A new gynecological instrument

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Communications

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February 15, 1964 :\m. ]. Obst. & Gyne<:.

brief

Fig. 1. Photomicrograph of the metastatic lung lesion showing large trophoblastic cells from chorioadenoma destruens. (Hematoxylin and eosm xl68.)

adopted children. Both tubes and ovaries were normal. The pathological diagnosis was hydatidiform mole with no trophoblastic infiltration of the myometrium. The patient made an uneventful recovery. Friedman tests performed at monthly intervals were negative. In September, 1954, 10 months following the operation, the Friedman test became positive, and the patient complained of fullness and soreness in the breasts. X-ray examination of the chest revealed no lesions. Quantitative Aschheim-Zondek tests were positive at 10,000 and 50,000 M.U. This test was repeated a month later with similar result. On Jan. 1, 1955, the patient had hemoptysis, and the next day x-ray examination showed a solitary metastatic lesion measuring about 3 em. at its greatest diameter, located in a superior division of the right lower lobe of the lung. On January 14, partial lobectomy w~s performed by one of us (W.M.T.), and the finding was a discrete 4 em. tumefaction in the basal segments, the lateral portion of the right lower lobe of the lung. Resection of four basal segments \Vas done, leaving the superior segment intact. The nodule was composed of trophoblastic tissue with hemorrhage. The diagnosis was either choriocarinoma or chorioadenoma destruens. Slides of the uterus and lung were sent to the late Dr. Emil Novak and other members of the Albert Mathieu Chorionepithelioma Registry. It was their conclusion that the lesions were benign. She has remained in good health to the present, and repeated biologic tests and chest x-rays have failed to detect any recurrence of this disease 10 years later. It appears that the original diagnosis of choriocarcinoma was in error. Novak and Seah 1 stated that over half of the cases sent to the

Albert Mathieu Chorionepithelioma Registry with the diagnosis of choriocarcinoma are in fact benign. It appears, therefore, that this is an error which has been rather frequently made and the difficulties in diagnosis are v-.rell pointed up by Smalbraak. 2 The long latent period between the performance of the hysterectomy and the appearance of the pulmonary metastasis is worthy of note. REFERENCES

I. Novak, E., and Seah, C. S.: AM. J. 0BST. & GYNEC. 68: 376, 1954. 2. Smalbrak, ]. : Trophoblastic Growths, Amsterdam, The Netherlands, 1957, Elsevier Press, Inc.

A new gynecological instrument ALVIN M. SIEGLER, M.D. LOUIS M. HELLMAN, M.D. State U1tiversity of liew York Downstate Medical Center College of Medicine, Brooklyn, New York.

Prior to reconstructive oviductal operation the presence of organic occlusion must be confirmed and the point of tubal obstruction located. Preoperative techniques are not infallible and even at the time of laparotomy the gross tubal morphology may not reveal the true anatomic

Volume B8 Number 4

Fig. 1. Clamp in place to demonstrate occlusive character and use with fundal patency test.

Fig. 2. Authors design of uterine isthmus occlusive clamp.

Communications in brief

551

or physiologic status. Therefore, tubal patency must be re-evaluated under direct vision prior to definitive operation. Previous attempts to occlude the cervical os vaginally by means of various kinds of rubber acorns, screw tips, and even the intrauterine balloon, handicapped abdominal uterine manipulations. Further, the surgeon could not be certain that a leak in the application did not occur during repeated tests. In addition another member of the staff was required to operate the insufflator. At first a rubber catheter was employed as a tourniquet about the internal os but the technique proved cumbersome. l•. Dartique "T-shaped" clamp was employed in our earlier studies but its use was limited by the size of the uterus. The ideal method requires that an occlusive instrument be placed about the internal os. Then a needle can be inserted into the uterine cavity via the fundus and either indigo carmine or carbon dioxide may be insufflated through the needle. Observation of these results help to decide the kind of tubal plastic operation that is warranted (Fig. 1). A clamp* was designed by the authors that occludes the internal os. The shaft measures 10 inches and has a box lock. Two fixed slightly curved bars at right angles to the shaft are rubber shod and 2 inches in length (Fig. 2). After visualization of the uterus the clamp is opened and the two angled bars are placed on the lower uterine segment in the region of the internal os. The bladder falls away from the anterior bar and need not be (in most instances ) dissected from the uterus. The posterior bar causes no problem in its placement unless there are adhesions of the intestine to the region of the uterosacral ligaments. The adnexa are displaced either anterior or posterior to the opening of the clamp. In some instances the tube and ovarian ligament course through thP. upright opening of the clamp but are not traumatized by it. When the clamp is closed the isthmus is occluded and tubal patency tests can be carried out. The clamp may remain on the uterus for the duration of the laparotomy if desired. Aside from the above described use the instrument helps to manipulate the uterus for traction and aids in the routine total abdominal hysterectomy in the dissection of the perivesical

*Manufactured by Marco and Son, 4 Kenneth Avenue, Old Bridge, New Je rsey.

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February l.~l. 1964 .\m . .). Ohst. & Gvnec.

Communications tn brief

fascia and vagina during the process of extirpation of tht' cervix . .\ new instrumrnt designed by the authors offt'fs the advanta.ges 11f direct nswn tubal patt·ncy test at laparotomy \l'ithout vaginal instrunwntation. It aids m
706 Eastern Parkwa) Brooklyn 13. N err• York

Theca cell tumor of the ovary with endometrial carcinoma S. D. KHANNA. M.D .. MAJOR. M.R.C.O.G. H. I\. SETH. M.D .. MAJOR :'1.. BANERJEE. MAJOR. M.B.B.S. Arrned Forces }v!edical College_. Pvona-1. India Prolonged intiut'nc•· of t•stm.~t·ns froru the krninizing IIH'senchyrnorna of llw m·arv can kacl ttl the clcn·lopment of enclometri
tion is higher with thPcomas than with granulosa

cell tumors, providing indirect evidence to t h" histochemical observation that the theca ··elb are the sourc<' of estrogens. ln a .><'ries uf SO cases of mt·sctl<:hymornas n·ported hy Manst·ll and HPrtig," :24: per r•·nl in patients ahov(' the agr of 50 years were associatt'd with cndomt'lrial carnnorna. Nu t•ndonwt ria I carcmorna was found in the voungmetri u Ill . .\ ,·;ts•· .,f tlwcoma of th<' tJ\'aJ'\ 11·i1h •·rHlo-

Mrs. T. K .. aged till vears. was admitted to the Military HospitaL Poona. on Sept. 20, 1962. with irregular bleeding per vaginum of 5 years duration. The periods. prior to this, had been normal and shl' had not passed through menopause. There was no history of estrogen administration. .A\t the tinH' of this report the hernoglobin \vas 6 Gm. per 100 rnl. of blood. The uterus was ~n­ larged to the siz<· of lll weeks' gestation. It was soft and symmetrical. Speculum .l'Xamination reITaled fr('sh bleeding fron1 the external os. There wa' no other abnormality. A clinical diagnosis of carcinon:a of thl· hod} of the uterus was made and :t laparotomy was perfonrwcl on Oct. 7, 1962. after bringing; the hemo-

Fig. l. This shows tht' gross appearance of the resected specimen. Note the fungating growth in the fundus of the ute.ru-; and tlH· turuor in the

right ovary.