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The Limitations of Radiotherapy in the Management of Fibromyoma of the Uterus*
THE
IJMITATIONH MENT
OF RADIOTHERAPY OF FIBR,OMYOMA
IN
OF THE
BY JAMES ALBERT CORSCADEN, M.D., NEW
THE
J[ASAGI:-
IJTF:RI’S” YORK,
N.
Y.
0
NE of the *greatest recent advances in gynecology has been tllc utilization of radiotherapy. About fifty per cent of those needing treatment for fibromyoma of the uterus have been saved from major operations. It is my purpose to outline those factors which, from an observat,ion of about six hundred cases of myoma and nterinc hemorrhage, have ruled out radiotherapy and hare indicated operation. If n-e can sharply define what radiotherapy will and will not do, our choice of procedure will be easier. The action of radium and s-ray is readil?- nndrrstand;~hle if we belieye t,hat life growth and physiological activity of a cell arc physical chemical manifestations and arc governed bv the laws of physitds and cheniist.ry. According to the electronic theory of the composition of matter. which seems to hc nniT-ersally accepted 1)~ the chemists, chemical cliang:c> tlq)tqids on the manipulation of the cllrctrons composing the atcm. thf> positivei!charcetl Radium furnishes three forms of rnrrg:\-. ;~lpha particle. the negatively cltargetl beta particle and the electroThe s-ray furnishes us with onI>- an tllcl*troniapnetic* gamma ray. These harr tbe power of dislodging the electrons magnetic wave. in various atoms and in consequence protluce chemical change. .\\‘e all know how variable is the action of heat and light on tlifferent substances. Ho in the body Iherr is a marked Tariatinn in the I,clilction of the tissues to radium anal s-ray iiistanced in the re[)rodllcti\-c s\-steIn 1,~ the praafian follicle which is about fi\-P times as rf~adil,v injured as is the skin. fift)- milligrams \\%cn H tube of conrentional shapr~ containing of r;j(lillm is left in tlie cavity of tllc uterus for t\\rllty-fnllr 110111~~ there occur: 1. A slongh of t,hc endometriunt ahont 1 ccntimcter wide, 111~~ centimeters long, and two or three millimeters deep. There is sub sequ~ntl;a slight inflammatory react,ion with discharge. 3. A replacement of the elastic tissue and smooth muscles of the blood vessels and uterine muscle by connective tissue. 3. A degeneration of myomatous tissue for a depth of about 1 centimeter. *Read at a meeting of the Section on Obstetrics anA Gynecology, New York Academy of Medicine. February 37, 1923. 42
CORSCADEN
:
LIMITATIONS
OF
RADIOTHERAPY
4x
4. Destruction of the mature graafian follicles which causes: a. Cessation of menstruation. b. Consequent atrophy of the uterus and of myomata with replacement by hyaline connective tissue. c. Loss of part of the internal secretion of the ovary with whatever consequences that may have. 5. Injury to the bowel and bladder (not observed in my experience). 6. Change in the blood count (also not observed).
These seem to he the actual tissue and physiological effects. Turning to their practical application in the management of fibromycma of the uterus we are met with mow than the simple problem of an anatomical or l~hysiological experiment. MTe face questions of (1) diagnosis, (2) the nature and potential menace of t.he tumor, (.3) the relief of the symptoms, (4) possible clisagreeable effects of the method of treat,ment, (5) the question of childbearing. 1. Of all these I think the first is of the greatest importance. Before applying radiotherapy in an individual who is a good operative risk, the diagnosis must always be nearly absolute because, in the alternative method of treatment by excision, an exploratory celiotomy
44
THE
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GYNECOLOGY
is included. This problem was more acute a few years ago than it is now. At that time the majority of gynecologkts were ignorant of radiotherapy and for the most part opposed to it. The management of the problem lay between the family doctor, the patient, and a radiologist. The results of such divided responsibility are illustrated by the following instances : -4 competent gynecologist made a diagnosis persuaded the family doctor to refer gave her a thorough course of x-ray trcatmcnts the end of .a year the mass had not reccdcd. with actively proliferating tissue.
patient
of fibromyonra of the uterus. her to a prominent radiologist, ou the diagnosis given to him. Operation revealed a dermoid
The who At cyst
To one of the leading radiologists of this city came a patient with a letter from a prominent Boston physician requesting that she be given the regular x-ray treatment for myoma. On taking a history it WLS found that the diagnosis had been first made ten years prcvionsly, the last vaginal examination had bcc~n made four
years small meters
previously, and the woman had not menstruated for two years. She had a rctroverted uterus which contained a stony hard mass, three or four centiNature had accomplished all that radiotherapy could do. in diameter.
The second phase of the diagnosis is the exclusion of dangerous complicating pathology. In my experience this has narrowed down to the exclusion of extrauterine and intestinal tumors on the one hand and to carcinoma of the body and epithelioma of the cervix on the other hand. We have discovered during the final examination on patients possessing a myoma of the uterus or suffering from uterine bleeding, diverticulitis of the sigmoid, carcinoma of the rectum, and dermoid and ‘several simple cysts of the ovary, as well as epithelioma to the of the cervix and carcinoma of the corpus ut,eri. ‘Contrary opinion often expressed, I do not fear chronic inflammations. I have cured by x-ray one tuberculous sinus following salpingectomy (followed 7 years) and have treated with massive x-ray dosage, two cases of large myoma of t,he uterus, complicat,ed with massive adhe-
CORSCADEN
:
LIMITATIONS
OF
45
RADIOTHERAPY
sions due to chronic salpingitis (in one case, tuberculous). This was done after an attempted hysterectomy had been abandoned because No apparent harm resulted. Several of the technical difficulties. cases of tuberculous peritonitis of tubal origin hare been markedly improved. To summarize: If at the end of an examination under anesthesia
Fig. I.-Section of the endometrium was applied.
taken and
from fundus in Fig. 1. still shows the hyperplasia
It
shows thr which existed
uninjured before
character the radium
and diagnostic curettage, extrauterine tumor cannot be excluded, the abdomen should be explored. Carcinoma and epithelioma are more easily excluded by the curette and if found properly handled. 2. The nature and potential menace of the tumor. A myoma is benign and needs no treatment until suspicious changes occur. This is in accord with the management of many other benign tumors, such as warts and moles. When however degeneration or inflammation is evidenced by toxic symptoms, anemias, unexplained by hemorrhage
46
THE
AMERICAN
JOI’RNAL
OF
OWTETKI(‘S
AK11
(:YNECOLO(;X
or loss of tIesI and strength, with or \vithollt local pain or temlerness. or rttpitl inereaw in size of the tumor. thr maw I)ecomes a potential menace and should he remove& Rapid growth might also signify sarcoma. and eYeI without other contril)uting factor indicates l;ll)ar0tcm1\-. JIasses of large size (ovtbr 12 to 15 centimeters) I l)eliel-e sho7~a higher incidence of degeneration and slionltl also be remo~wl.
It n-ill not stop, liowc:\-er. if the destrnvtion of the follicles has not hwn srdficiclnt to strip menstruation, or if thv rndom&rium has not been largely destroyed. ITnderdosagt~ ina! lw tleliberate. The effort is matlr to modify the bleeding without stopping it entirely, smull doses luring given with the idea that the local effect is the important one. Our specimens, showing the limited local reaction, wnulcl not bear this out. 1 have tried this method in only a few cases. In onl> one did the mass recede while menstruation persisted. The hlwdin: rarely )~e~~mesregular and the patients require more or less frequent The mental cond;tion of these patients is I~ad. The examinations. reappear;,nce cif the lderrling arouses the fear t.hat the original hemnrrhaprs will return. They lose ronfidencc in the original operatol
CORSCADES
:
LINITAI~IONS
OF
RADIOTHERAPY
47
ant1 in the method no matter what ln~gnosis has been given. Ill my opinion. if there is any objection to the sterilizin g dose and the woman is it good surgical risk, operation sho~~ld be performed. Other causes of underdosage are: a. I’ailure to appreciate the law of inverse squares. An o\-ark- liftvtl iIn-Cly from the uterine cavity will require more Of i\ dose thau nnt: that is normal in its position. If twice as far, four times ilS much. A radium tube slipped into or placed in the vagina will give a tlifferent dosage to the ovaries from one high in the fundus. 1). A broken
radium
tube gives off onlr part, of its arailab!e
t’~~(ar::‘~.
because of the escape of a considerable portion of the emanation ant1 consequent loss of the active degeneration products. Bleeding may not stop with cessation of menstruation if ulceration such as occurs in a protruding and traumatized polyp is the cause of the bleeding. A myoma, pedunculated and hanging out of the cervix or even st,ill intrauterine might be eroded and would bleed irrespective of menstruation. The most difficult variety upon which to pass OIlP is the small suhmucous tumor projecting into the uterine cavity. must judge whether, after the menopause, this will continue to be traumatized sufficiently to cause bleeding. If so it is better removed. Blood vascular disease such as pernicious anemia, congenital familial telangiectiasis may also continue to cause bleeding from the uterus
48
THE
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GYNECOLOGY
after the menopause as well as from the other delicate membranes of the body. Dysmenorrhea has always ceased with the onset of amenorrhea. 011 the other hand severe pain unassociated with menstruation has only occasionally stopped (30 per cent). In the operated cases pain associated with a uterine tumor smaller than a four months pregnancy has usually been due to causes outside of the uterus (appendicitis, cholelithiasis, salpingitis) and consequently would not always be relieved by the shrinkage of the uterine mass. Urinary- symptoms have been equally refractory. I have not conpared this result with that followin, 0” operation but I am under the impression that it is not as good. 4. The dangers and discomforts of the method. Dilatation and curettage followed by radium are not without danger. One w0ma.n died of pulmonary embolism 20 hours after operation. This must he attributed to the curettage and not to the radium. Two patients had slougl~s in the uterine cavity and required treatment. There mere three cases of fever and parametriti’s due, I believe, to operative They were infection and not to the lighting up of an old focus. uterine and broad ligament processes rat,her than tubal. Furthermore no such condition has followed x-ray exposures in our hands. A few All had cases showed albumin and casts? particularly after x-ra.y. Of the remote menopause some toxemia with nausea and vomiting. symptoms, only hot flashes and nervousness were of any importance. The discomfort caused by flashes is usually slight, rarely distressing. Properly instructed, a woman rarely mill need t,reatment by ovarian The patient must be warned of them however because they extracts. begin suddenly and if unlooked for. cause considerable apprehension. Severe nervous manifestations 1mJ.C occnrreil in five women. ,411 of them had more or less severe nrrvolis manifestations before the treatment. were worse for several months after ancl in all but one case recnvered or b&erect their previous nervous condition. Our experience corresponds with the observations of Adler on the of the natural menopause. He so-callecl “involutional psychosis” t,hat the psychoses of sa,m in his book on the “ Neurotic Constitution” this period occurred in women who had previously shown definite abnormal nervous symptoms. In women with an unbalanced nervous mechanism, especially those who have given signs of a decided nervous disorder, the artificial menopause should only be induced after a competent neurologic consultation. If under these circumstances radiotherapy is then given, there should he a well planned prophymctic and postoperative course of psychotherapy. Ovarian extract is of little help. We have not observed any of the vague anemias, trophic and meta-
CORSCADEN
:
LIMITATIONS
OF
RADIOTHERAPY
49
bolic changes sometimes attributed to the absence of menstruation. Blood pressure was slightly elevated in some of the women over forty years of age but in none of those under that age. Of the possible late changes in a myoma, sarcoma is the most important. I can find in the literature onl’y three such cases19 “3 3 Two of these were found in from three to six months after x-ray treatment and This inseem to have been mistaken diagnoses in the first place. significant number removes sarcoma as a danger. In the cases treated there have been no degenerations or inflammations. Accidents such a.s torsion may well occur, but have not been observed. 5. Effect on childbearing. Only two patients have become pregnant. One woman of thirty-seven with a myoma eight to ten centimeters in diameter received 1200 milligram hours intrauterine. She later became pregnant, miscarried at six months, had a perfectly formed macerated fetus, ran a peculiar long septic course without demonstrable pathology and recovered. I believe the cause of the miscarriage to lie in the local sclerotic changes in the endometrium and muscle added to the mechanical abnormality incident to t,he myoma. The other was a woman of twenty-four years referred by the late Doctor Cragin for excessive bleeding. She had no gross abnormalities of the uterus. She was given a moderate dose of x-ray. Her periods became normal in amount, slightly irregular in periodicity. Three years later she became pregnant and gave birth to an eight and one.half pound boy, perfectly formed. He is now three years old and healthy. The problem of future childbearing may he approached from two directions: first, the effect of radiotherapy on the uterus and second, the effect on the ovum. Radium as demonstrated above produces a slough mit,h scars in the endometrium and sclerosis of the vessels and myometrium. These uteri are not pliable. I know of one uterus treated by radium in which the cervix ruptured while dilating over the head The x-ray on the ot.her hand has and caused deat.h by hemorrhage. only a mild action on muscles and vessels. I see no objection, from this standpoint, to giving moderat,e doses of x-ray through the abdomen. The effect on the ovum, however, is much the same with either method. There is some evidence that injury without destruction of an ovum may alter the development of the embryo so as to cause physical abnormalities and disturbances of growth and mentality. Nevertheless some mothers have gone through the ordeal and produced perfect children. I should therefore say that with a view to future pregnancy, x-ray in nonsterilizing doses to patients suffering from bleeding without myoma is just.ifiable when hysberectomy is the only
50
THE
AMERICAN
JOURNAL
OF
OBSTETRICS
alternative, but that n-here a myoma n1yomectom>- is preferable.
AND
GYNECOLOGY
is responsible
for the ljleeding.
CONCLUSIONS
1. In the treatment cf myoma of the uterus by the radiotherap!the selection of the case is the most important phase. a. Responsibility should be undivided. 1). Extrauterine neoplasms and malignant growths of the uterus must be excluded. Chronic adnexal inflammation so light as to escape diagnosis need not be a deterrent. c. Symptoms of toxemia, anemia unexplained by loss of blood. local pain; tenderness, change in consistence of the tumor. rapid grojvth. and large size may indicate inflammation, degeneration or sarcomatons change and demand excision. 2. Of the symptoms associated n-it11 myoma: a. Hlrrding due to ulceration (polyps. submucous, pediuicnlatetl myomatw ) or blood vascular disease (pernicious anemia, familial trlIn 0111’ aiigiectahisi may not cease with the onsrt of the menopause. c~spr~ric~iic~rfiall others will. 1,. P;I;IJ ilssclc~iated with menstruation will cease but pain occ.ui*riiio. at other times may not.
5. (‘hiitlliwar;ng is possible after radiotherapy. :J. lZa(liuJrl should never be used in a woman who may lwcnmt~ Thrl sclerotic changes predispose to cl-stocia. Ilant. 11. S-ray map disturb the struct,nre of an owm and determine 1101-mal vtrueturC nr development nf the fetus. It should only be TV~~~JY~ li>.hterectomy is the only alternative.
pwgill)nsrtl
REFERENCES
[I ‘; .Ttrcfjfril~, G. E.: Tr. of Hint~,stoi.ss~r. 5'1
EAST
P.: Gynllrcologie rt Obet6triquc, 1921, iii, 90. (3) the College of Physicians8 of Phila(leJphia, 1915, xxsrii, IT. : Zentralblatt fiir Gynikologie, 1920, xliv, 977.
SIXTY-THIRD
Srcmr.
(For
discz~ssion,
slrotml~~r. ( :: ,I 142. SCF 21. lS9.)
IJMITATIONH MENT
OF RADIOTHERAPY OF FIBR,OMYOMA
IN
OF THE
BY JAMES ALBERT CORSCADEN, M.D., NEW
THE
J[ASAGI:-
IJTF:RI’S” YORK,
N.
Y.
0
NE of the *greatest recent advances in gynecology has been tllc utilization of radiotherapy. About fifty per cent of those needing treatment for fibromyoma of the uterus have been saved from major operations. It is my purpose to outline those factors which, from an observat,ion of about six hundred cases of myoma and nterinc hemorrhage, have ruled out radiotherapy and hare indicated operation. If n-e can sharply define what radiotherapy will and will not do, our choice of procedure will be easier. The action of radium and s-ray is readil?- nndrrstand;~hle if we belieye t,hat life growth and physiological activity of a cell arc physical chemical manifestations and arc governed bv the laws of physitds and cheniist.ry. According to the electronic theory of the composition of matter. which seems to hc nniT-ersally accepted 1)~ the chemists, chemical cliang:c> tlq)tqids on the manipulation of the cllrctrons composing the atcm. thf> positivei!charcetl Radium furnishes three forms of rnrrg:\-. ;~lpha particle. the negatively cltargetl beta particle and the electroThe s-ray furnishes us with onI>- an tllcl*troniapnetic* gamma ray. These harr tbe power of dislodging the electrons magnetic wave. in various atoms and in consequence protluce chemical change. .\\‘e all know how variable is the action of heat and light on tlifferent substances. Ho in the body Iherr is a marked Tariatinn in the I,clilction of the tissues to radium anal s-ray iiistanced in the re[)rodllcti\-c s\-steIn 1,~ the praafian follicle which is about fi\-P times as rf~adil,v injured as is the skin. fift)- milligrams \\%cn H tube of conrentional shapr~ containing of r;j(lillm is left in tlie cavity of tllc uterus for t\\rllty-fnllr 110111~~ there occur: 1. A slongh of t,hc endometriunt ahont 1 ccntimcter wide, 111~~ centimeters long, and two or three millimeters deep. There is sub sequ~ntl;a slight inflammatory react,ion with discharge. 3. A replacement of the elastic tissue and smooth muscles of the blood vessels and uterine muscle by connective tissue. 3. A degeneration of myomatous tissue for a depth of about 1 centimeter. *Read at a meeting of the Section on Obstetrics anA Gynecology, New York Academy of Medicine. February 37, 1923. 42
CORSCADEN
:
LIMITATIONS
OF
RADIOTHERAPY
4x
4. Destruction of the mature graafian follicles which causes: a. Cessation of menstruation. b. Consequent atrophy of the uterus and of myomata with replacement by hyaline connective tissue. c. Loss of part of the internal secretion of the ovary with whatever consequences that may have. 5. Injury to the bowel and bladder (not observed in my experience). 6. Change in the blood count (also not observed).
These seem to he the actual tissue and physiological effects. Turning to their practical application in the management of fibromycma of the uterus we are met with mow than the simple problem of an anatomical or l~hysiological experiment. MTe face questions of (1) diagnosis, (2) the nature and potential menace of t.he tumor, (.3) the relief of the symptoms, (4) possible clisagreeable effects of the method of treat,ment, (5) the question of childbearing. 1. Of all these I think the first is of the greatest importance. Before applying radiotherapy in an individual who is a good operative risk, the diagnosis must always be nearly absolute because, in the alternative method of treatment by excision, an exploratory celiotomy
44
THE
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GYNECOLOGY
is included. This problem was more acute a few years ago than it is now. At that time the majority of gynecologkts were ignorant of radiotherapy and for the most part opposed to it. The management of the problem lay between the family doctor, the patient, and a radiologist. The results of such divided responsibility are illustrated by the following instances : -4 competent gynecologist made a diagnosis persuaded the family doctor to refer gave her a thorough course of x-ray trcatmcnts the end of .a year the mass had not reccdcd. with actively proliferating tissue.
patient
of fibromyonra of the uterus. her to a prominent radiologist, ou the diagnosis given to him. Operation revealed a dermoid
The who At cyst
To one of the leading radiologists of this city came a patient with a letter from a prominent Boston physician requesting that she be given the regular x-ray treatment for myoma. On taking a history it WLS found that the diagnosis had been first made ten years prcvionsly, the last vaginal examination had bcc~n made four
years small meters
previously, and the woman had not menstruated for two years. She had a rctroverted uterus which contained a stony hard mass, three or four centiNature had accomplished all that radiotherapy could do. in diameter.
The second phase of the diagnosis is the exclusion of dangerous complicating pathology. In my experience this has narrowed down to the exclusion of extrauterine and intestinal tumors on the one hand and to carcinoma of the body and epithelioma of the cervix on the other hand. We have discovered during the final examination on patients possessing a myoma of the uterus or suffering from uterine bleeding, diverticulitis of the sigmoid, carcinoma of the rectum, and dermoid and ‘several simple cysts of the ovary, as well as epithelioma to the of the cervix and carcinoma of the corpus ut,eri. ‘Contrary opinion often expressed, I do not fear chronic inflammations. I have cured by x-ray one tuberculous sinus following salpingectomy (followed 7 years) and have treated with massive x-ray dosage, two cases of large myoma of t,he uterus, complicat,ed with massive adhe-
CORSCADEN
:
LIMITATIONS
OF
45
RADIOTHERAPY
sions due to chronic salpingitis (in one case, tuberculous). This was done after an attempted hysterectomy had been abandoned because No apparent harm resulted. Several of the technical difficulties. cases of tuberculous peritonitis of tubal origin hare been markedly improved. To summarize: If at the end of an examination under anesthesia
Fig. I.-Section of the endometrium was applied.
taken and
from fundus in Fig. 1. still shows the hyperplasia
It
shows thr which existed
uninjured before
character the radium
and diagnostic curettage, extrauterine tumor cannot be excluded, the abdomen should be explored. Carcinoma and epithelioma are more easily excluded by the curette and if found properly handled. 2. The nature and potential menace of the tumor. A myoma is benign and needs no treatment until suspicious changes occur. This is in accord with the management of many other benign tumors, such as warts and moles. When however degeneration or inflammation is evidenced by toxic symptoms, anemias, unexplained by hemorrhage
46
THE
AMERICAN
JOI’RNAL
OF
OWTETKI(‘S
AK11
(:YNECOLO(;X
or loss of tIesI and strength, with or \vithollt local pain or temlerness. or rttpitl inereaw in size of the tumor. thr maw I)ecomes a potential menace and should he remove& Rapid growth might also signify sarcoma. and eYeI without other contril)uting factor indicates l;ll)ar0tcm1\-. JIasses of large size (ovtbr 12 to 15 centimeters) I l)eliel-e sho7~a higher incidence of degeneration and slionltl also be remo~wl.
It n-ill not stop, liowc:\-er. if the destrnvtion of the follicles has not hwn srdficiclnt to strip menstruation, or if thv rndom&rium has not been largely destroyed. ITnderdosagt~ ina! lw tleliberate. The effort is matlr to modify the bleeding without stopping it entirely, smull doses luring given with the idea that the local effect is the important one. Our specimens, showing the limited local reaction, wnulcl not bear this out. 1 have tried this method in only a few cases. In onl> one did the mass recede while menstruation persisted. The hlwdin: rarely )~e~~mesregular and the patients require more or less frequent The mental cond;tion of these patients is I~ad. The examinations. reappear;,nce cif the lderrling arouses the fear t.hat the original hemnrrhaprs will return. They lose ronfidencc in the original operatol
CORSCADES
:
LINITAI~IONS
OF
RADIOTHERAPY
47
ant1 in the method no matter what ln~gnosis has been given. Ill my opinion. if there is any objection to the sterilizin g dose and the woman is it good surgical risk, operation sho~~ld be performed. Other causes of underdosage are: a. I’ailure to appreciate the law of inverse squares. An o\-ark- liftvtl iIn-Cly from the uterine cavity will require more Of i\ dose thau nnt: that is normal in its position. If twice as far, four times ilS much. A radium tube slipped into or placed in the vagina will give a tlifferent dosage to the ovaries from one high in the fundus. 1). A broken
radium
tube gives off onlr part, of its arailab!e
t’~~(ar::‘~.
because of the escape of a considerable portion of the emanation ant1 consequent loss of the active degeneration products. Bleeding may not stop with cessation of menstruation if ulceration such as occurs in a protruding and traumatized polyp is the cause of the bleeding. A myoma, pedunculated and hanging out of the cervix or even st,ill intrauterine might be eroded and would bleed irrespective of menstruation. The most difficult variety upon which to pass OIlP is the small suhmucous tumor projecting into the uterine cavity. must judge whether, after the menopause, this will continue to be traumatized sufficiently to cause bleeding. If so it is better removed. Blood vascular disease such as pernicious anemia, congenital familial telangiectiasis may also continue to cause bleeding from the uterus
48
THE
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GYNECOLOGY
after the menopause as well as from the other delicate membranes of the body. Dysmenorrhea has always ceased with the onset of amenorrhea. 011 the other hand severe pain unassociated with menstruation has only occasionally stopped (30 per cent). In the operated cases pain associated with a uterine tumor smaller than a four months pregnancy has usually been due to causes outside of the uterus (appendicitis, cholelithiasis, salpingitis) and consequently would not always be relieved by the shrinkage of the uterine mass. Urinary- symptoms have been equally refractory. I have not conpared this result with that followin, 0” operation but I am under the impression that it is not as good. 4. The dangers and discomforts of the method. Dilatation and curettage followed by radium are not without danger. One w0ma.n died of pulmonary embolism 20 hours after operation. This must he attributed to the curettage and not to the radium. Two patients had slougl~s in the uterine cavity and required treatment. There mere three cases of fever and parametriti’s due, I believe, to operative They were infection and not to the lighting up of an old focus. uterine and broad ligament processes rat,her than tubal. Furthermore no such condition has followed x-ray exposures in our hands. A few All had cases showed albumin and casts? particularly after x-ra.y. Of the remote menopause some toxemia with nausea and vomiting. symptoms, only hot flashes and nervousness were of any importance. The discomfort caused by flashes is usually slight, rarely distressing. Properly instructed, a woman rarely mill need t,reatment by ovarian The patient must be warned of them however because they extracts. begin suddenly and if unlooked for. cause considerable apprehension. Severe nervous manifestations 1mJ.C occnrreil in five women. ,411 of them had more or less severe nrrvolis manifestations before the treatment. were worse for several months after ancl in all but one case recnvered or b&erect their previous nervous condition. Our experience corresponds with the observations of Adler on the of the natural menopause. He so-callecl “involutional psychosis” t,hat the psychoses of sa,m in his book on the “ Neurotic Constitution” this period occurred in women who had previously shown definite abnormal nervous symptoms. In women with an unbalanced nervous mechanism, especially those who have given signs of a decided nervous disorder, the artificial menopause should only be induced after a competent neurologic consultation. If under these circumstances radiotherapy is then given, there should he a well planned prophymctic and postoperative course of psychotherapy. Ovarian extract is of little help. We have not observed any of the vague anemias, trophic and meta-
CORSCADEN
:
LIMITATIONS
OF
RADIOTHERAPY
49
bolic changes sometimes attributed to the absence of menstruation. Blood pressure was slightly elevated in some of the women over forty years of age but in none of those under that age. Of the possible late changes in a myoma, sarcoma is the most important. I can find in the literature onl’y three such cases19 “3 3 Two of these were found in from three to six months after x-ray treatment and This inseem to have been mistaken diagnoses in the first place. significant number removes sarcoma as a danger. In the cases treated there have been no degenerations or inflammations. Accidents such a.s torsion may well occur, but have not been observed. 5. Effect on childbearing. Only two patients have become pregnant. One woman of thirty-seven with a myoma eight to ten centimeters in diameter received 1200 milligram hours intrauterine. She later became pregnant, miscarried at six months, had a perfectly formed macerated fetus, ran a peculiar long septic course without demonstrable pathology and recovered. I believe the cause of the miscarriage to lie in the local sclerotic changes in the endometrium and muscle added to the mechanical abnormality incident to t,he myoma. The other was a woman of twenty-four years referred by the late Doctor Cragin for excessive bleeding. She had no gross abnormalities of the uterus. She was given a moderate dose of x-ray. Her periods became normal in amount, slightly irregular in periodicity. Three years later she became pregnant and gave birth to an eight and one.half pound boy, perfectly formed. He is now three years old and healthy. The problem of future childbearing may he approached from two directions: first, the effect of radiotherapy on the uterus and second, the effect on the ovum. Radium as demonstrated above produces a slough mit,h scars in the endometrium and sclerosis of the vessels and myometrium. These uteri are not pliable. I know of one uterus treated by radium in which the cervix ruptured while dilating over the head The x-ray on the ot.her hand has and caused deat.h by hemorrhage. only a mild action on muscles and vessels. I see no objection, from this standpoint, to giving moderat,e doses of x-ray through the abdomen. The effect on the ovum, however, is much the same with either method. There is some evidence that injury without destruction of an ovum may alter the development of the embryo so as to cause physical abnormalities and disturbances of growth and mentality. Nevertheless some mothers have gone through the ordeal and produced perfect children. I should therefore say that with a view to future pregnancy, x-ray in nonsterilizing doses to patients suffering from bleeding without myoma is just.ifiable when hysberectomy is the only
50
THE
AMERICAN
JOURNAL
OF
OBSTETRICS
alternative, but that n-here a myoma n1yomectom>- is preferable.
AND
GYNECOLOGY
is responsible
for the ljleeding.
CONCLUSIONS
1. In the treatment cf myoma of the uterus by the radiotherap!the selection of the case is the most important phase. a. Responsibility should be undivided. 1). Extrauterine neoplasms and malignant growths of the uterus must be excluded. Chronic adnexal inflammation so light as to escape diagnosis need not be a deterrent. c. Symptoms of toxemia, anemia unexplained by loss of blood. local pain; tenderness, change in consistence of the tumor. rapid grojvth. and large size may indicate inflammation, degeneration or sarcomatons change and demand excision. 2. Of the symptoms associated n-it11 myoma: a. Hlrrding due to ulceration (polyps. submucous, pediuicnlatetl myomatw ) or blood vascular disease (pernicious anemia, familial trlIn 0111’ aiigiectahisi may not cease with the onsrt of the menopause. c~spr~ric~iic~rfiall others will. 1,. P;I;IJ ilssclc~iated with menstruation will cease but pain occ.ui*riiio. at other times may not.
5. (‘hiitlliwar;ng is possible after radiotherapy. :J. lZa(liuJrl should never be used in a woman who may lwcnmt~ Thrl sclerotic changes predispose to cl-stocia. Ilant. 11. S-ray map disturb the struct,nre of an owm and determine 1101-mal vtrueturC nr development nf the fetus. It should only be TV~~~JY~ li>.hterectomy is the only alternative.
pwgill)nsrtl
REFERENCES
[I ‘; .Ttrcfjfril~, G. E.: Tr. of Hint~,stoi.ss~r. 5'1
EAST
P.: Gynllrcologie rt Obet6triquc, 1921, iii, 90. (3) the College of Physicians8 of Phila(leJphia, 1915, xxsrii, IT. : Zentralblatt fiir Gynikologie, 1920, xliv, 977.
SIXTY-THIRD
Srcmr.
(For
discz~ssion,
slrotml~~r. ( :: ,I 142. SCF 21. lS9.)