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92 R a d i u m
other hand, roentgen-ray treatment should be supervised directly by the
roentgenologist, for its dangers can be estimated and avoided only by
the specialist trained in this novel branch of physics. Neither remedy
should be in the hands of the novice, for each is attended by great
hazards if injudiciously employed.
While the value of irradiation has been established, it yields its best
therapeutic results only to the careful diagnostician who takes into account
the size and character of the tumor, its symptomatology, the age
and nervous stability of the patient, and the associated or coincident
pathological lesions. In the gynecologic clinic of the University of Pennsylvania
we have for some time rested our decision as to the irradiation
of these tumors upon one chief point, and that is hemorrhage. Furthermore,
experience has confirmed another rule, and that is to submit all
tumors over the size of a four months pregnant uterus to operation unless
there are such grave contraindications as to render surgical intervention
a too hazardous policy. Tumors which have as their chief
symptomatic manifestation pressure effects, should fall within ihe surgical
domain, whereas in those uncomplicated tumors of a size under ihat
of a four months pregnant uterus, whose sole symptom is excessive
bleeding, irradiation is the method of treatment par excellence provided
the patient is beyond her fourth decade, and that the tumor is not of the
large submucous type. Myomata in young women fall, as a rule, within
the surgical domain, as a myomectomy or partical hysterectomy, with
preservation of the ovarian function, is decidedly preferable to irradiation.
A point relative to the irradiation menopause: At one time we
held as a blanket rule that ihe nearer the meridian of life the menopause
was induced by any artificial means, ihe less the climacteric disturbances.
As a result of comparative reviews of a series of myomata
and pelvic inflammatory cases passing through the Gynecologic Service
of the University Hospital, in which a surgical or an irradiation climacterium
has been induced, it has been found that in general the age factor
is still of capital importance in estimating the severity of this precipitate
issue. However, another weighty factor, and one always to be
estimated most carefully, is the nervous stability of the patient. A
woman of equitable temperament at thirty years of age may be shaken
relatively little by the abrogation of the ovarian function, whereas a
nervous, apprehensive, neurotic woman in the fourth decade, will pass
through a veritable climacteric upheaval if nature is forestalled in this
event, just as she may when its natural termination arrives. In a nervous
woman, therefore, the extirpation of the tumor with the conservation
of ovarian tissue even in the menopausal years must take precedence
over irradiation. The fear of malignant transformation in myoma uteri
has been greatly overstressed in the past as is shown by a critical pathological
analysis of 816 myomatous tumors, which have passed through
the Gynecologic Laboratory of the Hospital of the University of Pennsylvania.
In this large number of cases only 25 sarcomata were discovered,
and of these 12 could in no sense be considered as malignant
transformations, but were sarcomata from the start and were so diagnosed
clinically. In more than 1.300 hysterectomies, sarcoma subsequently
developed in the cervical stump in only one case and this sequel
was cured by two applications of radium. The infrequency of this type
of malignant change and its dangers is therefore of negligible import
as an urgent indication for surgical intervention.
Since cancer of the fundus can practically always be determined