Lawrence M. Randall

Precancerous lesions of the endometrium

Abstract Fifty-four patients in whom a diagnosis of cancer of the endometrium was made had had curettage at intervals of 1 to 28 years prior to the diagnosis of cancer (cancer series). These subjects were divided into premenopausal-menopausal and postmenopausal groups. The findings in the curettage specimens in this series were compared with those in a series of 100 patients who had had curettage for atypical uterine bleeding but did not develop cancer of the endometrium during a follow-up period of at least 12 years (comparative series). In the premenopausal-menopausal group of the cancer series, there was some correlation between the histopathology of the endometrium at the time of curettement and the interval elapsing between curettement and the diagnosis of cancer. Such a tendency could be observed also in patients with multiple subsequent curettements. In the postmenopausal group of the cancer series, no relationship could be found between the histopathology of the endometrium and the interval between curettement and the diagnosis of cancer. There is some evidence that, in the instance of an atrophic endometrium, small areas of cancer may have been previously missed. With endometria manifesting minor abnormalities, such as polyps or glandular hyperplasia with atypical features, the average interval from curettement to the diagnosis of cancer was 6.3 years as compared with 12.5 years for the corresponding group of the premenopausalmenopausal cases, indicating a closer relationship of such endometrial lesions to cancer in postmenopausal women. Comparison of the findings in the premenopausal-menopausal group of the cancer series with the findings in the comparative series revealed that no single atypical feature is diagnostic of an oncoming cancer. However, there was a distinct difference in the degree of these atypicalities and in their incidence; a higher grade of atypical proliferation and a multiplicity of atypical features prevailed in the cases in which cancer was found subsequently. The findings obtained from prior curettements bring forth some evidence that a carcinoma of the endometrium might originate in an islet or islets of altered endometrium that do not differentiate into a secretory phase as does the surrounding endometrium. Such islets remain well de-lineated and sharply demarcated from the surrounding tissue for a long period. The time necessary for development of cancer approaches 10 years or more.

Quantitative studies on the production, destruction, and elimination of chorionic gonadotropin in normal pregnancy

Abstract The levels of chorionic serum gonadotropin in normal pregnancy have been determined in 112 patients in terms of International Units. A characteristic curve for this hormone has been obtained, agreeing in both pattern and absolute values with those reported by others. An analysis of the factors which might influence the characteristic hormonal pattern indicates that the renal function with respect to the hormone remains constant during normal pregnancy, that the extrarenal disposal of the hormone accounts for more than 90 per cent of the circulating hormone, and that probably the fluctuating character of hormonal level in serum or urine depends entirely on changes in rates of production of hormone during pregnancy.

Intratubal term pregnancy without rupture: Review of the literature and presentation of diagnostic criteria

Abstract We have reviewed the literature on intratubal pregnancies without rupture of the tube, occuring at or near term, and have endeavored to establish criteria by which the diagnosis of this condition may be made with precision. This variant of term ectopic gestation is of some importance and should be considered as distinct an entity as is primary ovarian pregnancy and abdominal pregnancy. Forty-five cases of this obstetrical rarity, including our own, were available for review. A fetal mortality of approximately 75 per cent and a maternal mortality in the neighborhood of 10 per cent were calculated. Not all of the cases in our presentation have met the rigid criteria which we propose but in all cases of pregnancy listed in Table II there has, at least, been no gross evidence of tubal rupture and the condition was or would have been susceptible to complete extirpation by localized adnexal surgery. Our primary purpose has been to establish a diagnostic yardstick for subsequent examples of this phenomenon.

The weight factor in pregnancy

Abstract Although the series of cases studied was not large, the average gain of 23.2 pounds by healthy pregnant women coincides with that observed by Davis and others. The number of toxemic patients is also small (twelve), but they fall in very definite weight groups. Noted in conjunction with careful urinalyses and the blood pressure readings, the amount and rate of increase in weight should aid materially in foretelling the toxemias of later pregnancy and make it possible to ward them off. With the increase in the number patients who are applying for, and who are interested in, antenatal care, the physician will be placed in a position to study such patients. This being true, no method should be slighted that will aid in reducing the toxemias of late pregnancy to a minimum.

Endometriosis (adenomyoma) in postoperative scars

Abstract Thirty-one cases of endometriosis in postoperative scars were analyzed. It was found that in the majority of cases the lesion followed operations performed on the uterus or fallopian tubes, but that in the performance of most of these operations the lining of these organs had not been exposed. A few of the tumors seem to have originated from exposedp ortions of endometrium and to have invaded the abdominal wall secondarily, but others were definitely separated from the uterine lining. The etiology of this condition is unknown, but, in most cases, the best evidence points toward transplantation or invasion (migration) of endometrium from the lining of the uterus. The endometriomas in question resemble endometrium, histologically, and in one case an unabsorbed suture was presented, which may or may not represent the contaminating vehicle during the original operation. In a large number of cases in which the condition followed ventral suspension of the uterus, the round ligaments were involved with endometriosis, at those points at which they were sutured to the anterior abdominal wall. Pain, worse at the menstrual period, and the presence of a palpable nodule, were most commonly complained of by the patients. Few of the tumors discharged a bloody fluid at the menstrual period. In a few cases there were no symptoms. The diagnoses were made more often in the ten years prior to the time of this report, for the medical profession is now more aware of this entity than it had been formerly. The differential diagnosis most often includes, keloids, desmoids, fibromas, neuromas, incarcerated omental hernias and uterine or tubal fistulas. If the condition is uncomplicated, cure may be obtained by wide excision. One instance of recurrence was encountered; undoubtedly the condition in this case was caused by inadequate excision at the time of the first operation.

Endometriosis as a cause of ileal obstruction.

Abstract This paper presents the first analysis of clinical data of a series of cases in which ileal obstruction was caused by endometriosis. The subject is of particular significance because the obstructive involvement of the distal part of the ileum by this highly invasive nonmalignant tissue often has been confused clinically with appendicitis accompanied by ileus, with malignant lesions causing obstruction of the intestine, and with intestinal obstruction caused by the adhesions of pelvic inflammatory disease. The importance of endometriosis as a cause of ileal obstruction has not been sufficiently stressed. The clinical picture of this condition, as revealed by a detailed analysis of the clinical data of sixteen cases, will be presented, as will also (1) certain facts higly pertinent to the differential diagnosis, (2) pathologic lesions and (3) surgical treatment. The term “endometriosis” indicates the existence of endometrial tissue in any extrauterine location.

Lipiodol as an adjunct to tubal inflation in the diagnosis of sterility

Abstract The use of lipiodol offers a further means of accurately diagnosing tubal obstruction and stenosis as a cause of sterility in women. After tubal inflation has shown nonpatency or stenosis of the tube, the site of closure or stenosis can be accurately detected by its use in connection with roentgenograms. This information is of value in considering the advisability of surgical treatment in an otherwise normal pelvis. Such tubes are always symptomless and frequently unaccompanied by other pelvic lesions; hence there would be no other indication for operation. As a rule, women who consult physicians primarily because of sterility are otherwise normal, and it certainly is not justifiable to subject them to surgical operation without the benefit of as accurate a diagnosis as possible. Uncomplicated tubal occlusion is a frequent cause of sterility and the question of laparotomy is often brought up by the patient. If the site of closure can be located, one can much better judge the value of operation in a given case. Should the obstruction be in the narrowed portion of the tube the prospect of success from a plastic operation on the tube will not be good. With pathologic change at the fimbriated end, which is relatively common, and the lumen patent to this point, operation may be justifiable. It carries with it a fair chance of success, provided other conditions are normal. The technic of injecting lipiodol is simple and involves no special apparatus. It is practically painless. The same care is used as in transuterine inflation of the tubes.

Amenorrhea not associated with pregnancy in young women

Abstract A menorrhea may be due to organic disease. Thus, it may be an early symptom in certain systemic conditions, disorders of metabolism, and tumors of the endocrine glands, or be related to pathologic changes. More commonly, an absence of the menses may be only an expression of physiologic disturbance of the glands primarily concerned with normal menstruation. Often it has been stated that menstrual function is not necessary for health. However, it should always be borne in mind, particularly if the patient is young, that amenorrhea may be a symptom of some condition that may adversely affect the health. Varying degrees of functional failure of the genital tract naturally may exist, and many patients come to the physician with menstrual irregularities. The duration and degree of such irregularities may vary within wide limits, and spontaneous remissions often occur. However, when amenorrhea has existed for a year or longer in young women, the fact should be evidence of a major derangement of function or of a disease process, and therefore merits a complete investigation. The present paper is based on data for 94 young women between the ages of 19 and 25 years who came to the Mayo Clinic and who had not menstruated for a year or longer. They have been divided into five groups for the sake of a discussion of the conditions associated with their amenorrhea.

True toxemia of pregnancy occurring before the third trimester: Report of three cases and review of the literature

Abstract We have reviewed the English literature relating to carly toxemia of pregnancy and have presented our own experience with this interesting complication. It is important for the obstetrician to recall that true toxemia may occur before the last trimester. It is also important to realize that the diagnosis of pre-eclampsia and eclampsia in the early months of gestation is hazardous. The obstetrical diagnostician must demand that there be no evidence of pre-existing cardiovascular or renal disease, and the diagnosis would be sub-stantiated if the signs and symptoms of toxemia cleared rapidly and completely with the termination of pregnancy. However, this latter criterion cannot be an absolute requisite for in many cases true toxemia occurring in the last trimester of pregnancy leaves the patient with residual cardiovascular renal damage. It is, perhaps, a defect of our presentation that we have not followed these patients for a longer period. However, it has seemed to us that at least two of these cases, and possibly the third, have been as definitive examples of this entity as we might hope to discover.