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Chorioepithelioma malignum
278
TIIJ?
AMERICAN
JOURN:iL
OP OBSTETRICS
AND
GYNECOLOGY
I. feel that it was thct one thirlg Ihal got t.he patient over the top. None of theso CPW~~S in which WC have used it were viridaus infections. There have been no cases of septicemia. In diseases WC haye used blood transfusion, it has proved a distinct addition to our treatment. 111 the pelvic inflammatory cases there is cvcry reason to believe that it will act as ix foreign protein as well as to stimulate t,he blood-making organs. DR. HAROLD W. JONES.-1 did not want to give the impression when I spoke cjf1hqticcmia and the use of transfusion that we were speaking of the bacteria in the blood stream. I wish to corroborate what Dr. -4nspach has said from my viewpoint that transfusion in infectious conclitions in the peritoneum has proved VPI’V ” successful. I do not recall any patient who had pelvic inflammatory d&case who was not benefited by it, iu the face of a mortality of about 75 per cent. We use, whole blood and I have never seen a serious reaction in the case of secondary anemia with the cxceptiou of those mentioned. We have done at the hospital about 700 transfusions iu conditions of secondary :tuemia, and about 300 ii, primary anemia. The cast: of Streptococcus viridans infection was not a gynecologic or obstetric case, but. it was a man in the hospital nineteen weeks who is perfectly we11 today.
DR. CFIARLES S. BARNES and DR.. J. H. CLARK (by invitation) a report of a case of Chorio@thelioma i&a.li~um.
presented
Mrs. I’. B., Albanian, wab twenty-scveu years of age. History probably of three prcguancies, cme full t,erm iu 1920; the child died of tuberculous meningitis at t\vo and one-half years. 0110 spontaneous early abortion, her attending physician believes occurred during the illness of her chil.d, without any complications. This was some six months previous to her final illness. On May 9, 1924 she had a spontaneous abortion at two nud one-half months. Nothing unusual was noted at the time except perhaps rat,& excessive hemorrhage. M’oderate bleeding persisted, the patieat apparently making slow recovery, when at the end of ten days, sudden and severe nietrorrhagia occurred. The patient was taken to a hospital, curettage performed with rcrp little tissue resulting and uterine packing done. The writer first saw the patient with her physician three days later, May 22, 1924. On 1~1:mova1of the packing there was no considerable hemorrhage. Some enlargement of the right adneral region was noted and. a probable diagnosis of old inflammatory disease made. The patient was allowed to return home four days later. During the week’s stay of the patient in !lospital, the temperature varied from 97.2” to 99.4”, pulse 64 to 100. Two days following her rrturn home genital bleeding suddenly became so serious At this time, suspicions already as to necessitate uterine and vaginal packing. were confirmed, by detection of a small flat Pntertained of chorioepitheliomn, mulberry-like nodule (resembling a localized varicosity) midway in the anterior vaginal wall. This was the site of most of the hemorrhage at this time. The next day, after admission to a hospital, the vaginal growth was excised, a laboratory report pronouncing it ehorioepithelioma. At tlli$ time, there was increased muscular t,ension, tenderness and pain with a palpable mass in the right lower abdominal region. Anemia was marked, hemoglobin 30 per cent, erythrocytes 2,500,000, leucocytes 6,350. Evidently the patient was a very poor surgical risk, but it was d&d.& to give She had a preoperative temperature of her a chance of life, by panhysterectomy. 100”. with a corrcspondi.nglp rapid pulse.
NEW
ORLEANS
GYNECOLOGICAL
AND
OBSTETRICAL
SOCIETY
279
Extension of the malignancy into the right broad ligament made hemostasis in this spongy tissue exceedingly difficult, suture ligature being freely employed. Despite most of the means for combatting such a condition (including blood transfusion) the patient succumbed to shock fourteen hours subsequent to opernlion. and symptomatology presents an average This patient as to age, multiparity, of east of its kind.. The malignancy doubtless began bef.orc the termilmtion There mere no symptoms indicatpregnancy by abortion, three weeks previously. The ing metastases except that to the vagina and the right broad ligament. primary growth, comparatively small, was situated in the fundus of the uterus. X0 neeropsy was secured.
NEW ORLEANS
GYNECOLOGICAL
AND
OBSTETRICAL
SOCIETY MEETING OF FEBBUABP 12, 1066 DR.
P.
R.
SALATICH
Congenital
Atresia
presented
the following
account of two cases of
of the Vagina.
Most surgeons of experience agree that the earlier operations for establishing an artificial vagina by opening the cellular tissue between the bladder and rectum and maintaining the opening by tampons or plugs have uniformly failed. The first man to operate by incision of the rectovesical septum was de Haen (January 25, 1761) and between that time and 1904, when the Baldwin operation was devised, over twenty-five different methods had been suggested. The Beck operation, which is probably the best of the grafting methods, utilizes large pieces of skin graft taken along the inner sides of the thighs at the vaginal outlet and turned so that the raw surfaces come in contact with the reconstructed. vagina. It is not very successful. Even if it does not contract, mucous membrane, when it is long exposed, comes to form a very fair substitute for skin but the converse of this is by no means true and a skin lined vagina must differ very widely from one formed with normal mucous membrane, Most of these cases require long continued tamponing or retention, either continuously or intermittently, to keep them from contracting. CASE 1. Miss V. D., sixteen years of age, first consulted me in 1918. At that time she was slender but well-formed, apparently perfect in health and rather an attractive girl. She had never menstruated, but as the general physical examination was negative and thcro were no apparent pelvic symptoms, I made no pelvic examination, simply prescribing a tonic and advising her to return if menstruation did not appear. I did not see her again until 1923. When I learned that menstruation had never appeared I made a pelvic examination, only to find no evidence at all of a vagina. When the situation was explained to the patient and to her mother, they were both insistent that I do something, and although I explained to them the extent and the seriousness of the necessary procedure they were willing to take the chance. A typical Baldwin operation was done a month or so later. Both ovaries were fairly normal in size but each contained several small cysts, most marked towards the lateral pelvic walls. The tube on the left was fairly normal, but there was no evidence of a tube on the right. The uterus was divided into two parts, widely separated, that on the right about the size of a pecan and that on the
TIIJ?
AMERICAN
JOURN:iL
OP OBSTETRICS
AND
GYNECOLOGY
I. feel that it was thct one thirlg Ihal got t.he patient over the top. None of theso CPW~~S in which WC have used it were viridaus infections. There have been no cases of septicemia. In diseases WC haye used blood transfusion, it has proved a distinct addition to our treatment. 111 the pelvic inflammatory cases there is cvcry reason to believe that it will act as ix foreign protein as well as to stimulate t,he blood-making organs. DR. HAROLD W. JONES.-1 did not want to give the impression when I spoke cjf1hqticcmia and the use of transfusion that we were speaking of the bacteria in the blood stream. I wish to corroborate what Dr. -4nspach has said from my viewpoint that transfusion in infectious conclitions in the peritoneum has proved VPI’V ” successful. I do not recall any patient who had pelvic inflammatory d&case who was not benefited by it, iu the face of a mortality of about 75 per cent. We use, whole blood and I have never seen a serious reaction in the case of secondary anemia with the cxceptiou of those mentioned. We have done at the hospital about 700 transfusions iu conditions of secondary :tuemia, and about 300 ii, primary anemia. The cast: of Streptococcus viridans infection was not a gynecologic or obstetric case, but. it was a man in the hospital nineteen weeks who is perfectly we11 today.
DR. CFIARLES S. BARNES and DR.. J. H. CLARK (by invitation) a report of a case of Chorio@thelioma i&a.li~um.
presented
Mrs. I’. B., Albanian, wab twenty-scveu years of age. History probably of three prcguancies, cme full t,erm iu 1920; the child died of tuberculous meningitis at t\vo and one-half years. 0110 spontaneous early abortion, her attending physician believes occurred during the illness of her chil.d, without any complications. This was some six months previous to her final illness. On May 9, 1924 she had a spontaneous abortion at two nud one-half months. Nothing unusual was noted at the time except perhaps rat,& excessive hemorrhage. M’oderate bleeding persisted, the patieat apparently making slow recovery, when at the end of ten days, sudden and severe nietrorrhagia occurred. The patient was taken to a hospital, curettage performed with rcrp little tissue resulting and uterine packing done. The writer first saw the patient with her physician three days later, May 22, 1924. On 1~1:mova1of the packing there was no considerable hemorrhage. Some enlargement of the right adneral region was noted and. a probable diagnosis of old inflammatory disease made. The patient was allowed to return home four days later. During the week’s stay of the patient in !lospital, the temperature varied from 97.2” to 99.4”, pulse 64 to 100. Two days following her rrturn home genital bleeding suddenly became so serious At this time, suspicions already as to necessitate uterine and vaginal packing. were confirmed, by detection of a small flat Pntertained of chorioepitheliomn, mulberry-like nodule (resembling a localized varicosity) midway in the anterior vaginal wall. This was the site of most of the hemorrhage at this time. The next day, after admission to a hospital, the vaginal growth was excised, a laboratory report pronouncing it ehorioepithelioma. At tlli$ time, there was increased muscular t,ension, tenderness and pain with a palpable mass in the right lower abdominal region. Anemia was marked, hemoglobin 30 per cent, erythrocytes 2,500,000, leucocytes 6,350. Evidently the patient was a very poor surgical risk, but it was d&d.& to give She had a preoperative temperature of her a chance of life, by panhysterectomy. 100”. with a corrcspondi.nglp rapid pulse.
NEW
ORLEANS
GYNECOLOGICAL
AND
OBSTETRICAL
SOCIETY
279
Extension of the malignancy into the right broad ligament made hemostasis in this spongy tissue exceedingly difficult, suture ligature being freely employed. Despite most of the means for combatting such a condition (including blood transfusion) the patient succumbed to shock fourteen hours subsequent to opernlion. and symptomatology presents an average This patient as to age, multiparity, of east of its kind.. The malignancy doubtless began bef.orc the termilmtion There mere no symptoms indicatpregnancy by abortion, three weeks previously. The ing metastases except that to the vagina and the right broad ligament. primary growth, comparatively small, was situated in the fundus of the uterus. X0 neeropsy was secured.
NEW ORLEANS
GYNECOLOGICAL
AND
OBSTETRICAL
SOCIETY MEETING OF FEBBUABP 12, 1066 DR.
P.
R.
SALATICH
Congenital
Atresia
presented
the following
account of two cases of
of the Vagina.
Most surgeons of experience agree that the earlier operations for establishing an artificial vagina by opening the cellular tissue between the bladder and rectum and maintaining the opening by tampons or plugs have uniformly failed. The first man to operate by incision of the rectovesical septum was de Haen (January 25, 1761) and between that time and 1904, when the Baldwin operation was devised, over twenty-five different methods had been suggested. The Beck operation, which is probably the best of the grafting methods, utilizes large pieces of skin graft taken along the inner sides of the thighs at the vaginal outlet and turned so that the raw surfaces come in contact with the reconstructed. vagina. It is not very successful. Even if it does not contract, mucous membrane, when it is long exposed, comes to form a very fair substitute for skin but the converse of this is by no means true and a skin lined vagina must differ very widely from one formed with normal mucous membrane, Most of these cases require long continued tamponing or retention, either continuously or intermittently, to keep them from contracting. CASE 1. Miss V. D., sixteen years of age, first consulted me in 1918. At that time she was slender but well-formed, apparently perfect in health and rather an attractive girl. She had never menstruated, but as the general physical examination was negative and thcro were no apparent pelvic symptoms, I made no pelvic examination, simply prescribing a tonic and advising her to return if menstruation did not appear. I did not see her again until 1923. When I learned that menstruation had never appeared I made a pelvic examination, only to find no evidence at all of a vagina. When the situation was explained to the patient and to her mother, they were both insistent that I do something, and although I explained to them the extent and the seriousness of the necessary procedure they were willing to take the chance. A typical Baldwin operation was done a month or so later. Both ovaries were fairly normal in size but each contained several small cysts, most marked towards the lateral pelvic walls. The tube on the left was fairly normal, but there was no evidence of a tube on the right. The uterus was divided into two parts, widely separated, that on the right about the size of a pecan and that on the