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A New Multipurpose Apparatus for use in the Diagnosis and Treatment of Sterility in the Female*†
A NEW MULTIPURPOSE APPARATUS FOR USE IN THE DIAGNOSIS AND TREATMENT OF STERILITY IN THE FEMALE*t ABNER I. WEISMAN, :VLD., NEw YoRK, N.Y.
N THE past twenty-five years much progress has been made in the diagnosis and treatment of female sterility. This is especially true with regard to Isterility originating in the genital tract. In surveying and evaluating the reproductive tract of the female, three separate and distinct schools of approach have been evolved. Headed respectively by Rubin/ Jarcho/ and Stein, 8 each group advocates a different method of diagnosis. Since 1920 Rubin and the men who adhere to his teaching have used carbon dioxide insufllation almost exclusively. Later, with the development of innocuous radio-opaque substances, Jarcho and his followers felt that uterotubal x-ray visualization was the method of choice in evaluating disorders of the female genital tract. Finally, Stein and his somewhat smaller group have reported that the most valuable diagnostic procedure in female sterility is the combined technique of gas insufllation together with uterotubal x-rays. Stein instills carbon dioxide as in the ordinary tubal test, then allows large amounts of gas to enter, causing a pneumoperitoneum. Finally, he injects the radio-opaque substance and obtains x-ray visualization. By this combined contrast method most excellent visualization of all the pelvic organs (including the ovaries) can be obtained. Each of the above-mentioned three procedures is a .valuable diagnostic agent and each has its place in gynecology depending upon the individual patient and the presenting problems. It is not within the province of this short paper to expound the well-known virtues of any particular one of the three procedures. Medical discussions of the "pros" and "cons" of each method will probably go on for decades. The purpose of this paper is simply to introduce a new apparatus, the '' Gynograph,'' so constructed that the physician has the facility to perform with this single mechanism whichever one of the' above-mentioned tests he desires. He mnv also perform all three tests simultaneously. This compact apparatus is beli<'~ed to be a highly efficient portable instrument for either office, clinic, or hospital work. After seven years of extensive trials the gynograph was finally evolved. And while its facilities are multiple, its dangers are minimal to the patient. For example, in 1,100 tests performed by the author over the seven-year period, the apparatus has been highly satisfactory clinically. It is interesting to note that, owing to the safety factors of the instrument, not one serious mishap resulted. The mechanical principle employed in the gynograph consists essentially of a completely closed gaseous circuit which is constantly under manometric control and in which carbon dioxide, under pressure, is the motivating force. Thus, not only can carbon dioxide be insufflated, but in addition the same source of carbon dioxide is used as the vis a tergo for the instillation of the radioopaque oil. •Presented before the Clinical Society of the Jewish Memorial Hospital, New York, N. Y., Jan. 7, 1947. tWith the technical assistance of Mr. John L. Mal'co of Goodman-Kleiner Co., New York, N.Y.
145
146
Am.]. Obst. &: Gynec. July, 1947
WEISMAN
Technique The patient is vlaet•d in lithotomy positio!l OIL t lw x-ra.r table. Then a specially devised self-retaining cannula (which itself is an incorporated part of the gynograph) is introduced into the ('ervic•al eanai. The cannula presents a number of new features including a rotating tip, a revolving acorn, a tenaculumgrasping device and an end-piN•e 'Nhirh conneets direc·tly to the gynograph. After the cannula is secured the patient can assume a more comfortable supine position with legs extended. The gynograpl1 is then placed on the x-ray table between the patient's legs and ronnected direc•tly to the indwelling cannula.
8 THE:
GYNOGRAF'H J;'ig. 1.
The source of carbon dioxide is a very smaH inexpensive cartridge similar to one used in producing artificial carbonated water. The gas, released from the cartridge (.t1) by a small piercing device, flows into a cylindrical expansion chamber (B). As the gas expands, the pressure decreases so that it is completely under control of the main valve (C). By a slow counterclockwise turn of this valve the gas escapes. Before allowing the carbon dioxide to enter the patient, the rate of flow is established and predetermined by shunting the gas bubbles (by means of a two-way valve) (D) into an outlet-counting chamber containing water (E). A rate of flow of from 60 to 80 hubbies per minute, or less, is essential for safety. After the rate of flow has been established, the twoway valve is released and the gas is then allowed to flow slowly into the patient through the cannula under manometric observation. Prom this point on the determination of tubal patency and gaseous entrance into the peritoneal cavity is similar to that of the Rubin test, i.e., with a drop in manometric pressure, tubal patency can be said to exist. The test can be repeated as often as necessary by simply releasing the carbon dioxide into the water chamber and starting over again. If tubal patency is established a11d a pneumoperitoneum desired, the gas can be allowed to flow into the abdominal cavity for three to five minutes or longer, if necessary, at the same rat~ of gas flow ( 60 to 80 bubbles per minute).
Volume 54 Number I
APPARATUS FOR STERILITY IN FEMALE
147
Finally, for uterotubal x-ray visualization an ordinary 10 c.c. syringe containing 5 c.c. of a radio-opaque oil, already set up on a rack (F), is swung over and inserted into the cannula. The gas is then directly connected to an adapter attached to the top of the syringe (G), completing the circuit once more. Under direct carbon dioxide pressure (up to 200 mm.), the oil is forced through the cannula into the uterus and tubes. As the oil enters, x-ray pictures are fractionally taken in the usual manner. During the entire process of tubal insufflation and hysterosalpingography, the hands of the operator are entirely free for fluoroscopy, etc. (The manometer [H] and other parts of the instrument are prepared with a luminous paint for use in the dark room.) In this paper it is not necessary to go into the details of the preliminaries to tubal testing, such as complete vaginal examination, blood sedimentation rate, premedication, local preparation, etc. These important preliminary steps should be employed here with the same care and precantion as they would he in the ordinary Rubin test or hysterosalpingography. Summary A new instrument, the "Gynograph," for use in evaluating the status of the female genital tract in sterility studies, is presented. With this single apparatus, tubal carbon dioxide i!lsufflation, uterotu,llal x-rays, and pelvic viscerography can be performed easily. In the author's hands this simple compact portable device has proved highly satisfactory in 1,100 clinical tests.
References' 1. Rubin, I. C.: J. A. M. A. 75: 661, 1920. 2. Jarcho, J.: Surg., Gynec. & Obst. 45: 129, 1927. 3. Stein, I. F.: Radiology 15: 83, 1930.
N THE past twenty-five years much progress has been made in the diagnosis and treatment of female sterility. This is especially true with regard to Isterility originating in the genital tract. In surveying and evaluating the reproductive tract of the female, three separate and distinct schools of approach have been evolved. Headed respectively by Rubin/ Jarcho/ and Stein, 8 each group advocates a different method of diagnosis. Since 1920 Rubin and the men who adhere to his teaching have used carbon dioxide insufllation almost exclusively. Later, with the development of innocuous radio-opaque substances, Jarcho and his followers felt that uterotubal x-ray visualization was the method of choice in evaluating disorders of the female genital tract. Finally, Stein and his somewhat smaller group have reported that the most valuable diagnostic procedure in female sterility is the combined technique of gas insufllation together with uterotubal x-rays. Stein instills carbon dioxide as in the ordinary tubal test, then allows large amounts of gas to enter, causing a pneumoperitoneum. Finally, he injects the radio-opaque substance and obtains x-ray visualization. By this combined contrast method most excellent visualization of all the pelvic organs (including the ovaries) can be obtained. Each of the above-mentioned three procedures is a .valuable diagnostic agent and each has its place in gynecology depending upon the individual patient and the presenting problems. It is not within the province of this short paper to expound the well-known virtues of any particular one of the three procedures. Medical discussions of the "pros" and "cons" of each method will probably go on for decades. The purpose of this paper is simply to introduce a new apparatus, the '' Gynograph,'' so constructed that the physician has the facility to perform with this single mechanism whichever one of the' above-mentioned tests he desires. He mnv also perform all three tests simultaneously. This compact apparatus is beli<'~ed to be a highly efficient portable instrument for either office, clinic, or hospital work. After seven years of extensive trials the gynograph was finally evolved. And while its facilities are multiple, its dangers are minimal to the patient. For example, in 1,100 tests performed by the author over the seven-year period, the apparatus has been highly satisfactory clinically. It is interesting to note that, owing to the safety factors of the instrument, not one serious mishap resulted. The mechanical principle employed in the gynograph consists essentially of a completely closed gaseous circuit which is constantly under manometric control and in which carbon dioxide, under pressure, is the motivating force. Thus, not only can carbon dioxide be insufflated, but in addition the same source of carbon dioxide is used as the vis a tergo for the instillation of the radioopaque oil. •Presented before the Clinical Society of the Jewish Memorial Hospital, New York, N. Y., Jan. 7, 1947. tWith the technical assistance of Mr. John L. Mal'co of Goodman-Kleiner Co., New York, N.Y.
145
146
Am.]. Obst. &: Gynec. July, 1947
WEISMAN
Technique The patient is vlaet•d in lithotomy positio!l OIL t lw x-ra.r table. Then a specially devised self-retaining cannula (which itself is an incorporated part of the gynograph) is introduced into the ('ervic•al eanai. The cannula presents a number of new features including a rotating tip, a revolving acorn, a tenaculumgrasping device and an end-piN•e 'Nhirh conneets direc·tly to the gynograph. After the cannula is secured the patient can assume a more comfortable supine position with legs extended. The gynograpl1 is then placed on the x-ray table between the patient's legs and ronnected direc•tly to the indwelling cannula.
8 THE:
GYNOGRAF'H J;'ig. 1.
The source of carbon dioxide is a very smaH inexpensive cartridge similar to one used in producing artificial carbonated water. The gas, released from the cartridge (.t1) by a small piercing device, flows into a cylindrical expansion chamber (B). As the gas expands, the pressure decreases so that it is completely under control of the main valve (C). By a slow counterclockwise turn of this valve the gas escapes. Before allowing the carbon dioxide to enter the patient, the rate of flow is established and predetermined by shunting the gas bubbles (by means of a two-way valve) (D) into an outlet-counting chamber containing water (E). A rate of flow of from 60 to 80 hubbies per minute, or less, is essential for safety. After the rate of flow has been established, the twoway valve is released and the gas is then allowed to flow slowly into the patient through the cannula under manometric observation. Prom this point on the determination of tubal patency and gaseous entrance into the peritoneal cavity is similar to that of the Rubin test, i.e., with a drop in manometric pressure, tubal patency can be said to exist. The test can be repeated as often as necessary by simply releasing the carbon dioxide into the water chamber and starting over again. If tubal patency is established a11d a pneumoperitoneum desired, the gas can be allowed to flow into the abdominal cavity for three to five minutes or longer, if necessary, at the same rat~ of gas flow ( 60 to 80 bubbles per minute).
Volume 54 Number I
APPARATUS FOR STERILITY IN FEMALE
147
Finally, for uterotubal x-ray visualization an ordinary 10 c.c. syringe containing 5 c.c. of a radio-opaque oil, already set up on a rack (F), is swung over and inserted into the cannula. The gas is then directly connected to an adapter attached to the top of the syringe (G), completing the circuit once more. Under direct carbon dioxide pressure (up to 200 mm.), the oil is forced through the cannula into the uterus and tubes. As the oil enters, x-ray pictures are fractionally taken in the usual manner. During the entire process of tubal insufflation and hysterosalpingography, the hands of the operator are entirely free for fluoroscopy, etc. (The manometer [H] and other parts of the instrument are prepared with a luminous paint for use in the dark room.) In this paper it is not necessary to go into the details of the preliminaries to tubal testing, such as complete vaginal examination, blood sedimentation rate, premedication, local preparation, etc. These important preliminary steps should be employed here with the same care and precantion as they would he in the ordinary Rubin test or hysterosalpingography. Summary A new instrument, the "Gynograph," for use in evaluating the status of the female genital tract in sterility studies, is presented. With this single apparatus, tubal carbon dioxide i!lsufflation, uterotu,llal x-rays, and pelvic viscerography can be performed easily. In the author's hands this simple compact portable device has proved highly satisfactory in 1,100 clinical tests.
References' 1. Rubin, I. C.: J. A. M. A. 75: 661, 1920. 2. Jarcho, J.: Surg., Gynec. & Obst. 45: 129, 1927. 3. Stein, I. F.: Radiology 15: 83, 1930.