Jacob Hoffman

Cervical carcinoma in situ: Difficulties in differential diagnosis

Abstract 1. Existing confusion regarding carcinoma in situ of the cervix and reasons for delay in clarification of the problem are discussed. 2. Our findings among 4,152 cervical biopsy specimens, obtained between 1930 and 1946 and previously reported, are briefly summarized, with particular emphasis on 9 invasive carcinomas with previous biopsy specimens, among which 1 true intraepithelial carcinoma was found. 3. The findings among 4,187 cervical biopsy specimens obtained between 1946 and 1952 are presented, with particular emphasis on 6 cases diagnosed “carcinoma in situ” and followed by repeat cervical biopsies without treatment other than the repeat biopsies, which, to date, showed the lesions to be reversible. 4. The etiology of benign carcinomimetic cervical lesions is discussed and the difficulties of differential diagnosis between them and genuine incipient carcinoma are emphasized. 5. Attention is directed to the extreme atypism of such lesions and the suggestion is made that it is not pathognomonic of incipient carcinoma but represents a nonspecific reaction of normal cells to injurious influences in the environs. 6. The desirability of a policy of watchful waiting in the doubtful case, particularly if the patient is young, and the comparative safety of such a policy are stressed.

A clinical evaluation of the use of radium therapy in the control of benign uterine bleeding

S INCE its introduction into gynecologic practice about forty years ago, radium has been regarded as a satisfactory means of treating benign uterine bleeding. Although certain defects and inadequacies of the method have been recognized, its wide utilization has not been seriously challenged until recent years. In 1936 Norris and Behney” stated before this Society that “radium irradiation is now generally accepted as the method of choice in the treatment of certain types of uterine hemorrhage of benign origin.” Their paper which reported 1.09 per cent of carcinoma of the genital tract in the patients followed and the subsequent. discussion did not seriously challenge the validity of their opening statement although Eardley Holland of London raised the question as to whether or not radium in the uterus has any effect in promoting the incidence of cancer of the body of the uterus. Pemberton reported upon four patients who developed pelvic malignancy among 425 patients treated and followed for two or more yea,rs. Since then, a number of papers*-lo have appeared which have called attention to the subsequent development of cancer principally of endometrial origin in patients who have been treated with radium for uterine bIeeding of benign origin. These reports have aroused quite a bit of controversy with respect to the wisdom of this procedure. A few similar experiences have prompted us to nndertake an evaluation of our own results with this method which has been the accepted practice in The Division of Gynecology, Department of Obstetrics and Gynecology of The Jefferson Medical College and Hospital. Our material consists of the case records of 1,232 patients treated from 1930 to 1950, inclusive, this period being chosen because of the greater validity of the follow-up records. Four hundred sixty-five were ward patients and 767 were treated on the private service. All of the patients complained of abnormal bleeding. One hundred seventy-six of these had symptoms referable to pelvic floor relaxations which were correct,ed by appropriate vaginal plastic procedures at the time of the radium application. Careful pelvic examination under anesthesia, thorough diagnostic curettage specifically directed toward iscraping the entire surface, particularly the cornual areas, and the cervical canal, together with cervical biopsy in appropriate instances, was customary in every case.

The foundation of an endocrine clinic for the study and treatment of amenorrhea, uterine bleeding, and sterility

I T IS becoming more and more apparent that enclocrine dysfunct,ion is a frequent cause of menstrual disorders and sterility. We constantly meet with patients who complain of menstrual dist,urbances, in whom there is no gross lesion in the pelvis. The same statement may be made relative to the female partner in the barren marriage. ln a further general study of these two groups one often concludes that none of the usual constitutional diseases are present and then asks whether imbalance of the endocrine glands may be at the bottom of the trouble. Sometimes our attention is turned in this direction by the very obvious stigmas of the endocrinopathies in the individual, and sometimes our att,ention is turned to the endocrine glands because, so far as we know, we have excluded all other causes. The patientas who complain of these symptoms form a considerable part of the gynecologist’s clientele. The need of methods of precision in diagnosis is obvious and a successful plan of treatment is much to be desired. The problems presented are perplesing for what appears to be true one da.y may be shown to be a fallacy t,he next. Perhaps the time has arrived when the theories that have been built up may be applied. For that reason we have organized at the Jefferson Medical College Hospital a special clinic to which all endocrine cases are referred. This paper is for the purpose of reviewing the information that is now at hand relative to the influence of the endocrine glands upon t,he genital function and of appraising the available means of treatment,. We are especially interested in two groups, first, the deficiences of the menstrual flow, complete or partial and the lowering of the fertility index with which it is often associated, and second, the abnormal hleedings appearing as menorrhagia or metorrhagia in which an exhaustive search for organic lesions in the pelvis has been fruitless. L411 outstanding fact which should be mentioned at, this point is that