UTERINE FIBROIDS.
The treatment of fibroids is in the main operative, and this is due entirely to the fact that the operative measures for their removal have been so far perfected in technique that the risk of myomectomy or hystero myomeetomy is now comparatively negligible, while the results both immediate and remote arc gratifying in the extreme. So completely has operative treatment won the field, that at the present day I do not think a single gynxeologist of note could be found who does not recommend the removal of fibroids as soon as they give rise to symptoms of pain, hemorrhage or discharge,since experience shows that once symptoms have made their appearance there is no treatment short of removal which can he relied on to put an effectual check upon them, and since the risk of operation is so slight that it cannot be held to outweigh the practical certainty of shortened life, and more or less chronic invalidism which a bleeding or infected tumour entails.
While the views just put forward are undoubtedly those of the majority of gynayologiral surgeons, it is but fair to say that within the past few years a very large amount of work has been done in the treatment of fibroid tumours by X rays and by radium, and the results already reported are so encouraging that the day seems almost to have arrived when, in cases suffering from uterine fibroids, a choice will have to be made between operation and radiotherapy. This is especially the case in patients whose main symptom is hemorrhage. The rationale of radio therapy is partly the destructive effect of the rays on the ovaries, causing a premature menopause, and partly direct action on the tumour elements, causing shrinkage of the growth. Although a number of cases have been reported in which the action of the rays was so nicely graduated that a menorrhagia gave place to normal menstruation, instead of an amenorrhoea, it seems to be generally admitted that the most suitable cases for radiology arc those which are already approaching the menopause, and that cases of submucous or gangrenous fibroids, and those in which inflammatory lesions such as pyosalpinx complicate the case, are unsuitable for the method.
Fibroids without Symptoms.—There is a growing body of opinion, in fluenced by the established fact of malignant degeneration in a certain percentage of fibroids, and by the very great probability that the tumour will ultimately cause symptoms, to the effect that once the presence of a fibroid is discovered it should be marked as suspect even in the absence of symptoms, that it should be carefully watched and examined at regular intervals, and that rapid growth or the development of tenderness should be regarded as signals for its immediate removal. In estimating the possibilities of such a tumour, it should be remembered that a subperitoneal or pedunculated fibroid is less likely to cause symptoms, while an in terstitial and still more a submucous one is almost certain to set up hremorrhage sooner or later. The patient's time of life should he kept in mind. If she is near the menopause or past it, there is a greater chance of her escaping practically every risk of a fibroid except malignant de generation, but at the same time her age removes one strong objection to a hysterectomy, for her hope of offspring is already gone. In a young woman, on the other hand, it is important not to perform an operation unless there are strong indications for it, which would so mutilate her that pregnancy ceases to he possible, but we must bear in mind that the years of sexual life still to come give every opportunity for the growth of the tumour and the development of symptoms, while, if large or multiple fibroids are present, the probability of the patient becoming pregnant and going to term is very slender. The general condition as to health and estate of the patient should also be considered. If she is a strong healthy woman compelled to lead an active life, one would be more inclined to recommend removal than if she were weak, the subject of chronic disease, or were enabled by her circumstances to take life easily.