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valuable treatment was bleeding, which had beenwidely used in the sixteenth century, and certainlyrelieved flushing, especially if there was hyperpiesis.The most important late symptom was obesity ; itoccurred twice as often in married women as in

single ones. This seemed to relate to their greaterability to take care of themselves, whereas the singlewoman had to carry on. An arthritis of the knees

might occur in women at the menopause who becamefat, owing to wear and tear ; but Dr. Thomson hadnever seen a case in a thin woman. The psychoticgroup represented the physician’s failures. Quite alarge number of alcohol and drug addictions began atthe menopause.

THE PITUITARY AND OVARIAN RELATIONSHIP

Dr. P. M. F. BISHOP said that the gradual decline ofovarian activity was undoubtedly the starting-point,and a compensatory over-secretion of prolan Afollowed. It seemed logical to treat with cestrin,and this had met with some success. The symptoms,however, were not due to withdrawal of cestrin butto the presence of prolan A ; they did not appearuntil four or six weeks after oophorectomy. Theprolan A curve ran more or less parallel with the hotflushes. CEstrin damped down the prolan A produc-tion. When both prolan A and cestrin were absentfrom the urine, hot flushes never appeared. Prophy-actic treatment seemed highly undesirable. The

object of oestrin administration was not to cut outprolan A altogether but to keep it down and let thepatient become gradually accustomed to higher andhigher levels of it. There was usually no need forhigh doses or injections, or of cestrin estimations.Doses of 500-1000 international units were generallysufficient ; and the flushes themselves were a goodenough indication of the imbalance. Patients oftensaid they felt well during cestrin treatment; and avaluable change of mental attitude was sometimeseffected thereby.

Dr. F. STOLKIND thought reassurance was veryvaluable treatment. Endocrine preparations bymouth were waste of time and money and the resultsfrom injections were probably psychological. Hehad not seen any benefit from diathermy to the

cervix, bleeding, or psycho-analysis.Dr. A. H. DOUTHWAITE agreed that menopausal

arthritis of the knees was simply an osteo-arthritisrelated to the increased weight, but questionedwhether there were not also a true rheumatoidarthritis related to the menopause, less cripplingthan in younger people and very resistant to treat-ment. Complete achylia often suggested chronic

gastritis in these cases and the blood uric acid wasabove normal, though lowering it did not relieve thesymptoms. Venesection did relieve symptoms if

hyperpiesia was present.Dr. PHILIP ELLMAN mentioned a syndrome of

obesity, arthritis, and hypertension in women withdefinite hypothyroidism. The disturbance of equilib-rium due to excessive fat produced the jointchanges. Astonishing results were obtained bythyroid medication, especially relief of the arthriticsymptoms. Menopausal acromegaly was another

syndrome, and in one case had been repeatedlyrelieved by intrapelvic diathermy-possibly for

psychological reasons. The syndrome of obesity,hypertension, and hypothyroidism was not an

uncommon late sequel of artificial menopause withremoval of the ovaries.

Sir WALTER LANGDON-BROWN, in reply, agreedthat many women looked forward to the menopauseas a chance of pursuing their intellectual interests

without interference. Cancerophobia was one of thecommonest diseases of the day. The high percentageof achlorhydria was probably a factor of increasingage. Psychological treatment was of the greatestimportance but formal psycho-analysis was likely todo more harm than good.

NORTH OF ENGLAND OBSTETRICAL

AND GYNÆCOLOGICAL SOCIETY

A MEETING of this society was held in Sheffield onFeb. 28th, with Dr. RuTH NICHOLSON, the president,in the chair. A joint communication onRadium Treatment of Carcinoma of the Cervix

was made by Prof. W. FLETCHER SHAW and Prof.DANIEL DOUGAL. They had been struck by the factthat although radium treatment of carcinoma of thecervix had been practised in this country for manyyears, there had been singularly few reports based onfive years’ freedom from recurrence. The staffs ofinstitutions where radium treatment was carried outhad stated that they were obtaining good resultsbut had not as yet published any figures com-

parable with those from foreign clinics. On theother hand, the results likely to be obtained by theWertheim operation were well known. Unfor-tunately this operation entailed both a high immedi-ate mortality and a long and trying convalescence,and for this reason most gynaecologists wouldundoubtedly have been prepared to abandon it if

convincing evidence had been produced by the

radiologists that radium treatment could give equallygood results. Such evidence had not as yet beenforthcoming in this country and for this reason Prof.Shaw and Prof. Dougal had determined in 1928 topurchase their own supply of radium and to treattheir own cases both in private and in hospital. Asthis step was in the nature of an experiment, it wasdecided to treat all cases by the same method and tofollow up every case with the idea of publishing resultsas soon as a sufficient number had been collected.

After due consideration the method of Heymanof Stockholm had been chosen, with certain modi-fications suggested by Dr. Helen Chambers andProf. S. Russ of the Middlesex Hospital. Fortymilligrammes of radium, suitably screened,was insertedinto the uterine cavity and 60 mg. in three box

applicators was applied to the cervix and vaginalfornices. Each patient was treated on three occasionsfor 24 hours, with an interval of one week betweenthe first and second application and three weeksbetween the second and third application. Thecases treated up to Jan. 1st, 1931, numbered 94,and the results five years later were :

Alive and well five years later.... 39 (41-4%)Dead or untraced ........ 55 (68-6 %)

The immediate mortality was 2-1 per cent., one

patient having died from peritonitis and one frompulmonary embolism. Microscopical confirmationhad at first not been carried out in advanced cases,because the diagnosis in such cases was deemed to beso definite to an experienced clinician that confirma-tion was unnecessary. Later, when it was realisedthat readers of the report would not have seen thecases, and would have to accept the diagnosis on theauthors’ unconfirmed statement, a piece of growthwas excised for laboratory examination as a routine.Microscopical examination was therefore carried out inabout half the cases ; but those not so examined wereso advanced that no error in diagnosis was possible.

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In considering the results with regard to the stageof the growth, the classification of the radiologicalsubcommittee of the League of Nations CancerCommittee had been adopted.

Stage. Cases. Alive. Dead.I....... 11 ...... 7 ...... 4II....... 27 ...... 12 ...... 15

III....... 40 ...... 17 ...... 23IV....... 10 ...... 1 ...... 9Six cases were unclassified.

Two patients with cervical stump carcinoma followingsubtotal hysterectomy were included, and both diedof recurrence. These cases should perhaps havebeen omitted, for it had obviously not been possibleto follow the full routine as regards application.

In considering the question of radium versus theWertheim operation, the results in the present series(94 cases with 41-4 per cent. of five-year cures) couldbe compared with the surgical results of Bonney(384 cases with 39 per cent. five-year cures) andFletcher Shaw (154 cases with 38-3 per cent. five-yearcures). The operability rate had also to be takeninto consideration (Bonney 63 per cent.). Prof.Shaw and Prof. Dougal considered their series a

small one ; whether the high percentage of freedomfrom recurrence would be maintained when theyhad larger figures remained to be seen. But theywere convinced that the results with radium werebetter than those with Wertheim’s hysterectomy.At the same time they were by no means satisfiedwith figures which showed less than half the patientsalive after five years. Certain of their patients werenow having deep X ray therapy after radium treat-ment, but this had been done for too short a timeto allow of any comparison of results. They wereconvinced that the surgical treatment of carcinoma ofthe cervix was a thing of the past.The PRESIDENT congratulated Prof. Shaw and

Prof. Dougal on the excellence of their results. Sheread on behalf of Mr. P. Malpas the figures from theLiverpool Radium Centre, of cases treated duringthe years 1929 and 1930, the total five-year survival-rate of all cases treated being 33 per cent. The methodused was that of Heyman, followed by deep X rays.Mr. J. W. BURNS asked if any of the patients had

suffered from annular constriction of the rectumafter treatment. He had observed the condition in2 cases. He also expressed the view that radiumtherapy was well worth while even in very advancedcases, since it relieved pain and made the end easier.Mr. T. F. TODD commented on the excellence of

the results obtained, which he regarded as far andaway ahead of anything else so far achieved. Exceptfor one single year’s results from the Marie CurieHospital, he knew of nothing comparable in theinternational literature. He considered radiationdefinitely preferable to surgery even in early cases ;at least eight of the international radium centres hadpublished a five-year survival-rate of over 50 percent. in operable cases-i.e., 10 or more per cent.better than surgery. Mr. Todd recalled BeckwithWhitehouse’s published figures of 500 cases treated atseveral teaching hospitals in this country, with afive-year survival-rate of about 11 per cent.Dr. FRANK ELLis gave figures from the Jessop

Hospital for Women, Sheffield, showing a 30 per cent.five-year survival-rate. It was customary in Sheffieldto perform Wertheim’s operation on Stage I. cases(if fit for operation) after preliminary radiation. Ifthe tumour was bulky and infected the patient had(1) X ray treatment for two weeks to the wholepelvis; (2) two weeks’ rest with douches; (3) radium ;(4) one day later, Wertheim’s operation; and

(5) further X ray treatment to the whole pelvisif glands were found to be involved. If the tumourwas small and uninfected, the procedure was :

(1) single dose of radium ; (2) one day later,Wertheim’s operation ; and (3) a full course of X raysto the whole pelvis if glands were involved. Casesin Stages II., III., and IV. were given X rays, radium,and then X rays again. Dr. Ellis showed a series ofslides, indicating the technique of the methods

employed ; also a slide to show the type of X rayburn of the skin, which while healing perfectlymight be thought by the uninitiated to indicate anoverdose-being in reality the dose aimed at. Healso quoted Doderlein’s figures in operable cases

which showed 80 per cent. five-year cures after

complete radiation, as compared with 46 per cent.after operation. They afforded adequate reason forDoderlein having given up the operative procedure.

Dr. E. A. GERRARD drew attention to the excellenceof the results in a series of cases which had beenhandled entirely by gynaecologists, without resort totheir radiological colleagues. Was this a point ofimportance-even significance ? He thought so,particularly as there was a growing tendency incertain areas for the general practitioner to refer

malignant cases directly to the radiologist. Wasthis in the best interests of the patient ? The radio-

logist could hardly be expected to have had a wideexperience in a special branch like gynaecology.The diagnosis in carcinoma of the cervix, particu-larly of the endocervical type, was not always easy,and the correct application of the radium was liableto present real difficulty unless the operator wasregularly engaged in vaginal surgery.

Mr. J. E. STACEY advocated Wertheim’s operationin first-stage and early second-stage cases-alongwith radiation, as this precluded the ill-health fromcystitis, proctitis, &c., which was liable to follow ifradiation alone were employed. He believed thatcooperation between gynaecologist and radiologist wasadvisable; the gynaecologist should diagnose thecondition and the radiologist should decide the doseand apply the treatment.

Prof. MILES PHILLIPS also advocated the coöpera-tion of gynaecologist and whole-time radiologist. Helaid stress on the necessity of doing all one could toprevent carcinoma by the ruthless removal of thecervix whenever it was found in a badly damagedor chronically infected condition. The fact that theannual mortality-rates showed, for a number of years,a steadily falling death-rate from cancer of the

uterus, whereas that from cancer in all other organswas increasing, was at least highly suggestive thatthis method of preventive treatment was becomingeffective.

Dr. 1. A. B. CATHIE spoke of the grading of tumoursas an aid to prognosis. He was inclined to disagree withthe prevalent idea that the columnar-cell type ofgrowth was resistant to irradiation.

Prof. DOUGAL, in reply, said that Prof. Shaw andhimself, recognising that their series was a small one,realised that they might have been fortunate in theirresults. He agreed with Mr. Todd that there was nowno justification whatever for the Wertheim operation.He had seen one case in which application of radiumhad been followed by a fistula, but the dose givenhad been unduly high-11,000 mg.-hours. He heldthat cooperation between surgeon and radiologistwas undoubtedly desirable, though the dose forcarcinoma of the cervix was largely standardised.He did not think that a radiologist was the bestperson to apply the radium in this region, for even

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an experienced operator sometimes found greatdifficulty in advanced cases with the insertion of theintra-uterine portion of the dose.-Prof. DOUGALagreed with Dr. Cathie that the columnar-cell typeof growth was proving to be less resistant to radiumthan had been thought in the past.

Naegele Pelvis

Dr. CLANCY reported the case of a 6-gravidawho had had two stillbirths and three live children,all by instrumental deliveries. After the first deliverythere had been paralysis of the left leg. She wasadmitted to hospital at the thirtieth week and onvaginal examination the membranes were found tohave ruptured. The cervix and vaginal vaultexhibited marked laceration indicating severe traumaat previous deliveries, and in view of this fact, itwas decided to have a radiogram taken. Thisrevealed a Naegele pelvis, of which there had beenno indication by vaginal or other examination.The external appearance of the patient was alsonormal, and neither figure, gait, or carriage gaveany suggestion of deformity. The following measure-ments were taken : interspinous, 84 in. ; intercristal,92 in. ; external conjugate, 64 in. ; external obliques,7 and 7t in ; posterior superior spine to symphysison each side, 61 in. ; spine of last lumbar vertebra toanterior superior spine, 6t and 64 in. On examina-tion of the patient’s back a definite bony lump wasfound over the sacro-iliac joint on the affected side.The striking feature of these cases was the difficultyin diagnosis ; for apart from the bony lump there wasnothing to indicate the serious deformity. The

customary measurements, as stated by WhitridgeWilliams, merely suggested a justo-minor pelvis.Dr. Clancy felt that there was much to be said forhaving a radiogram taken wherever there was a

history of former dystocia.The PRESIDENT spoke of the rarity of spontaneous

delivery in the type of case, also the high mortalityrecorded-Litzmann, 22 deaths in 28 cases.-

Dr. J. W. BRIDE referred to the temporary paralysis ofthe leg from which the patient had suffered after thefirst delivery. It was remarkable that nerve injuryshould be so rare even after difficult instrumentation.-Prof. PHILLIPS said that this case showed the desir-

ability of all maternity hospitals being providedwith an X ray apparatus.

Malignant Ovarian Tumours andHysterectomy

Mr. C. H. WALSH showed a specimen of calcifiedfibroids associated with malignant pseudomucinousovarian cyst and adenocarcinoma of the body of theuterus with haematometra.

The patient was a nullipara, aged 66, who had passedthe menopause at 52, since when there had been novaginal discharge. She had been perfectly well untilthe day before she was admitted to hospital for severeabdominal pain and vomiting. The pulse, respiration,and temperature were normal, but abdominal palpationrevealed a hard mass in the right iliac fossa and a cystictumour in the left side of the abdomen. The cervixfelt normal and there was no vaginal discharge. Inview of a possible diagnosis of carcinoma of the colon,a barium meal was given, and on radiography a calcifiedmass was seen in the right iliac fossa, which had theappearance of a calcified fibroid. The cystic mass wasthought to be ovarian in origin, and a laparotomy wasperformed. There was no ascites. The uterus containedmultiple fibroids, and the large calcified tumour seen inthe radiogram was found to be a pedunculated fibroid,arising from the right side of the fundus uteri. The

swelling on the left side was an ovarian cyst the size of a

football. Total hysterectomy with bilateral salpingo-oophorectomy was performed, and on incising the uterusafter operation the surgeon was surprised to find it fullof malignant growth and distended by about 6 oz. ofblood-stained fluid. The tubes were also found to containseveral malignant nodules, but in no instance had thegrowth reached the peritoneal surface. The ovariantumour proved to be a papillary pseudomucinous cystadenocarcinoma.

Prof. FLETCHER SHAW, in advocating removal ofthe uterus in all cases of malignant disease of theovaries, recalled a case which supported the viewthat the growth in the uterus was secondary to theone in the ovaries. The patient, aged 39, had haddouble ovarian carcinomata-each the size of an

orange and both free from adhesions. These wereremoved and ’the uterus retained ; but after the

operation the patient had amenorrhaea for 18 months,succeeded by irregular and increasing bleeding.About two years from the first operation, the irregularhaemorrhage having been present for about six months,panhysterectomy was performed and an advancedcarcinoma was found in the interior of the uterus.If the growth had been primarily in the uterus it washardly possible for it to have remained quiescentand for the woman to have 18 months’ amenorrhceaafter the removal of the ovaries. If, as seemedmore likely, the uterine growth was secondary tothe ovarian, it must have been in an early stage whenthe ovarian growths were removed and have progressedslowly, for haemorrhage began only 18 months later.The first operation was in 1912 and the second in1914, and the patient was alive now, 24 years afterthe first operation.

Dr. ELLIS thought it an advantage when operating’on these cases to leave the uterus with a view to

subsequent radium therapy. He quoted a recent

paper by Schroeder giving results of treatment of arelatively large number of cases of proved malignantdisease of the ovary treated by radiation. Schroederdivided his cases into three groups: (1) those inwhich he was able to remove all visible growth;(2) those in which most of the visible growth wasremoved ; and (3) those in which only a portionof the growth was removed for biopsy. The five-

year cures were 66 per cent. in Group 1 and 16 percent. in Group 2. The latter was, however, sub-divided into two sub-groups. In first of these theuterus was not removed, so that it was used afterwardsfor intrapelvic application of radium in addition tothe X ray treatment which all the patients received;the five-year survival-rate was 25 per cent. In the

second, in which the uterus was not left and thereforeradium was not applied, there were no five-yearsurvivals. These figures indicated the advisabilityof supplementing operation with radium as well asX ray treatment, with the corollary that it wasadvisable to leave the uterus in position if all obviousgrowth was removed.

Mr. BURNS referred to a case in which a malignantovarian tumour, the size of an orange, was removedand the patient had no symptoms for two years.After this time, uterine haemorrhage occurred, andcurettage showed a growth similar to that of theovary. A dose of 2000 mg. hours of radium was given,and the patient had no further symptoms. Curettage18 months later revealed merely fibrous tissue.

Mr. C. R. MACDONALD showed a specimen of acutetorsion of a hydrosalpinx in pregnancy.

Dr. BRIDE reported two cases of unusual EctopicPregnancy.