Search

A brief summary of various aspects of the lives of people living in the rural areas of developing countries introduces this article. From these a few of the problems faced in efforts to improve maternal and child health and to affect population in countries with birth rates of 40 or more per 1,000 become apparent. A plan for promoting family planning based upon integration of such services with existing and improved maternal and child health organization is described. The first four years of effort toward the planning and implementation of a series of four to six trial projects situated in various parts of the world are described. The first statistical data on results will not be available for a year or two and final figures not for 6 years or more. Nevertheless the progress of this program, even through its developing stages, should be a matter of interest and importance. The rapid increase in the world's population is a major concern and problem. People may contribute toward the solution of this problem according to their particular knowledge and skills. For the gynecologist-obstetrician the type of program here described presents a special opportunity and responsibility.

The relationship of hyperplasia to carcinoma of the endometrium has therefore an etiologic and a clinical aspect. 1.I. Etiologic relationship: The position of endometrial hyperplasia as a precancerous lesion rests upon the following evidence: 1.1.1. Morphologic similarity: The weight given such evidence is largely dependent upon individual conception of form and is not susceptible to direct proof. A review of 85 cases of endometrial hyperplasia suggests, however, that this entity consists in reality of a series of types varying from those which differ little from normal endometrium to others which closely resemble certain differentiated carcinomas.1.2.2. Biologic similarity. The frequent association of endometrial hyperplasia with adenomyosis or the invasion of the muscularis by mucosal tissue and the tendency of the disease to return after curettage are perhaps to be interpreted as representations in miniature of two of the chief properties of malignancy, infiltration and recurrence.1.3.3. Transformation of hyperplasia into carcinoma, as indicated by a change in the character of the tissue obtained in successive curettings in the same patient, has been reported in the literature in at least six instances. Such cases must, however, be regarded critically because of the frequent lack of precision in the use of the term hyperplasia and the possibility that undetected carcinoma may have been present in the uterus at the time of the first operation. The only two instances occurring among 85 cases treated for hyperplasia of the endometrium at the Roosevelt Hospital from 1925 to 1929 of apparent transformation to carcinoma were dependent upon such errors.A review of 122 histories in cases of corpus carcinoma brings out the fact, however, that very many of these women had at some time before their final operation for cancer been under treatment for abnormal uterine bleeding. These cases may be divided as follows: 1.3.1.a. Cases in which endometrial hyperplasia almost certainly preceded carcinoma (Cases 5, 9).1.3.2.b. Cases in which the time and characteristics of the previous bleeding make it probable that a period of benign endometrial disease preceded the development of the malignant tumor (Cases 10, 11, 18, 20).1.3.3.c. Cases in which the earlier condition was obviously regarded by the clinician or pathologist as benign but which subsequent events indicate was very likely malignant (Cases 3, 4, 6, 7, 8, 17, 19, 21).1.3.4.d. Cases in which the earlier bleeding was later definitely proved to be due to an unrecognized malignant growth (Cases 1, 2, 12).1.4.4. The association of diffuse endometrial hyperplasia and carcinoma in the same uterus has been reported by previous observers and was noted in five instances (Cases 24, 25, 26, 27, 28) in the present cancer series. Similar proliferative changes were observed in 4 cases (Cases 1, 29, 30, 31) in women over sixty, in which, on account of the patient's age the unqualified use of the term endometrial hyperplasia has been withheld. In two further instances the carcinoma occurred with hyperplastic glands which were probably a part of an adenomatous polyp. Finally there were 9 cases of carcinoma associated with areas of invasion of the superficial muscularis by benign glands, constituting a condition termed adenomyosis and indicating abnormal properties in the basal endometrial glands.Although in a total of 152 cases there were only 15 with definite histologic evidence of an associated hyperplastic condition of some type, one cannot speak in terms of percentages, since it is obvious that many cases are so advanced that possible benign preexistent lesions have been completely displaced by carcinoma.2.II. Clinical relationship. Several cases in this series indicate that even with thoughtful handling, endometrial cancer may be mistaken for a benign condition. These cases lead to the following more or less obvious conclusions: 2.1.1. Postmenopausal bleeding from the uterine canal even if limited to a single attack should always be treated by curettage. No period of observation is sufficient to give security because further clinical evidence of carcinoma may not appear for even ten years after such an attack (Cases 17, 18, 19).2.2.2. Curetted material, no matter how scant, may be carcinomatous, and it is never justifiable to dispense with microscopic examination (Case 7).2.3.3. An incomplete curettage is not satisfactory as a diagnostic measure, for a small carcinoma may be missed by the instrument.2.4.4. A single microscopic section of curettings is not sufficient to rule out cancer in suspicious cases because the microtome may not cut the particle containing the growth (Cases 1 and 26).2.5.5. The histologic differentiation of hyperplasia from certain types of carcinoma requires at times considerable experience and the examination of multiple sections. The possibility of errors in diagnosis is very real and mistakes may lead to disastrous results (Cases 2, 12, and possibly 3, 4, and 6).Whether from a practical standpoint hyperplasia is to be regarded as precancerous and treated as such must remain an open question. The relative frequency of hyperplasia undoubtedly indicates that the individual patient with the disease is reasonably safe. Nevertheless it appears that when the hyperplasia is at all marked, the possibility of a predisposition to the development of cancer should be considered and the case regarded with the same degree of suspicion now bestowed upon the diffuse forms of hyperplasia of the breast epithelium. In patients of the menopause age and older an adequate dose of radium is particularly indicated, certainly as the most efficient method of controlling bleeding, possibly as a prophylactic measure against the development of cancer.

1. The titers of the isoagglutinins anti-A and anti-B in pregnant women at term do not differ significantly from the isoagglutinin titers in normal male adult blood donors. This indicates that pregnancy itself does not ordinarily stimulate a rise in isoagglutinin titer. 2. The frequency of incompatible blood groups in the infants of 31 mothers with toxemia of pregnancy was slightly higher (29 per cent) than that in a series of 166 infants of mothers without toxemia (22.3 per cent), but the difference was not statistically significant. 3. Of 37 normal mothers whose infants had blood groups incompatible with theirs, 9 were found to have a significant rise in isoagglutinin titer one week post partum. An appreciable rise in isoagglutinin titer occurred under similar circumstances in 6 of 9 mothers with toxemia. The series are too small to permit definite conclusions regarding the significance of this in relation to toxemia. However, there appears to be no doubt that under certain circumstances parturition can stimulate a rise in the maternal isoagglutinin titer. 4. No correlation was found between the occurrence of Rh incompatibility and toxemia of pregnancy. 5. The data obtained furnish additional evidence to support the theory of multiple allelic genes of heredity of the Rh blood types and also Race and Taylor’s theory of inheritance of the Hr factor.

A case of metastatic chorionepithelioma of the lung successfully treated by lobectomy is reported. The Aschheim-Zondek test which was positive prior to operation became negative following lobectomy. Panhysterectomy performed a month after lobectomy failed to reveal any evidence of disease in the pelvic organs. The patient is well and free of evidence of disease over three years following pulmonary lobectomy. The plan of therapy pursued in this case could be feasible only in a very small percentage of cases of chorionepithelioma.

Between the years 1930 and 1966, 52 patients with primary carcinoma of the vagina were treated at the Delafield and Presbyterian Hospitals. Forty-two were treated between 1930 and 1961, and of these 15 (35.7 per cent) survived for 5 years or more. The majority, 34 in number with survival of 11, were managed by a combination of external radiation and intravaginal or interstitial radium treatment. Eight patients with primary disease underwent radical operation, of which 4 survived for 5 years or more. On the basis of this experience, comments are made on the indicated type of therapy.

1.1. Two hundred cases of primary carcinoma of the ovary with at least fiveyear follow-up are presented. The papillary serous cystadenocarcinomas make up almost two-thirds of the total series.2.2. The five-year over-all survival rates are 30.8 per cent absolute and 27.5 per cent relative.3.3. The so-called borderline papillary serous cystadenocarcinoma is a malignant tumor.4.4. Prognosis depends chiefly upon the histogenetic type of tumor and upon the histological degree of malignancy, both of which largely control the clinical extent of disease. Ovarian tumors of low-grade histological malignancy have the most favorable prognosis. Similarly, tumors still confined to the adnexa are most favorable to treat. Clinical extent of disease is usually greater in tumors of high-grade histological malignancy.5.5. The following tumors are regarded as being of low-grade histological malignancy; papillary serous cystadenocarcinoma, borderline and Grade I; most papillary pseudomucinous cystadenocarcinomas; and most granulosa cell tumors. The best chances for survival occur in these cases.6.6. Complete surgical removal of the internal genitals remains the treatment of choice in ovarian carcinoma. Conservative surgery is rarely justifiable.7.7. Radiation therapy has a definite place in the treatment of certain cases of ovarian carcinoma chiefly to prolong survival time and perhaps occasionally (although rarely) to cure residual disease. It should be administered to all patients with tumors of high-grade histological malignancy even if localized to one or both ovaries. It seems of no value in tumors of low-grade histological malignancy unless there is operative evidence of spread beyond the ovaries; in the latter event, x-ray should be given. It should be given to all patients with extension of tumor beyond the ovaries regardless of the amount of spread and regardless of histological type.

Two distinct general conceptions of the nature and origin of the toxemias of pregnancy have guided recent research in two apparently quite divergent channels. In one direction are the endocrines, a very promising field, for it seems hardly possible that the substances which determine to such an extent the characteristic physiologic changes of pregnancy should not be in some sense responsible for a disease which occurs only in pregnancy. On the other hand are the physical and chemical phenomena of water and electrolyte exchange, which for the moment seem more closely related to the classical symptoms and signs of pre-eclamptic toxemia. Recent experiments showing that the estrogens and progesterone may cause the retention of sodium and of water suggest a line of investigation by which the hormonal and the physicochemical conceptions of toxemia may perhaps be reconciled.

The presence of a fibrinogenolytic enzyme and a cytofibrinokinase has been demonstrated in extracts of human myometrium, placenta, decidua, and endometrium

The alterations that take place in the maternal physiology with the onset of pregnancy may be ascribed to one cause or to a combination of causes. The more important include the pressure effects of the enlarging abdominal mass, the changes produced on the maternal circulation by the development of the vascular system of the placenta, the demands made by the growing ovum and by the reproductive organs of the mother for nutritive materials and perhaps the need for disposal of certain waste products or antibodies produced in the developing fetus. Finally, there are the so-called sex hormones formed in the placenta which from a period early in pregnancy are found in the maternal body fluids in concentrations far above anything ever observed in the nonpregnant state.Specific toxemia, or "hypertensive albuminuria." is a disease which apparently can develop only in women and only under the peculiar conditions of pregnancy. It

1.1. The results of the treatment of 148 cases of cancer of the ovary, from 1944 to 1951, inclusive, have been reviewed and compared with the results in cases treated from 1924 to 1943.2.2. The importance of histogenetic type, histological grade, and stage of clincal extension in prognosis has again been stressed.3.3. No significant improvement in the results in the more recent as compared with the earlier period was noted.4.4. The prospect of successful chemotherapy and of improved x-ray therapy is discussed.

CLINICAL STUDY The following pages contain a report of the results of a study of 271 women who entered the Memorial Hospital primarily on account of some form of neoplastic disease of the breast. The special object of the analysis of these cases is to afford a rough test of the fitness of the conceptions derived from the preceding theoretical discussion for explaining the origin of a series of typical breast neoplasms. The material used, although relatively small, has been examined with considerable care and it is felt that such an approach by means of a detailed study of a few cases is essential in what must be looked on as a preliminary survey of a rather new field.The entire group of cases came under my direct observation while the patients were attending one of the outpatient clinics at the Memorial Hospital. The majority were questioned and examined during