William C. Keettel

The viability of the cast-off menstrual endometrium

Abstract The histogenesis of endometriosis is still under discussion, although Sampsons implantation theory has been widely accepted in this country. Some experimental work has been advanced to support Sampsons hypothesis but evidently no one has shown definitely that the endometrium exfoliated at menstruation is capable of survival and growth. The purpose of this communication is to show that under some conditions cast-off menstrual endometrium is viable in tissue culture preparations. A contraceptive diaphragm was inserted in the vagina on the second day of menstrual bleeding and left in place from eight to twelve hours. After removal the diaphragm was placed in a sterile Petri dish and the collected fluid was immediately examined for bits of tissue. In two out of seven instances sufficient material was obtained for tissue culture explantation.

Experience with peritoneal cytology in the management of gynecologic malignancies

Abstract A summary of a 21 year experience with peritoneal cytology obtained by cul-de-sac and peritoneal lavage is presented. The interpretation of this type of cytology requires well-trained, experienced cytologists. Vaginal cul-de-sac lavage in asymptomatic patients has not proved effective in the early detection of ovarian cancer. Peritoneal cytology obtained at operation, on the other hand, has promise of considerable value. It was positive in 78 per cent of patients with ovarian cancer. Significantly, malignant tumors with an intact capsule shed malignant cells into the peritoneal cavity in 36 per cent of Stage I a patients. The over-all percentage of positive cytology for Stage I a, b, and c tumors was 45 per cent. There were 39 cases of Stage I endometrial carcinoma, of which 12.8 per cent had positive cytology. In patients with Stage III cervical carcinoma, who were explored as a part of their primary treatment, 14.7 per cent of those with negative nodes and 55.5 per cent of those with positive nodes had postive peritoneal cytology. Evidence is presented to prove that shed cancer cells are viable and capable of continued growth and that some form of adjunctive therapy should be considered.

Experience with radioactive colloidal gold in the treatment of ovarian carcinoma

Abstract 1.1. In 247 patients, cul-de-sac aspirations at the time of dilation and curettage revealed no abnormal cells. 2.2. In 275 patients, peritoneal washings at laparotomy revealed abnormal cells in 17 instances. Fourteen had ovarian cancer, 2 extensive uterine malignancy, and one instance was a false positive. 3.3. Five patients with cystadenocarcinoma showed no clinical evidence of spread yet abnormal cells were found in the peritoneal washings. 4.4. Patients with Stage I and IIA ovarian carcinoma are now treated with abdominal total hysterectomy, bilateral salpingo-oophorectomy, and Au 198 . 5.5. The remainder of the patients with ovarian carcinoma are treated with surgery, external irradiation, and radioactive gold when feasible. 6.6. The majority of patients tolerate Au 198 with minimal complications. 7.7. Colloidal gold is of value in controlling formation of ascitic fluid in certain patients. 8.8. Sufficient time has not elapsed to evaluate 5 year survival rates but results seem encouraging.

The hazards of elective induction of labor

Abstract 1. 1. A review of 6,860 cases of electively induced labors has been presented. 2. 2. The most effective method of inducing labor is simple amniotomy. 3. 3. Eighty-two and three-tenths per cent of the patients were in labor within 4 hours, and only 2.3 per cent had a latent period of over 24 hours. 4. 4. Pitocin stimulation was used in patients with prolonged latent periods or desultory labors with intrapartum fever. 5. 5. Serious though must be given to performance of cesarean section when the latent period is prolonged and infection is present, if labor cannot be stimulated within 24 to 36 hours. 6. 6. There was one maternal death related to induction. 7. 7. The principal fetal hazards were (a) prematurity, 3.1 per cent; (b) prolonged latent period, 5.0 per cent; (c) malpresentation, 0.9 per cent; (d) prolapsed cord, 0.3 per cent. 8. 8. There were 6,889 babies born. Of these, 37, or 0.6 per cent, were 9. stillborn, and 55, or 0.8 per cent, died neonatally. The perinatal mortality was 1.4 per cent. 10. 9. Thirty-nine of the perinatal deaths (0.6 per cent of the babies delivered) were directly related to the elective induction. 11. 10. A conservative attitude should be maintained by the specialist toward the elective induction of labor. The average general physician should allow labor to start spontaneously.

Management of Recurrent Carcinoma of the Cervix

Abstract Early diagnosis and management of recurrent cervical carcinoma are the most difficult problems encountered by physicians. In this study there were 145 patients with recurrent disease who were re-treated by additional radiation and 17 patients were treated by radical operation. In the patients treated by reirradiation, there were 4 patients who survived 5 years (3.1 per cent). Satisfactory palliation was achieved in 54 per cent of the patients without an excessive number of serious complications. The unanswered question is: How can operable recurrence be detected earlier in our Stage I and Stage II cases?

Surgical management of urethrovaginal and vesicovaginal fistulas

This report reviews a 50 year period during which 157 vesico- and 24 urethrovaginal fistulas were managed. Although the etiologic factors have changed, there has not been a dramatic decrease in the incidence of this complication. In the last 17 years we have noted an increased number of both types of fistula, primarily related to the increased frequency of gynecologic operative procedures. Only 11 (6%) of the fistulas reported in this series resulted from surgical procedures performed in our department. In this series 96% were repaired vaginally but the abdominal approach was used for certain complicated fistulas. Our initial cure rate was 89% and the final success rate in 157 vesicovaginal fistulas was 94.3%. The urethrovaginal fistulas represent a special problem because of the location, scarring, and lack of sufficient fascia for a second-layer closure. In such instances we have successfully used the bulbocavernous fat pad. The success rate for 24 patients with this type of fistula was 87.5%.

Carcinoma of the vulva: A review of 156 cases from the University of Iowa Hospitals

Abstract A review of 156 cases of cancer of the vulva is presented with 5 year follow-up. The over-all 5 year salvage is 36 per cent (56/156). Sixt-eigh t patients were treated by radical vulvectomy and bilateral groin dissection. The 5 year salvage in this group is 51.5 per cent. The relationship between lymph node involvement and survival is discussed.

Premature elective rupture of the membranes

Abstract In 1936, Plass and Seibert 1 reported on the results obtained in 681 consecutive patients in whom premature rupture of the membranes had been employed as a means for inducing labor, and concluded that this procedure offers the safest and most efficient method for inaugurating parturition. Since the series included 84 patients who presented some complication of pregnancy and since no control material was utilized, the data did not permit a real comparison except in most general terms. Because of the apparent good results, and because of the peculiar conditions in regard to obstetric patients in the University Hospitals, elective premature rupture of the membranes has been employed extensively during the intervening period. The present study was designed to permit an accurate comparison between patients who had late spontaneous rupture of the membranes and those who were subjected to induction of labor by elective early rupture of the bag of waters.

Endocrine studies of lactation amenorrhea

Lactation amenorrhea was studied in 40 lactating and 14 nonlactating postpartum patients. A 24-hour urine sample and a vaginal smear were ob tained from each patient each week until the onset of the 1st menstrual period. 3 patterns of gonadotropin excretion occurred with equal frequency in the 2 groups: 1 characterized by a continuous excretion of gonadotropins and a tendency toward prolonged atrophic vaginal smears indicating low estrogen production due to temporarily refractory ovaries 2 characterized by intermittent excretion of gonadotropins and a relatively early restoration of vaginal cornification indicating fairly responsive ovaries and 3 characterized by the absence of gonadotropins and varried vaginal epithelial patterns which seems to represent a delayed recovery of pituitary function. It is concluded that with lactation the duration of amenorrhea is prolonged because of either ovarian refractoriness or delayed recovery of pituitary gonadotropic activity.

Tubal sterilization; a review of 1,169 cases

Abstract During recent years 12 patients who had been sterilized at the University of Iowa Hospitals by the Madlener technique are known to have become pregnant. These failures stimulated this study in which the records of all patients sterilized were reviewed in regard to indications, the various techniques employed, the morbidity, and the end results of operation. An attempt was made to follow each patient by personal interview or letter, and was successful in 68 per cent. The remaining 32 per cent were considered to have been successful since failures of this nature usually are brought to the attention of the institution or surgeon.