THE ANAMNESIS

Women, radical operation was performed on 96 patients with an operative mortality rate of 8'3% and an operability rate of 14%. In their combined results Read and a colleague, Frank Cook, had an operative mortality rate of 3% in 207 Wertheim hysterectomies performed in public hospital and private practice, and he considers that the operative mortality rate among properly selected patients should not exceed 5%. In his view the present indications for Wertheim hysterectomy for carcinoma of the cervix are radioresistant growths proved to be such either clinically or cytologically, columnar-celled carcinoma of the cervix, stenosis of the vaginal vault, the presence of large fibroid tumours or ovarian cysts complicating cervical cancer, salpingitis complicating cervical cancer, refusal of irradiation by the patient, and pregnancy complicating cervical cancer. He feels that it is obvious that treatment by radium alone by means of vaginal applicators can never hope to give adequate irradiation to the lymphatic field of the pelvis, and the efficiency of deep X-ray therapy in this respect is questioned. There is a place for lymphadenectomy in selected cases of stage III growths cured locally by radium, and this may be extended to include those in stage II and selected cases in stage 1. In recent years, Read states, radical surgery for carcinoma of the cervix has tended to be underrated in its usefulness, but, while he emphatically agrees that in the present state of our knowledge the routine treatment of election in the average case is radiotherapy, in certain selected cases surgery offers the best prospect for the patient; the absolute cure rate can be increased by a surgical approach to those growths which prove to be radioresistant or for which adequate irradiation is not possible. Further light is thrown on the two questions asked by Read by the work of Alfred Glucksmann and Stanley Way,' who used a cell-count technique, introduced by Glucksmann, of determining whether or not the response of a tumour to radiotherapy was favourable. This. appeared to offer a rational basis of selection of patients who would be unsuitable for treatment with radiotherapy alone and to aid the attempt to salvage by surgery as many patients with radio-incurable tumours as possible. Among 149 patients studied the tumour yielded in 54 cases a favourable or probably favourable response to radium treatment and in 88 an unfavourable response, as based on serial biopsies obtained before and during irradiation. Routine treatment consists of examination under ansesthesia, "staging" and assessment of the tumour, preliminary biopsy, and the first application of radium. A week later a second biopsy is taken and the second application of radium is given. During the following two weeks the histological analysis is made and the prognosis is obtained. If the prognosis is favourable the third application of radium is given, followed two weeks later by bilateral iliac adenectomy in some cases. If the prognosis is unfavourable and the condition is suitable for radical surgery, no further radium is given and operation is performed six weeks later. If the prognosis is unfavourable and the tumour is inoperable, a further application of radium is given, but iliac adenectomy is not performed. The histological analysis is made by counting the resting cells, mitotic cells, differentiating cells and degenerating cells. In cases in which tumours fail to respond to irradiation the histological picture before and after exposure to radium is approximately the same. A favourable prognosis holds only for the fully treated local lesion. It has been found that the differentiated types of cervical carcinoma tend to respond favourably in a greater proportion of cases than do the anaplastic types. The capacity to increase in extent and degree of differentiation distinguishes the radio-curable from the radio-incurable tumours. The estimated operability rate among the 88 patients with an unfavourable response to radiotherapy was 52%, but wits reduced to 26%. Wertheim's hysterectomy was performed on 28 patients, the operation had to be abandoned for various reasons in 10 cases, and the operation was not attempted in eight cases. Lymph gland involvement was present in 25 of 37 cases in which