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to the extent of involving the lower limbs until the pain is almost unendurable ; and, at the same time, the recurrent growth is rapidly increasing. We have therefore adopted these rules: Operate in every approved operable case, as in former days. Use X rays or radium immediately afterward, but do not apply directly over the site of the incision. Use X rays or radium again about four Non Prescription Cialis Online to eight weeks later. Radiate all borderline cases preferably with radium Non Prescription Cialis Online in the uterus and x rays with a hard Coolidge tube through the abdominal wall. Use radium and x rays in all advanced inoperable cases, Non Prescription Cialis Online not with the hope of effecting a cure, except pos- sibly in an extremely small percentage of cases, but, because, when not too far advanced, the growth may be retarded over a considerable period of time, nearly always alleviating the pain and checking the foul discharge. Also, it is sometimes possible to render an inoperable case operable. In cases in which there is a large pelvic involve- ment, I favor highly a combination of radium and X rays: It is thus possible to crossfire the tissues completely and thereby obtain the combined bene- ticial results from the hard rays of radium and the hard rays from the Coolidge tube. Non Prescription Cialis Online Doubtless to a great many the use of both radium and x rays in the treatment of deep seated malignant conditions has been more or less a disappointment, however, there are other conditions, not of Non Prescription Cialis Online a malignant nature con- fronting the gynecologist in which our expectations have been more than realized and our optimism jus- tified. I refer especially to uterine fibroids with or without menorrhagia or metrorrhagia ; also, to menorrhagia and metrorrhagia due to remote and indefinite causes. Kelly (2), in an article on The Radium Treat- ment of Uterine Fibroids, says : "Tumors of all kinds have been treated and the submucous and subperitoneal, and even the pedunculate, have seemed to respond as well as the interstitial." In reporting thirty-six cases he says : '"The results in every case but one have been either the shrinkage of the tumor or its complete disappearance. . . . One of the most striking results," he adds, "is upon the menstrual function, where the radium can in all cases be depended upon to bring about complete amenorrhoea. ... If care is Non Prescription Cialis Online taken to avoid giving too large a treatment, it is possible in some cases, especially with young women to avoid amenorrhoea." Lange (3), of Cincinnati, says: "The X ray treatment of menorrhagia and uterine fibroids by the production of the artificial meno- pause has been given a new impetus by the inven- tion of the Coolidge tube. ... If the proper technic is etnployed, the efifect of the Coolidge tube radiation upon the ovaries is one of the most cer- tain of medical phenomena. If sufficient radiation be absorbed by the ovaries they will cease to func- tionate in their fullest physiologic aspect and a ces- sation of menstruation will result." It is thus seen that in the hands of competent men the results obtained, although produced by dif- ferent agents, are practicallv parallel. Non Prescription Cialis Online However, I do not think the indications are by any means always the same, and that the method most available can always be substituted for the other. My own opinion is that in selecting the method of treatment of uterine fibroids we should be governed by the type of tumor to be treated, and also should take into consideration other conditions that might be complicating factors. Kelly (4) says: "While radium has thus made a place for itself as the treatment of election, the best possible treatment in fibroid tumors, it does not take the place of operation in the exceptional case, for instance, where there are urgent pressure symptoms, or other complicating conditions, such as diseased appendix, gallbladder, etc." The submucous varieties, by reason of their loca- tion and consequent composition, cause copious and weakening hemorrhages, and there is a resulting complication of the endometrium. For this reason radium is preferable to x rays in such cases, as it acts directly upon the endometrium thus causing Non Prescription Cialis Online a cessation Non Prescription Cialis Online of the bleeding by its efifect upon the en- dometrium primarily and the ovaries secondarily. While the x rays perform the same phenomenon, if is by afifecting the ovaries primarily and, possibly to a less degree, the endometrium. Therefore, the radium produced menopause is usually much less severe in its effects than that produced by x rays. In the- interstitial and subserous varieties, I also believe that radium is more dependable than x rays for reasons already explained, while in the peduncu- late the Non Prescription Cialis Online X rays are probably as efficient as radium In both the subserous and pedunculate tumors I be- lieve Non Prescription Cialis Online their combined use — radium in the uterus and X rays through the abdominal wall — is theoretically and practically correct. . Radium is of ec[ual value in the treatment of ob- stinate cases of menorrhagia and metrorrhagia not associated with fibroid tumors. In a great many of these cases it is desirable to bring on the menopause as there is often danger of impending malignancy. This is invariably accomplished easily with but few of the pronounced symptoms that usually accom- pany the menopause. It is preferable to the x rays because it can be given Non Prescription Cialis Online with much less inconvenience and risk to the patient ; also, as the endometrium is primarily afifected and the ovaries secondarily, the nervous phenomena accompanying and following the menopause is much less noticeable. In the treat- ment of menorrhagia of young women the dosage is so easily regulated that the desired efifect may be produced in many cases without bringing on a com- plete amenorrhoea, the functioning power of the ovaries not being entirely destroyed. I have treated a number of cases of uterine hemorrhage in which the patients had had repeated curettages without receiving permanent benefit ; not one of these cases failed to yield to radium. One advantage not men- tioned of radium over x rays in the treatment of pelvic conditions is that, by virtue of its method of application, there is no danger of dermatitis. It is known that the mucous membrane is far more tolerant of both x rays and radium than is Non Prescription Cialis Online the cutaneous surface. This is no little Non Prescription Cialis Online consideration in the treatment of these conditions. When both are used conjointly it is always possible to keep the dose of the x rays well within the bounds of safety.