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Errors in technique and interpretation of hysterosalpingography and tubal insufflation
Volume 64 Number 5
SELECTED
ABSTRACTS
1185
Gynecology Preston, P. 0.: A Review of 100 Cases of Transplantation of the Ureters in the Treatment of Obstetrical Vesicovaginal Fist&, J. Obst. & Gynaec. Brit. Emp. 58: 2x2, 1951. Transplantation of the ureters was done in 100 African native women with vesicovaginal fistula. Indications for the operation were: a fistula large enough to admit one finger; a In these cases transplantation vesicoeervical fistula; or marked fibrosis of the vaginal wall. of both ureters into the pelvic colon was done in one stage by t.he technique described by Grey Turner and others, except that no drain was inserted in the ureter. The first 35 patients in this series were operated on in an out-station (‘ ‘bush hospital”), where blood urea estimations could not be made.. In all other cases, if blood urea was over 40 mg. per cent, operation was not done until it had been diminished by adequate treatment. Every patient was admitted to the hospital at least seven days before operation and given potassium citrate mixture and a sulfonamide; three or four days before operation proseptazine (1 Gm. three times a day) was given because it is more effective against Bacillzls faecalis and Bacillus coli than the sulfonamides. A sulfonamide drug was also given for three days after operation. Anuria if it persisted after that time a conoften persisted for twenty-four hours after operation; tinuous intravenous drip of 4.45 per cent sodium sulfate solution was given. There Tvere 21 postoperative deaths, the chief causes of which were peritonitis, hypostatic pneumonia, and pyrlitis and pyelonephritis; while this mort,ality rate is high, it compares favorably with that Hospital and nursing facilities are often inadequate reported by Murray and Ahmed in 1943. in African hospitals. Eleven patients have died since operation, . in 2 cases death occurred during childbirth; t,he exact cause of death could not be ascertained in most instances, but in at All the surviving patients are releast 6 cases death could not be attributed to the operation. lieved of their urinary incontinence. In most cases these large vesicovaginal fistulas requiring transplantation of the ureters in African women were due to prolonged labor of three or more days. The only may in which the incidence of these fistulas can be reduced is for t.he women to seek the help of European antenatal and obstetrical services. HARVEY B. MATTHEWS
White, Margaret Moore: Errors in Technique and Tubal Ins&l&ion, J. Obst. & Gynaec.
and Interpretation Brit.
Emp.
58:
of Hysterosalpingography 573,
1951.
From experience in over 6,750 cases in which tubal insufflation or hysterosalpingography was done to determine tubal patency, the author emphasizes the following points in technique, failure to observe which may lead to error in the diagnosis: A preliminary roentgenogram of the pelvis should be made, especially if the patient has had a previous salpingogram. A cannula should be used that is suitable for each case, and its patency should be tested. The opaque medium should be warmed, as this renders a heavy oil medium more penetrable and reduces the danger of cornual spasm. If there is marked angulation of the cervix, a vulsella should be a6lxed to the cervix to alter the position of the uterus and tubes. The opaque medium should not be allowed to escape from the cervix until two or three minutes after radiograms have been taken. If the introduction of the opaque medium is not controlled radiographically, too great pressure on the syringe should be avoided. An oily opaque medium should not be used if there is evidence of previous infection or if the kymographic tracing has indicated tubal stenosis. A sufficient amount of opaque medium should be used, and a number of films taken in each case. A second salpingography should be done if t.he diagnosis is uncertain. In the interpretation of the findings on tubal insufflation, intestinal borborygmi may be mistaken for escape of the gas from the tube; the sound of gas bubbling through a hydrosalpinx or a tube with the fimbriated end occluded may also be mistaken for escape of the gas into the peritoneal cavity; or the sound of gas escaping from the cervix may be mistaken for gas escaping from the tubes. These mistakes are best avoided if the operator uses the stet,hoscope himself for auscultation of the abdomen. In the interpretation of the
SELECTED
1186
ABSTRACTS
Am. J. Obst. P Gynec.’
November.
1952
kymographic tracing, the possibility of spasm must always be considered, and the significance of variations from normal, such as no fluctuations or poor fluctuations under normal or increased pressure, must be. carefully interpreted. In the study and interpretation of the hysterosalpingogram, careful assessment of the size of the uterus and any irregularities of its contours must be made. Details of the length, caliber, tortuosity, and irregular filling of the tubes must be noted and the findings compared with clinical findings and the kymographic tracing. Opaque medium still in the tubes and other pelvic shadows must not be misinterpreted as peritoneal spill, and the localized ((pockets” of peritoneal spill must be recognized. The preliminary x-ray study of the pelvis is of value in avoiding some of these errors of interpretation of the hysterosalpingogram. HARRY B. MATTHEWS Zondek,
B.,
Bromberg, Y. M., and Bozin, 5.: (Excessive Uterine Bleeding, & Gynaec. Brit. Emp. 58: 525, 1951.
Syndrome
An Anterior Galaotorrhoea,
Pituitary
Hyperhormonotrophic
Hyperthyroidism),
J.
Obst.
In 280 eases of uterine bleeding due to hyperestrogenism, there were 5 eases in which the excessive bleeding was accompanied by galactorrhea and symptoms of thyrotoxicosis. The excessive uterine bleeding in these cases was of long duration; the uterine mucosa showed glandular cystic hyperplasia characteristic of hyperestrinism. The signs of hyperthyroidism were exophthalmos (marked in 2 cases, of lesser degree in 3 cases), sudden loss of weight, nervous symptoms, and increase in the basal metabolic rate. Galactorrhea was present in all cases, with a flow of milk from both breasts. In 3 cases there was a slight hypoglycemia, with a flat blood sugar curve in the glucose tolerance test; there was no hypersensitivity to insulin. Other secondary symptoms were fatigue, anemia, and sterility. This syndrome is attributed to hyperactivity of the anterior lobe of the pituitary, resulting in a hyperproduction of the gonadotrophic hormone (FSH) and also of the thyrotrophic and lactotrophic hormones, and possibly of the. pancreatrophic hormone (in cases showing hypoglycemia). HAFCVEY B. MATTHEWS
Labor, Management, Bobak,
Complications
J., Fields, Charles, and Fitzgerald, James B.: Antibiotics and Low Cervical Cesarean Section in Dystocia or Intrapartum Sepsis, J. A. M. A. 148: 1478, 1952. Alfred
The authors open their discussion with the frank statement that the low cervical section may be safely employed in the presence of sepsis. This statement is supported by 140 consecutive transperitoneal cesarean sections without a fatality in patients who were either In cases of dystocia and with the application of antibacinfected or potentially infected. terial agents, a full test of labor can now be given without nullifying the safety of a transRegardless of the ultimate manperitoneal eesarean section when it later becomes necessary. ner of delivery, the obstetrician must be mindful of keeping the patient in the best possible condition. It is important to combat dehydration and acidosis. Blood transfusions are an important adjunct to therapy. Abdominal delivery is decided upon when it is obvious that labor is not progressing. Penicillin, the safest and most dependable antibiotic, is weak in counteracting the effects therefore, it should be supplemented by sulfaof the gram-negative intestinal group bacilli; Chloramphenicol may interfere diazine or streptomycin to increase the chances of recovery. with the action of penicillin and should be used cautiously. WILLIAM BERMAN
Monckeberg, ginec.
Use
G.: 16:
134,
Dihydroergotamine This hydrogen atoms.
of
Dihydroergotamine
in
Obstetrics,
Bol.
Sot.
chilena
de
obst.
1951. derivative is a synthetic drug, while being less toxic
of
ergotamine by introduction than ergotamine, has a more
of two powerful
y
.
SELECTED
ABSTRACTS
1185
Gynecology Preston, P. 0.: A Review of 100 Cases of Transplantation of the Ureters in the Treatment of Obstetrical Vesicovaginal Fist&, J. Obst. & Gynaec. Brit. Emp. 58: 2x2, 1951. Transplantation of the ureters was done in 100 African native women with vesicovaginal fistula. Indications for the operation were: a fistula large enough to admit one finger; a In these cases transplantation vesicoeervical fistula; or marked fibrosis of the vaginal wall. of both ureters into the pelvic colon was done in one stage by t.he technique described by Grey Turner and others, except that no drain was inserted in the ureter. The first 35 patients in this series were operated on in an out-station (‘ ‘bush hospital”), where blood urea estimations could not be made.. In all other cases, if blood urea was over 40 mg. per cent, operation was not done until it had been diminished by adequate treatment. Every patient was admitted to the hospital at least seven days before operation and given potassium citrate mixture and a sulfonamide; three or four days before operation proseptazine (1 Gm. three times a day) was given because it is more effective against Bacillzls faecalis and Bacillus coli than the sulfonamides. A sulfonamide drug was also given for three days after operation. Anuria if it persisted after that time a conoften persisted for twenty-four hours after operation; tinuous intravenous drip of 4.45 per cent sodium sulfate solution was given. There Tvere 21 postoperative deaths, the chief causes of which were peritonitis, hypostatic pneumonia, and pyrlitis and pyelonephritis; while this mort,ality rate is high, it compares favorably with that Hospital and nursing facilities are often inadequate reported by Murray and Ahmed in 1943. in African hospitals. Eleven patients have died since operation, . in 2 cases death occurred during childbirth; t,he exact cause of death could not be ascertained in most instances, but in at All the surviving patients are releast 6 cases death could not be attributed to the operation. lieved of their urinary incontinence. In most cases these large vesicovaginal fistulas requiring transplantation of the ureters in African women were due to prolonged labor of three or more days. The only may in which the incidence of these fistulas can be reduced is for t.he women to seek the help of European antenatal and obstetrical services. HARVEY B. MATTHEWS
White, Margaret Moore: Errors in Technique and Tubal Ins&l&ion, J. Obst. & Gynaec.
and Interpretation Brit.
Emp.
58:
of Hysterosalpingography 573,
1951.
From experience in over 6,750 cases in which tubal insufflation or hysterosalpingography was done to determine tubal patency, the author emphasizes the following points in technique, failure to observe which may lead to error in the diagnosis: A preliminary roentgenogram of the pelvis should be made, especially if the patient has had a previous salpingogram. A cannula should be used that is suitable for each case, and its patency should be tested. The opaque medium should be warmed, as this renders a heavy oil medium more penetrable and reduces the danger of cornual spasm. If there is marked angulation of the cervix, a vulsella should be a6lxed to the cervix to alter the position of the uterus and tubes. The opaque medium should not be allowed to escape from the cervix until two or three minutes after radiograms have been taken. If the introduction of the opaque medium is not controlled radiographically, too great pressure on the syringe should be avoided. An oily opaque medium should not be used if there is evidence of previous infection or if the kymographic tracing has indicated tubal stenosis. A sufficient amount of opaque medium should be used, and a number of films taken in each case. A second salpingography should be done if t.he diagnosis is uncertain. In the interpretation of the findings on tubal insufflation, intestinal borborygmi may be mistaken for escape of the gas from the tube; the sound of gas bubbling through a hydrosalpinx or a tube with the fimbriated end occluded may also be mistaken for escape of the gas into the peritoneal cavity; or the sound of gas escaping from the cervix may be mistaken for gas escaping from the tubes. These mistakes are best avoided if the operator uses the stet,hoscope himself for auscultation of the abdomen. In the interpretation of the
SELECTED
1186
ABSTRACTS
Am. J. Obst. P Gynec.’
November.
1952
kymographic tracing, the possibility of spasm must always be considered, and the significance of variations from normal, such as no fluctuations or poor fluctuations under normal or increased pressure, must be. carefully interpreted. In the study and interpretation of the hysterosalpingogram, careful assessment of the size of the uterus and any irregularities of its contours must be made. Details of the length, caliber, tortuosity, and irregular filling of the tubes must be noted and the findings compared with clinical findings and the kymographic tracing. Opaque medium still in the tubes and other pelvic shadows must not be misinterpreted as peritoneal spill, and the localized ((pockets” of peritoneal spill must be recognized. The preliminary x-ray study of the pelvis is of value in avoiding some of these errors of interpretation of the hysterosalpingogram. HARRY B. MATTHEWS Zondek,
B.,
Bromberg, Y. M., and Bozin, 5.: (Excessive Uterine Bleeding, & Gynaec. Brit. Emp. 58: 525, 1951.
Syndrome
An Anterior Galaotorrhoea,
Pituitary
Hyperhormonotrophic
Hyperthyroidism),
J.
Obst.
In 280 eases of uterine bleeding due to hyperestrogenism, there were 5 eases in which the excessive bleeding was accompanied by galactorrhea and symptoms of thyrotoxicosis. The excessive uterine bleeding in these cases was of long duration; the uterine mucosa showed glandular cystic hyperplasia characteristic of hyperestrinism. The signs of hyperthyroidism were exophthalmos (marked in 2 cases, of lesser degree in 3 cases), sudden loss of weight, nervous symptoms, and increase in the basal metabolic rate. Galactorrhea was present in all cases, with a flow of milk from both breasts. In 3 cases there was a slight hypoglycemia, with a flat blood sugar curve in the glucose tolerance test; there was no hypersensitivity to insulin. Other secondary symptoms were fatigue, anemia, and sterility. This syndrome is attributed to hyperactivity of the anterior lobe of the pituitary, resulting in a hyperproduction of the gonadotrophic hormone (FSH) and also of the thyrotrophic and lactotrophic hormones, and possibly of the. pancreatrophic hormone (in cases showing hypoglycemia). HAFCVEY B. MATTHEWS
Labor, Management, Bobak,
Complications
J., Fields, Charles, and Fitzgerald, James B.: Antibiotics and Low Cervical Cesarean Section in Dystocia or Intrapartum Sepsis, J. A. M. A. 148: 1478, 1952. Alfred
The authors open their discussion with the frank statement that the low cervical section may be safely employed in the presence of sepsis. This statement is supported by 140 consecutive transperitoneal cesarean sections without a fatality in patients who were either In cases of dystocia and with the application of antibacinfected or potentially infected. terial agents, a full test of labor can now be given without nullifying the safety of a transRegardless of the ultimate manperitoneal eesarean section when it later becomes necessary. ner of delivery, the obstetrician must be mindful of keeping the patient in the best possible condition. It is important to combat dehydration and acidosis. Blood transfusions are an important adjunct to therapy. Abdominal delivery is decided upon when it is obvious that labor is not progressing. Penicillin, the safest and most dependable antibiotic, is weak in counteracting the effects therefore, it should be supplemented by sulfaof the gram-negative intestinal group bacilli; Chloramphenicol may interfere diazine or streptomycin to increase the chances of recovery. with the action of penicillin and should be used cautiously. WILLIAM BERMAN
Monckeberg, ginec.
Use
G.: 16:
134,
Dihydroergotamine This hydrogen atoms.
of
Dihydroergotamine
in
Obstetrics,
Bol.
Sot.
chilena
de
obst.
1951. derivative is a synthetic drug, while being less toxic
of
ergotamine by introduction than ergotamine, has a more
of two powerful
y
.