[M.A. Mendes de Leon (1856-1924), a founding father of gynaecology]. / M.A.Mendes de leon (1856-1924), gynaecoloog van het eerste uur.

M.A. Mendes de Leon (1856-1924) was appointed private lecturer at the Department of Obstetrics of the University of Amsterdam in 1884. He promoted gynaecology in the Netherlands as a separate speciality, partly because of the new surgical possibilities following the discoveries of anaesthesia and antisepsis, but also due to the prevailing belief that the physiology of reproduction qualified the physical and psychological disorders of women. In his private gynaecological clinic he devoted himself to the surgery of ovarian tumours, uterus myomatosus and genital prolapse, but also to the diagnosis and treatment of supposed inflammations of the cervix and endometrium as cause of psychological disorders. In this he followed the opinions of contemporary English gynaecologists. As he was not aware of physiological histology, he nearly always found signs of inflammation. He treated this with curettage and drastic caustics, sometimes after using a dilation knife (hysterotome) for the cervix. At the turn of the twentieth century Dutch gynaecologists such as Treub and Nijhoff began to cast doubt on such theories of "reflex neurosis", but Mendes de Leon persisted in his views. Nevertheless, he can still be considered one of the founding fathers of gynaecology in the Netherlands, partly because of his surgical skills, but also due to his study into the interaction between gynaecological and psychological problems.

Effect of providing cancer patients with the audiotaped initial consultation on satisfaction, recall, and quality of life: a randomized, double-blind study.

PURPOSE: By means of a randomized double-blind study, the effect of providing taped initial consultations on cancer patients' satisfaction, recall, and quality of life was investigated. PATIENTS AND METHODS: Consecutive cancer patients referred to either the gynecology or medical oncology outpatient clinic were eligible. Initial consultations were audiotaped. Patients were either provided with the tape (experimental group) or not (control group). Baseline variables included sociodemographics, preferences for information, coping styles, and clinical characteristics. Follow-up (after 1 week and 3 months) variables included attitudes toward the intervention, satisfaction, recall, and quality of life. Assessments took place through mailed questionnaires and telephone interviews. RESULTS: Two hundred one patients were included (response, 71%), 105 in the experimental group and 96 in the control group. Most patients (75%) listened to the tape, the majority of which (73%) listened with others. Almost all patients, both in the experimental group (96%) and control group (98%) were positive about the intervention. Expectations were confirmed; patients provided with the tape were more satisfied (P <.05) and recalled more information (P <.01) than patients without the tape. The intervention did not have an effect on quality of life. An interaction effect was found between the intervention and patients' age on satisfaction with the taped consultation (P <.01) and recall of diagnostic information (P <.01); access to tapes seems more helpful in enhancing satisfaction in younger patients and recall of diagnostic information in older patients. CONCLUSION: Cancer patients and their families value the taped initial consultation. This intervention enhances their satisfaction and improves their recall of information. Tapes seem more helpful in enhancing satisfaction in younger patients and recall of diagnostic information in older patients.

[Enigmas surrounding an obstetric forceps belonging to Albertus Titsingh (1714-1790)]. / Raadsels rond een verlostang van Albertus Titsingh (1714-1790).

In the collections of the Society of the Dutch Journal of Medicine there is a small box containing a small obstetric forceps modelled on that of the British physician Smellie and some documents with information about its origin. The instrument belonged to the Amsterdam surgeon-obstetrician Albertus Titsingh and is claimed in the documentation to have been used during the birth of the later King William I (1772-1843) in 1772. However, historical research indicates that this is very unlikely: it is an established fact that the birth of William I was rapid and successful, while Albertus Titsingh was an authoritative obstetrician in an 'obstetric climate' of biding one's time and taking no action until the natural powers have failed.

The contribution of MIB 1 in the accurate grading of vulvar intraepithelial neoplasia.

AIM: To determine the interobserver variation in scoring presence and grade of vulvar intraepithelial neoplasia (VIN) in haematoxylin/eosin (H/E) slides, MIB 1 slides, and the combined use of H/E and MIB 1 slides. METHODS: 10 slides were stained with H/E and MIB 1 with each of the following diagnoses: normal vulvar skin, VIN 1, VIN 2, and VIN 3. Six observers first scored the H/E slides separately from the MIB 1 slides and second the combined H/E and MIB 1 slides. RESULTS: Unweighted group kappa for MIB 1 was 0.62 and the weighted group kappa was 0.91. This was significantly better than the unweighted group kappa for H/E slides (0.47, p = 0.023) as well as the weighted group kappa for H/E slides (0.82, p = 0.014). There was no improvement by the combined use of H/E and MIB 1 slides. VIN 2 is far less confused with VIN 3 in the combined use of H/E and MIB 1 slides (9%) than in H/E slides (38%) (p = 0.007). There is a tendency to grade VIN in a two tailed grading system rather than a three tailed grading system, which became more apparent with the combined use of H/E and MIB 1 slides. CONCLUSIONS: The interobserver variation with sole use of MIB 1 is better than with the use of H/E stain in VIN. The use of MIB 1 in grading VIN diminishes confusion between VIN 2 and VIN 3 fourfold. A two tailed grading system for VIN seems already to work in daily practice.

Long-term results of hysteroscopic myomectomy for abnormal uterine bleeding.

OBJECTIVE: To analyze the efficacy of transcervical resection of submucous myomas and to identify prognostic factors for long-term results. METHODS: Two-hundred eighty-five women were treated with transcervical resection of submucous myomas without endometrial ablation. In case of incomplete resection a repeat procedure was offered. Long-term follow-up was obtained. Recurrence was defined as the need for further surgery. The relation of several variables with the outcome was analyzed using Cox proportional hazard regression analysis. RESULTS: Seventeen cases (6%) were lost to follow-up. The median follow-up was 46 months (range 1-104 months); for cases without recurrence median follow-up was 42 months (range 16-104 months). Forty-one (14.5%) patients had repeat surgery. An independent prognostic value of uterine size (P < .001) and number of submucous myomas (P < .001) for recurrence was noted. Twenty of 41 patients who had repeat surgery subsequently had a hysterectomy. None of the variables investigated predicted the need for hysterectomy. The surgery-free percentage of 165 patients with normal sized uteri and not more than two myomas was 94.3% (standard error +/- 1.8%) at 2 years and 90.3% (+/- 3.0%) at 5 years. CONCLUSION: Transcervical resection of submucous myomas is a safe and effective treatment for patients with a normal sized uterus and not more than two myomas. It is an acceptable alternative for selected other patients. The need for a combined endometrial ablation is questionable. Transcervical resection of submucous myomas will give patients a high chance of averting further surgery and should modify the way patients are counseled.

The prognosis of cervical cancer associated with pregnancy: a matched cohort study.

OBJECTIVE: To assess the effect of pregnancy on the prognosis of cervical cancer and the morbidity of standard treatment. METHODS: We analyzed 44 women with cervical carcinoma associated with pregnancy, who were matched with 44 controls. Matching criteria were age, stage of disease (according to the International Federation of Gynecology and Obstetrics classification), tumor type, treatment modality, and period of treatment. RESULTS: In 23 cases, cervical cancer was diagnosed during pregnancy and in the other 21 cases, within 6 months after delivery. Thirty-nine women had early-stage disease (eight IA, 25 IB, and six IIA), and five had advanced stages (four IIB and one IIIB). The overall 5-year survival rate was 80% among subjects and 82% among controls, whereas the relative risk (RR) of dying within 5 years was 1.12 (95% confidence interval [CI] 0.48-2.65). With regard to the 5-year survival rate (85% for both subjects and controls, the RR of dying was 1.00 [95% CI 0.35-2.83]); no differences were found between subjects and controls for early-stage cervical carcinoma. The size of the group with advanced-stage cervical carcinoma was too small to allow any statistical analysis. No statistically significant differences in survival were observed between cases diagnosed during pregnancy and cases diagnosed after delivery. In addition, the mode of delivery had no effect on survival. Early complications within 6 weeks after treatment were seen 33 times in 25 subjects and 29 times in 23 controls. No differences were observed in the prevalence and type of early complications in subjects versus controls. Late complications after 6 weeks of treatment were seen nine times in nine subjects and 11 times in ten controls. No significant differences were observed in the prevalence and type of late complications in subjects versus controls. CONCLUSION: The prognosis of early-stage cervical cancer is similar in pregnant and nonpregnant patients when standard treatment is given. Because of the limited number of patients, no conclusions can be drawn about advanced-stage cervical cancer. The goal should be standard oncologic treatment, which does not lead to increased morbidity in pregnant patients.

Results of artificial insemination at home by the partner with cryopreserved donor semen: a randomized study.

The use of cryopreserved semen offers the possibility of home insemination by the instructed partner. A comparative study was designed whereby participants were randomly allocated to use home or clinic insemination for six cycles. If no pregnancy had occurred after six cycles, the site of insemination was switched to the opposite location for a maximum of six further cycles. Fifty-three women with primary infertility fulfilling all entry criteria entered the study. In the first 6 cycles out of 29 home starters, 13 pregnancies were conceived, whereas in 24 clinic starters 11 pregnancies occurred, yielding no statistical difference in pregnancy rate. Of 138 couples who did not meet the criteria in the same period, 45 opted for home insemination, resulting in 20 home-inseminated pregnancies. Again, for comparable subgroups no statistical difference in pregnancy rate between home and clinic insemination was found.

Feasibility of transposition of the ovaries in the surgical and radiotherapeutical treatment of cervical cancer.

Ovaries are seldom subject to metastases and therefore their preservation is possible in radical cervical cancer surgery. However, with postoperative radiotherapy they cannot be preserved unless they are placed outside the radiation field. The practicality of this transposition was analysed in a series of 126 patients with cervical cancer. The ovaries were transposed intraperitoneally in a lateral and cranial direction in 44 of the 64 women under the age of 50 years. In 16 of these 44 women, only one ovary could be preserved and transposed. A critical analysis was performed of the ovaries' new location by plotting their position, marked by 2 clips each, in a single pelvis. In 68% of the women at least one ovary was placed outside the radiation field. However, because of scattered radiation, i.e. 5% of the total radiation dose at a distance of 4 cm outside the radiation field, a substantial loss of ovarian function may occur. In 32% of the women at least one ovary received less than this 5%. Optimal transposition may be achieved after extension of the abdominal incision. However, this will be unnecessary in most cases, since postoperative radiotherapy will be indicated in only approximately 15% of the women.

Doctor-patient communication: a review of the literature.

Communication can be seen as the main ingredient in medical care. In reviewing doctor-patient communication, the following topics are addressed: (1) different purposes of medical communication; (2) analysis of doctor-patient communication; (3) specific communicative behaviors; (4) the influence of communicative behaviors on patient outcomes; and (5) concluding remarks. Three different purposes of communication are identified, namely: (a) creating a good inter-personal relationship; (b) exchanging information; and (c) making treatment-related decisions. Communication during medical encounters can be analyzed by using different interaction analysis systems (IAS). These systems differ with regard to their clinical relevance, observational strategy, reliability/validity and channels of communicative behavior. Several communicative behaviors that occur in consultations are discussed: instrumental (cure oriented) vs affective (care oriented) behavior, verbal vs non-verbal behavior, privacy behavior, high vs low controlling behavior, and medical vs everyday language vocabularies. Consequences of specific physician behaviors on certain patient outcomes, namely: satisfaction, compliance/adherence to treatment, recall and understanding of information, and health status/psychiatric morbidity are described. Finally, a framework relating background, process and outcome variables is presented.

Intestinal obstruction in patients with advanced ovarian cancer.

A retrospective analysis of the management of intestinal obstruction in 31 patients with advanced ovarian carcinoma is described. Between 1981 and 1992 31 patients developed intestinal obstruction after their initial treatment. Nineteen patients underwent surgery, while the remaining 12 were treated conservatively. Careful evaluation with contrast studies of both the small intestine and colon is recommended to improve the prediction of site(s) of obstruction, and may reduce the number of unsuccessful operative procedures. Fifteen of the surgically treated patients survived for a period of 60 days or more. The majority, 13, were discharged to their homes after an average hospital stay of 24 days. Major postoperative complications occurred in three of the 19 patients. There was no surgical-related mortality. Two patients died within 30 days postoperatively (urosepsis and advanced tumor). While the median survival in the 19 surgical treated patients was 109 days (range 15-775), the conservatively treated 12 patients survived for a mean of 37 days (range 6-260). Surgical management of intestinal obstruction in selected cases is feasible and improves quality of life substantially.

Restricted surgical management of vulvar intraepithelial neoplasia 3: Focus on exclusion of invasion and on relief of symptoms.

van Beurden M, van der Vange N, ten Kate FJW, de Craen AJM, Schilthuis MS, Lammes FB. Restricted surgical management of vulvar intraepithelial neoplasia 3: Focus on exclusion of invasion and on relief of symptoms. Int J Gynecol Cancer 1998; 8: 73-77. A study was undertaken to determine the effectiveness of extensive and restricted surgery for vulvar intraepithelial neoplasia (VIN) 3. All consecutive patients with VIN 3 admitted to a tertiary referral hospital were included. The main outcome measures were relief and recurrence of symptoms and progression to invasive disease in patients with VIN 3 after extensive or restricted surgery. Of every vulvoscopic visible lesion a biopsy was taken to establish extent and grade of VIN and to rule out invasive carcinoma. Patients with unifocal VIN 3 underwent extensive surgery. Patients with multifocal VIN 3 underwent extensive or restricted surgery or an expectant management was adopted, depending on the existence of symptoms and the presence of invasive vulvar carcinoma. Forty-seven patients were evaluated. Eighty-three percent of patients had a long history of symptoms. Eight patients (17%) had unifocal VIN 3. In 9% of the patients a superficially invasive vulvar carcinoma was found, ie with a depth of invasion of 1 mm or less. Only 20% of the extensively operated patients had free surgical margins. There was recurrence of symptoms in all of the extensively operated patients, in contrast to a 26% persistence or recurrence rate of symptoms in the restrictedly operated patients. In patients with multifocal VIN 3 who underwent restricted surgery, young age of the patient (P = 0.02) and large extension of VIN 3 (P = 0.02) were significant factors in predicting persistence or recurrence of symptoms. Only once was a superficially invasive vulvar carcinoma diagnosed during follow-up, and this was in an extensively operated patient. Vulvoscopically directed biopsies in VIN 3 are a safe method to exclude invasive disease. Restricted surgery is effective in relieving symptoms in multifocal VIN 3.

Recurrent cervical carcinoma after radical hysterectomy: an analysis of clinical aspects and prognosis.

Samlal RAK, van der Velden J, van Eerden T, Schilthuis MS, Gonzalez Gonzalez D, Lammes FB. Recurrent cervical carcinoma after radical hysterectomy: an analysis of clinical aspects and prognosis. Int J Gynecol Cancer 1998; 8: 78-84. The purpose of the present study was to evaluate the clinical aspects and prognosis of patients with tumor recurrence in surgically treated stage IB and IIA cervical carcinoma patients. Two hundred and seventy-one stage IB and IIA cervical carcinoma patients underwent a Wertheim Okabayashi radical hysterectomy with pelvic lymphadenectomy. The median follow-up time was 60 months. Recurrence occurred in 27 patients (10%): 14 had a pelvic recurrence and 13, and extrapelvic recurrence. The site of recurrence was influenced by various pathological factors as well as by the primary treatment mode. 77% of recurrences were detected within three years after primary treatment. The median recurrence-free interval in patients with a pelvic recurrence was significantly shorter than in patients with an extrapelvic recurrence (14 months vs. 17 months, P = 0.03). The mortality rate of the group of patients with recurrent disease was 85% (23/27). Patients with a pelvic central recurrence had a significantly better outcome than did patients whose recurrences were located at the pelvic sidewall. Two patients with a pulmonary recurrence were treated with surgery and show no evidence of disease after 4 and 8 years respectively, of follow-up. The overall detection rate of recurrent disease by routine follow-up was only 36%. However, asymptomatic patients had a significantly better prognosis when compared with symptomatic patients. Therefore, we recommend frequent follow-up visits during the first 3 years after primary treatment to detect recurrence in an early stage.

Doctor-patient communication and cancer patients' quality of life and satisfaction.

In this study, the relationship between (a) doctor's and patients' communication and (b) doctors' patient-centredness during the oncological consultation and patients' quality of life and satisfaction was examined. Consultations of 96 consecutive cancer patients were recorded and content analysed by means of the Roter Interaction Analysis System. Data collection (mailed questionnaires) took place after 1 week and after 3 months. Oncologists' behaviours were unrelated to patients' quality of life. Their socio-emotional behaviours related to both patients' visit-specific and global satisfaction. Patients' behaviour related to both patient outcomes although mostly to satisfaction. Multiple regression analyses showed that patients' quality of life and satisfaction were most clearly predicted by the affective quality of the consultation. Surprisingly, oncologists' patient-centredness was negatively related to patients' global satisfaction after 3 months. In summary, doctor-patient communication during the oncological consultation is related to patients' quality of life and satisfaction. The affective quality of the consultation seems to be the most important factor in determining these outcomes.

Symptom perception: psychological correlates of symptom reporting and illness behavior of women with medically unexplained gynecological symptoms.

Medically unexplained (gynecological) symptoms can be viewed as an indication of the somatization of negative emotions. Most studies regarding psychological correlates of medically unexplained gynecological symptoms have paid attention only to certain personality characteristics of women with these symptoms. In this study the reporting of physical symptoms and the resulting illness behavior is explained in terms of information processing or a perception process, i.e. the process by which people detect and interpret physical sensations as symptoms of illness (symptom perception). Symptom perception is in part determined by environmental characteristics and cognitive and emotional processes, such as variation in daily life, (coping with) emotional threat and the use of cognitive illness schemes. Differences in symptom perception and illness behavior of women with medically unexplained and explained gynecological symptoms, compared to women with medically explained gynecological symptoms and a control group, were established with the help of a questionnaire, containing a number of scales. As expected, women with medically unexplained gynecological symptoms had higher reports of common symptoms and sensations and showed also more other illness behavior than the other two groups. They reported less variation and more threat in daily life than the other two groups. These variables together with the use of illness schemes contributed most to symptom reporting of women with medically unexplained symptoms. It is concluded that defence against threat is probably an important determinant. Suggestions for further research and some practical implications are discussed.

Focal vulvitis: a psychosexual problem for which surgery is not the answer.

In the last decade focal vulvitis has been identified as a distinct syndrome, characterized by unexplained burning vulvar pain and superficial dyspareunia. A 'Woodruff perineoplasty' has been recommended as a treatment method. A research project was conducted, investigating the long-term results of surgical treatment and the etiology of focal vulvitis. Results showed that the great majority of women continued to suffer from focal vulvitis after the operation, which leads to the conclusion that the procedure should be abandoned. Retrospective data revealed several immediate causes of mechanical and chemical irritation of the vulva. All women exhibited 'inadequate sexual behavior': having intercourse without a sufficient amount of lubrication and/or in the presence of hypertonia of the pelvic floor. Psychosexual processes were further characterized by deterioration of sexual and general well-being, resulting in lack of libido and depression, which contributed considerably to the problem. An integrated approach to treatment is recommended, which incorporates protection of the vulvar skin, relaxation of pelvic muscles and sexological treatment of the psychosexual and relational aspects.

CA 125 in ovarian cancer.

The serum tumour marker CA 125 is useful in the management of ovarian cancer, although it has its limitations. Approximately 85% of the ovarian cancer patients have an increased serum CA 125 at the start of treatment. There is a good correlation between the course of CA 125 and the clinical response of the tumour. Patients with an increasing CA 125 are found to have progressive disease in 97%. In these patients further examinations to document progression should be performed. A decrease in serum CA 125 corresponds in 87% of the patients with tumour regression. A normal serum CA 125, however, does not exclude tumour. More than 40% of the patients with a normal CA 125 still have microscopic or macroscopic tumour at second look surgery. On the other hand, an increased serum CA 125 corresponds in 90% of the patients with the presence of tumour or tumour progression shortly after the second look. The same holds for secondary debulking surgery. Patients with an increasing serum CA 125 before secondary debulking surgery have progressive disease at or shortly after surgery, even if an adequate tumour debulking has been performed. In these patients surgery should be omitted as long as no effective second line therapy is available. The course of serum CA 125 during the first 3 months of treatment is of prognostic value for response rate as well as time to progression and overall survival. Patients with a serum half-life of more than 20 days, or a CA 125 which is still high 3 months after the start of treatment, have a significantly lower response rate and progression-free survival. Whether it is possible to improve the prognosis of these patients by dose-intensification will have to be investigated in randomized trials. Serum CA 125 is not specific for ovarian cancer. High levels can also be found in patients with non-ovarian gynaecological and non-gynaecological tumours as well as patients with benign diseases and even in apparently healthy persons. In view of this aspecificity, serum CA 125 cannot be proposed for mass screening. For the same reason, serum CA 125 and the immunohistochemical staining with OC 125 are of limited value in the differential diagnosis between a primary ovarian tumour and metastatic disease in an ovary, as well as for differential diagnosis of pelvic tumours.

Miraculous cures in gynaecology.

As a gynaecologist-oncologist one will quite often have been confronted with patients who have informed one of fairly impressive results of methods of alternative medicine. These convincing stories must have been impressive. Very often one may wonder about these 'cures'. There are, however, patients who give quite accurate and detailed reports, thereby surprising one that such cures were achieved by non-regular treatment. Because of such stories, one will probably start wondering what there is between heaven and earth that conventional medical science does not know of. Now we should certainly not preclude that there may be therapeutic possibilities that are not yet rationally explicable; on the other hand one should be armed when forming an opinion. It is necessary to realise that there may be quite different explanations for miraculous results that alternative therapies may have in cures.

The hysterophore: a new instrument for uterine manipulation during laparoscopy.

The hysterophore was developed for moving the uterus around during laparoscopy. The instrument provides an intra-uterine sound variable in length and direction, fixed to the cervix by a sliding cup. Especially in cases of a large retroverted uterus or multiple pelvic adhesions the hysterophore can place the uterus in a safe position for sterilization procedures.

PIP: During laparoscopic sterilization it is very useful to be able to move the uterus into the correct position. Different instruments have been used for this purpose; they differ in ease of handling, but none makes it possible to place a sound in the whole length of the uterine cavity, or to correct the position of a large retroverted uterus, or to move it left or right in case of adhesions. This paper describes a new instrument for manipulating the uterus during laparoscopy. The instrument is called a hysterophore and was developed with the following criteria: 1) it consist of an intrauterine sound variable in length and direction, 2) prevention of perforation by fixation of the sound by a cup to the cervix, and 3) preservation of the motility of the uterus. The instrument was successfully used in more than 2500 laparoscopic sterilizations. There were 3 perforations in the beginning; after that the instrument was altered by decreasing the diameter of the sound from 6 to 3 mm, and by using an active length sound 1 cm shorter than the measured length. No uterine perforations were reported after this modification. This instrument is indispensable in case of a retroverted uterus, obese patient, or multiple adhesions. Moreover, it allows the safe positioning of the tubes far away from the intestines in cases of sterilization by diathermy coagulation, thus avoiding the possibility of burns.

The labour of Constanze Mozart--a musical occasion?

In the diary of Mary and Vincent Novello it is mentioned that Constanze Mozart has told that the Quartet in D Minor (K 421/417 b) was written by Mozart during her delivery. The evidence for this information is discussed.

Office hysteroscopic tubal occlusion with siloxane intratubal devices (the Ovabloc method).

OBJECTIVES: To study the results of the Ovabloc method for female sterilization used in an outpatient setting. METHODS: A prospective longitudinal study at the Schieland Hospital of 411 patients who consented for the method for sterilization. For statistical analyses the x2 test is used for detection of differences between groups of patients. The life-table analysis is used for events during the follow-up period. RESULTS: Our results reflect those done under strict clinical conditions. The majority of the events took place in the first 36 months on Ovabloc. Unplanned pregnancies were mainly due to misdiagnosis in X-ray images and to incomplete procedures. CONCLUSIONS: The method failures are 3/1000 women in 12 months and 8/1000 women in 36 months. The follow-up should be extended to 12 months. The reversibility of the method remains questionable. The method should be offered to women with (relative) contraindications for laparoscopic sterilization such as severe obesity, extensive pelvic adhesions or anesthetic risks.