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X-ray and radium in conservative gynecology
X-RBY
AND
RBDIUM
BY ~THUR
IN
CONSERV~4TIVE
E. HERTZLER, M.D., From
the
Ha81stead
GYNECOLOGY
HALSTEAD, KAISSM
Hospital
T
0 those surgeons who have lived through the terrible years of the wholesale castration of women, the present trend of the development of the actinic ray therapy must be regarded wit.11 a feeling akin to consternation. On one day I recently had three experiences which awakened my gravest apprehension. These mere as follows : A patient came to me, a school teacher, age thirty-three, with the complaint of pa.in in the pelvis and flooding. A fibroid was dia,gnosticated hy her surgeon and operation advised. She consulted a roentgenologist who assured her that he could relieve her of her trouble. Radium and sray were used. The hemorrhages ceased and t.he pelvic discomfort lessened and she was hopeful. The hemorrhages ceased altogether and she was apprehensive of a premature menopause. Then came a series of nervous phenomena which she attributed to worry over the absence of her menses. The symptoms were typical of the castration menopause. She was followed by a woman in her early thirties who, following the She care of a sick parent, had a, prolonged and painful menstruation. consulted her physician who after the failure of simple remedies advised s-ray and radium. The metrorrhagia ceased and in three months the menses also ceased. She divined the import and consulted her physician. Would the menses return ? He did not know. She came to me with the same question. 1 did not have a better answer. Could anything be done in a surgical way to bring them back? Nothing. Her lamentations were pitiful. She had devoted her life to an ailing parent, whose death now made possible a lon, n deferred marriage which now must remain childless. A patient, aged forty-five had had a pelvic tumor for some years atOperation was advised but she tended by an increasing hemorrhage. was told she could be cured by radium. She was treated by one of OLW The hemorrhages ceased but the tumor most competent radiologists. filled the pelvis. She asked if there was any danger of the tumor becoming cancerous. Nobody knows. I could not even be sure if it n-as a myoma, or an ovarian sarcoma, so snugly did it fill the pelvis. I chanced to read the same day, an article written in 18’72, an account of the then new treatment of myoma. It stated that by the removal of the ovaries the hemorrhages would cease and sometimes the t,umor shrank. Then I read in the latest number of a well-known journal an article bearing the heading of this paper, by one of our most prominent gynecologists. It said that by means of radium we could make the hemorrhages stop, sometimes the tumor shrank, using the very same 33
294
THE
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GYNECOLOGY
words of the all too famous Massey ( ?). Neit’her article mentioned the suffering of the artificial menopause. If there is one operation in surgery now on a sound basis, it is the surgical treatment of myomas of the uterus. The mortality after hysterectomy for myomas is the mortality of complications. Many operators have had runs of a hundred or more cases without a death. h good operator, if he be not too lazy, can remove the tumor by conservative myomectomy and preserve for his patient a menstruating organ. The uterus is more than a reproductive organ, it is also the balance wheel of civilization. There is no zoological classification that has reserved a place for the castrated woman. No method of treatment that brings this state in its wake can have a place in modern therapeutics. No procedure that does not give the surgeon an opportunity to determine the pathology of the tumor is sound surgical practice. Three or four per cent of myomas become malignant. The operator who has an operative mortality so high as this is not a good surgeon. He is doing things he ought not to do. It is argued that one should con6ne the radium treatment only to those patients whose myomas are uncomplicated. Expert gynecologists with an extensive clinical experience cannot diagnosticate the various complications, to which myomas are liable, with infallibility. Even they find unsuspected changes in the tumors which are revealed only on section. Early sarcomatous degeneration, hemorrhagic myomas and early carcinomas of the fundus are beyond the ken of physical examination. The x-ray operator, untutored in pathology, cannot hope to make the niceties of distinction the selecting of the uncomplicated cases require. *4t best he can control but one symptom : hemorrhage. The effect of the rays on the tumor itself is problematic. Some shrinking sometimes occurs but complete disappearance is the exception. It is not uncommon to see sarcomas develop in myomas which have ceased to bleed because of the natural menopause and we are not sure but that the same thing may follow the amenorrhea due to radiation. It is said the patient should be examined first by a competent gynecologist in order to determine if the myoma is complicated. Such an arrangement, like the purification of politics, is, in the language of a famous Kansan, an irridescent dream. Roentgenologists as a class are a “cocky” lot and seldom require consultation. This is the natural mental attitude of the specialist in a narrow field and roentgenologists can escape it only by broadening the field of their knowledge. Experience already has proved that they as a rule, do not inquire further than to know that the patient bleeds, a symptom they are able to control. Even more undesirable is the use of radiation in the metrorrhagia of adolescence. In these patients the nervous disturbances from the loss of ovarian function is most severe. It is only slightly less so in
HERTZLER
:
S-RAY
AND
RADII231
2%
mature nonparous women. These cases can be managed by less radical means. We now know that the majority of these are endocrine disorders and are amenable to other treatment. Sterilization is never warranted. If we cannot trust the competent roent.genologist to properly select the cases, and trained gynecologists realize full well they are not able to do so, what shall we say of those possessed of radium who are neither trained radiologists nor surgeons? It is not right to condemn a method because it has fallen into hands wholly incompetent to even approximately select the cases most suitable to its use. Sererthelesx, patients are being treated by such as these. Many of the unfortunate patients I have seen have been dealt with by men the best of their class. We cannot expect more of the incompetent. Yet the incompetent cite the opinion of prominent gynecologists as a warrant for treating these patients with radium. We now know that when a uterus bleeds abnormally we can find out w-hy it bleeds. No man can tell by physical examination alone why it does so. When the cause has been found it may be gently removed and sent to the laboratory and there studied in its ultimate detail. It is only by pursuing this method of study that we may hope to advance and permit the rising generation of surgeons to maintain the present level of efficiency. If we treat bleeding uteri by radium the next generation of gynecologists, like the roentgenologists, will know only two kinds of uteri-those that bleed and those that do not. The clinical diagnosis of uterine hemorrhages, like the clinical diagnosis of syphilis, will go into the discard. We will become a profession of vulva inspectors just as we are in danger of becoming one of Wassernmnn readers. The management of myomas is one of the most brilliant achievements of surgery and all this knowledge should not be cast into the discard because it has been discovered that hemorrhage may be stopped by radium. It does not cure the disease, it but controls one of its most obvious symptoms. The surgical management of myomas is based on sound knowledge of pathology and the results are guaranteed by a vast clinical experience. The use of actinic rays is not a proper treatment of myoma. It controls one symptom only. We know nothing of the ultimate fate of the tumor left behind. The Massey method of castration was unsatisfactory and the profession labored for fifty years to get away from it. Let the rising profession take this word from one who has lived through one period of promiscuous cast.ration ; there is nothing more pitiable than the castrated female who does not understand the cause of her multitudinous complaints ; nothing more heart rending than the sufferer who understands the cause and appreciates its meaning; and nothing more damnable in the eye of the surgeon who has been through it all and knows it is all wholly unnecessary. In the language of Olshausen, “I have seen enough. ”
AND
RBDIUM
BY ~THUR
IN
CONSERV~4TIVE
E. HERTZLER, M.D., From
the
Ha81stead
GYNECOLOGY
HALSTEAD, KAISSM
Hospital
T
0 those surgeons who have lived through the terrible years of the wholesale castration of women, the present trend of the development of the actinic ray therapy must be regarded wit.11 a feeling akin to consternation. On one day I recently had three experiences which awakened my gravest apprehension. These mere as follows : A patient came to me, a school teacher, age thirty-three, with the complaint of pa.in in the pelvis and flooding. A fibroid was dia,gnosticated hy her surgeon and operation advised. She consulted a roentgenologist who assured her that he could relieve her of her trouble. Radium and sray were used. The hemorrhages ceased and t.he pelvic discomfort lessened and she was hopeful. The hemorrhages ceased altogether and she was apprehensive of a premature menopause. Then came a series of nervous phenomena which she attributed to worry over the absence of her menses. The symptoms were typical of the castration menopause. She was followed by a woman in her early thirties who, following the She care of a sick parent, had a, prolonged and painful menstruation. consulted her physician who after the failure of simple remedies advised s-ray and radium. The metrorrhagia ceased and in three months the menses also ceased. She divined the import and consulted her physician. Would the menses return ? He did not know. She came to me with the same question. 1 did not have a better answer. Could anything be done in a surgical way to bring them back? Nothing. Her lamentations were pitiful. She had devoted her life to an ailing parent, whose death now made possible a lon, n deferred marriage which now must remain childless. A patient, aged forty-five had had a pelvic tumor for some years atOperation was advised but she tended by an increasing hemorrhage. was told she could be cured by radium. She was treated by one of OLW The hemorrhages ceased but the tumor most competent radiologists. filled the pelvis. She asked if there was any danger of the tumor becoming cancerous. Nobody knows. I could not even be sure if it n-as a myoma, or an ovarian sarcoma, so snugly did it fill the pelvis. I chanced to read the same day, an article written in 18’72, an account of the then new treatment of myoma. It stated that by the removal of the ovaries the hemorrhages would cease and sometimes the t,umor shrank. Then I read in the latest number of a well-known journal an article bearing the heading of this paper, by one of our most prominent gynecologists. It said that by means of radium we could make the hemorrhages stop, sometimes the tumor shrank, using the very same 33
294
THE
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
GYNECOLOGY
words of the all too famous Massey ( ?). Neit’her article mentioned the suffering of the artificial menopause. If there is one operation in surgery now on a sound basis, it is the surgical treatment of myomas of the uterus. The mortality after hysterectomy for myomas is the mortality of complications. Many operators have had runs of a hundred or more cases without a death. h good operator, if he be not too lazy, can remove the tumor by conservative myomectomy and preserve for his patient a menstruating organ. The uterus is more than a reproductive organ, it is also the balance wheel of civilization. There is no zoological classification that has reserved a place for the castrated woman. No method of treatment that brings this state in its wake can have a place in modern therapeutics. No procedure that does not give the surgeon an opportunity to determine the pathology of the tumor is sound surgical practice. Three or four per cent of myomas become malignant. The operator who has an operative mortality so high as this is not a good surgeon. He is doing things he ought not to do. It is argued that one should con6ne the radium treatment only to those patients whose myomas are uncomplicated. Expert gynecologists with an extensive clinical experience cannot diagnosticate the various complications, to which myomas are liable, with infallibility. Even they find unsuspected changes in the tumors which are revealed only on section. Early sarcomatous degeneration, hemorrhagic myomas and early carcinomas of the fundus are beyond the ken of physical examination. The x-ray operator, untutored in pathology, cannot hope to make the niceties of distinction the selecting of the uncomplicated cases require. *4t best he can control but one symptom : hemorrhage. The effect of the rays on the tumor itself is problematic. Some shrinking sometimes occurs but complete disappearance is the exception. It is not uncommon to see sarcomas develop in myomas which have ceased to bleed because of the natural menopause and we are not sure but that the same thing may follow the amenorrhea due to radiation. It is said the patient should be examined first by a competent gynecologist in order to determine if the myoma is complicated. Such an arrangement, like the purification of politics, is, in the language of a famous Kansan, an irridescent dream. Roentgenologists as a class are a “cocky” lot and seldom require consultation. This is the natural mental attitude of the specialist in a narrow field and roentgenologists can escape it only by broadening the field of their knowledge. Experience already has proved that they as a rule, do not inquire further than to know that the patient bleeds, a symptom they are able to control. Even more undesirable is the use of radiation in the metrorrhagia of adolescence. In these patients the nervous disturbances from the loss of ovarian function is most severe. It is only slightly less so in
HERTZLER
:
S-RAY
AND
RADII231
2%
mature nonparous women. These cases can be managed by less radical means. We now know that the majority of these are endocrine disorders and are amenable to other treatment. Sterilization is never warranted. If we cannot trust the competent roent.genologist to properly select the cases, and trained gynecologists realize full well they are not able to do so, what shall we say of those possessed of radium who are neither trained radiologists nor surgeons? It is not right to condemn a method because it has fallen into hands wholly incompetent to even approximately select the cases most suitable to its use. Sererthelesx, patients are being treated by such as these. Many of the unfortunate patients I have seen have been dealt with by men the best of their class. We cannot expect more of the incompetent. Yet the incompetent cite the opinion of prominent gynecologists as a warrant for treating these patients with radium. We now know that when a uterus bleeds abnormally we can find out w-hy it bleeds. No man can tell by physical examination alone why it does so. When the cause has been found it may be gently removed and sent to the laboratory and there studied in its ultimate detail. It is only by pursuing this method of study that we may hope to advance and permit the rising generation of surgeons to maintain the present level of efficiency. If we treat bleeding uteri by radium the next generation of gynecologists, like the roentgenologists, will know only two kinds of uteri-those that bleed and those that do not. The clinical diagnosis of uterine hemorrhages, like the clinical diagnosis of syphilis, will go into the discard. We will become a profession of vulva inspectors just as we are in danger of becoming one of Wassernmnn readers. The management of myomas is one of the most brilliant achievements of surgery and all this knowledge should not be cast into the discard because it has been discovered that hemorrhage may be stopped by radium. It does not cure the disease, it but controls one of its most obvious symptoms. The surgical management of myomas is based on sound knowledge of pathology and the results are guaranteed by a vast clinical experience. The use of actinic rays is not a proper treatment of myoma. It controls one symptom only. We know nothing of the ultimate fate of the tumor left behind. The Massey method of castration was unsatisfactory and the profession labored for fifty years to get away from it. Let the rising profession take this word from one who has lived through one period of promiscuous cast.ration ; there is nothing more pitiable than the castrated female who does not understand the cause of her multitudinous complaints ; nothing more heart rending than the sufferer who understands the cause and appreciates its meaning; and nothing more damnable in the eye of the surgeon who has been through it all and knows it is all wholly unnecessary. In the language of Olshausen, “I have seen enough. ”