is urged to study the disease in some standard treatise on dermatology. The roentgenologist should know how the disease may behave when left alone and how it may act under the influence of various kinds of treatment." And: "It is doubtful if any therapeutic agent or combination of agents can compare with x-rays (intelligently employed) in general efficacy for the treatment of the lesions of psoriasis, provided the case is one that is suited for x-ray treatment." And: "In spite of the excellent results obtained with x-rays in the treatment of psoriasis, irradiation is by no means the method of election. Extreme caution and judgment in the use of the x-rays and in the selection of cases for such treatment are necessary, not only in order to obtain good results but in order to avoid bad results."
Treatment of Psoriasis by Irradiation of the Thymus Region
MacKee and Wise provide a brief discussion (pp.513-514) of treatment of psoriasis by irradiation of the thymus gland with x-rays or radium. They note that "In the United States, most dermatologists have abandoned this method of treatment"; they do not say how widely or for how long it was used. The patient "may receive a fractional dose (137 r) once weekly." MacKee and Wise cite some papers reporting very good results (for example, success in 65.8% of the cases) and some other papers reporting failure (few improvements).Part 4. Lichen Planus, Involving "Almost Any Part of the Body"
This disorder, lichen planus, is treated by MacKee and Wise in their Chapter 31. "Lichen planus usually develops slowly and runs a chronic course. The sites of predilection are the flexor surfaces of the forearms, the inner aspects of the thighs, the glans penis and the buccal mucosa; but almost any part of the body may be involved; the eruption, in fact, may be generalized ... The elementary lesion is a pinhead-sized, flat-topped, shiny, smooth, more or less polygonal, sometimes umbilicated papule. The color is lilac --- violaceous. The subjective symptom is itching, which may vary from mild to intense" (p.524).
A Challenge to "the Consensus Opinion"
"Lichen planus, treated or untreated, may last for months or years. Individual lesions may persist or the eruption may continue to exist through the formation of new lesions, the older lesions undergoing spontaneous involution. It seems to be the consensus of opinion that the spontaneous cure of lichen planus is uncommon. This, however, is not our impression. While not desiring to make a definitive statement, personal impression is that many cases of ordinary lichen planus will disappear without treatment in from six months to a year or two" (pp.524-525).
Radiation Therapy: "Variable and Capricious" Results
"Lichen planus responds in a variable and capricious manner to roentgen therapy. As a general rule, the acute and subacute varieties of eruptions, whether occurring as isolated crops or as widespread exanthems, undergo fairly prompt involution as a result of a series of fractional doses of unfiltered radiation. On the other hand, patients whose eruptions are resistant to treatment, even when such treatment is pursued up to a `dosis tolerata,' not infrequently are encountered by most dermatologists" (p.525).
"Strange to Say," We Didn't See What We Thought We Saw
In this chapter, as in his Preface, Dr. MacKee seems to allude with some awe to the physician's potential for self-delusion (see our Chapter 33, Part 2). Referring to the observation, above, that radiotherapy for lichen planus fails "not infrequently," MacKee and Wise say (p.525):
"An interesting side-light in connection with this observation is that during the initial period of fifteen to twenty years in which irradiation therapy had been used, the general impression prevailed that the disease is in most cases readily amenable to such therapy. Strange to say, in the past ten years or so, experience has demonstrated the fact that we were too optimistic in this regard. Cases are encountered in which the eruption not only is refractory to radiation therapy, but in which fresh lesions appear during active treatment long after the stage of acute development of the eruption. (In some instances, this holds true also with respect to medicinal therapy.) Hence one should be guarded in making prognostic pronouncements in relation to all varieties of lichen planus."
Their comment reminds us how it has often happened in medicine that a new pharmacologic therapy has been introduced with initial, peer-reviewed reports which positively glowed about the fabulous results observed. The key word is "observed." And yet after a couple of decades, some of these therapies have been discarded --- as ineffective. Is there really any profession which is immune to the pitfalls of wishful self-delusion?
# # # # #
"Universal acceptance of a procedure [in medicine] does not
necessarily make it right."
- George Crile, Jr., M.D. (from p.9 in
Oncology Times Vol.15, No.2: Feb. 23, 1993).