Richard W. TeLinde

The present-day status of noninvasive cervical carcinoma

Abstract Four years ago we 1 presented before this Society a paper which concerned itself with the minimal histologic changes in the cervical biopsy which would justify a diagnosis of carcinoma. Our observations followed those of Schottlander and Kermauner, 2 who noted a thin layer of carcinoma extending over the surface, surrounding advanced cervical cancer. They also followed the epochal work of Schiller, 3, 4 who first conceived the idea that surface carcinoma could be the beginning of invasive cancer. He described many cases without evidence of invasion in which cellular changes in the surface epithelium were found that were identical to those of invasive cancer. When we undertook our study it appeared to us that there was not sufficient evidence in the literature to justify completely the belief that these intraepithelial changes were precursors of invasive cervical carcinoma. To elucidate this point, we made a comparative histologic study of the biopsy specimens showing malignant changes in the surface epithelium and the ultimate specimens of the cervices removed at hysterectomy. The cervices were cut into several blocks and sections made from different levels in a search for evidence of invasion. In fifteen of the sixteen cervices removed, histologic evidence of invasion was found. Since our publication of 1944, we have continued to collect histologic and clinical evidence concerning this subject and it would seem that we have amassed sufficient data to crystallize our ideas on diagnosis and treatment. This paper is presented before this Society to give our conclusions based on a much wider experience and also with the hope of stimulating discussion concerning this subject.

The metabolism of progesterone in the hysterectomized woman

Abstract Progesterone has been injected into hysterectomized women and recovered, in part, in the urine as pregnanediol. The percentage recovered was the same as that observed for a normal woman in the follicular phase of the cycle who was injected with an equal amount of the hormone. Pregnanediol, in amounts comparable to those found in normal cyclic women, was recovered from the urine of hysterectomized women at a time when they were estimated to be in the luteal phase of the cycle. It is estimated that the hysterectomized woman is able to metabolize both exogenous and endogenous progesterone.

The Goebell-Stoeckel operation for universal cases of urinary incontinence

Abstract The Goebell-Stoeckel fascia lata strap operation for stress incontinence of urine has been used for 30 years. This is a review of eight cases from our practice using this operation for problems of total urinary incontinence secondary to congenital defects and complications of vaginal surgery. The Goebell-Fragenheim-Stoeckel 1–3 operation was first described in 1917. In the original operation, strips of fascia lata were not used for the strap. In later modifications of the procedure, a strip of fascia lata and a small transverse suprapubic incision were employed. The basic principle of the operation is having a supporting structure beneath the urethrovesicle junction that slightly elevates the urethra in this area upon downward or caudad movement of the bladder. Such movement occurs in all Valsalva maneuvers such as coughing, sneezing, laughing, lifting heavy objects, and many body movements. During these movements, the intravesical pressure is raised. If the intraurethral pressure is lower than the intravesical pressure, at that particular moment, urine in the bladder moves to the lower pressure area in the urethra and drains to the outside. The strap procedure, by supporting the suburethral tissue and the urethral vesical angle, probably increases the intraurethral pressure to a level greater than the intravesical pressure preventing urinary incontinence associated with Valsalva maneuvers but the pressure is not elevated to such a level as to retard urinary drainage during detrusor muscle contraction for voluntary voiding. If the above physiologic explanation is true for stress incontinence, how can the Goebell-Stoeckel strap procedure be explained for total incontinence, particularly secondary to congenital defects such as total bladder exstrophy and epispadias? A physiologic explanation of the success of the strap operation in congenital defects cannot be given. This physiologic explanation remains to be answered. However, the clinical results achieved in these eight cases deserve further study. Consideration of this operation may be warranted in these severe cases of incontinence.

The background of studies on experimental endometriosis

I HAVE BEEN ASKED to remark on the circumstances leading up to the experimental work on endometriosis in monkeys done by Dr. Roger Scott and me. I am very glad to do so since I have been particularly interested in the subject for many years. In fact, we at Johns Hopkins have always had an unusual interest in the disease since it was first described in our pathology laboratory by Russell* in 1899. To Sampson belongs the credit for publicizing the condition to the medical profession. Sampson had been one of the early residents in gynecology at Johns Hopkins under Dr. Howard Kelly. From his residency he went to Albany Medical College as a professor of gynecology. It was from there that he published extensively on external endometriosis in the 1920’s and 1930’s. Her’, 6 pronounced his theory of its etiology by retrograde menstruation via the Fallopian tubes. Robert MeyerIs of Germany, who was perhaps the greatest gynecologic pathologist of all time, did not accept Sampson’s theory and propounded the theory of metaplasia of the serosal cells of the peritoneum, having previously published his views on metaplasia of epithelial cells. Novak, who at this time was in charge of our pathology laboratory, supported Meyer’s views. To Dr. Scott and me, this theory seemed to be a bit hypothetical, without much real evidence to support it. Hence, we determined to test Sampson’s theory of retrograde menstruation. We were very fortunate in having access to a rhesus monkey colony through the courtesy of Dr. George Corner who was in charge of the Carnegie Embryological Laboratory. These monkeys menstruate much as women do but almost never have endometriosis. I had previously worked with Dr. Hartman in removing embryos by hysterotomy from pregnant monkeys. Some of these monkeys developed endometriosis. This suggested to me that we had transplanted endometrial cells by surgery, which gave