- Email: [email protected]
INSTRUMENT FOR PROSTATECTOMY
1197
presumably is followed by absolute withdrawal of luteinising hormone (L.H.), produces involution of spermatogenesis to the level of spermatogonia. It is equally clear from our findings that the administration of
which F.s.H.
and
gonadotrophin at this stage initiates division of the spermatogonia, followed by maturation of daughter cells through every stage of spermatogenesis. What we have not determined is whether spermatogenesis, once started at the level of spermatogonia, is thereafter autonomous. Plainly, however, the claim of Gemzell and Kjessler that the influence of gonadotrophins is mainly restricted to the maturation process of transforming early spermatids into mature spermatozoa " is not tenable. We cannot argue the relative merits of gonadotrophin extracts of the pituitary and extracts derived from menopausal urine, both of which seem to be highly potent in Fig. 2-Seminiferous tubule after 64 days of menopausal gonadoproducing ovulation. Nor can we discuss the possible role trophin. of L.H. (pergonal does have some L.H. activity) in initiating are and present spermatozoa Primary spermatocytes and maintaining human spermatogenesis. The important therapy was begun. Only the right testis (in which only conclusions are that complete hypophysectomy produces spermatogonia had been previously found) was biopsied. involution of human spermatogenesis to the level of The testes seemed larger and firmer. Microscopy clearly spermatogonia within 31/2 months, and that gonadodemonstrated all stages of spermatogenesis (primary spermatotrophins obtained from menopausal urine will reactivate cytes, early and mature spermatids, and spermatozoa which spermatogenesis at that level. seemed ready for exfoliation, if some cells had not already been "
exfoliated) (fig. 2). The interstitial tissue showed of development.
no
evidence
We are indebted to Dr. Hayes, of the Cutter Laboratories, Berkeley, California, for a liberal supply of’Pergonal’.
DISCUSSION
Since the
patient described by Gemzell and Kjessler was
only partly hypophysectomised and since these workers used pituitary gonadotrophins obtained from extracts of the hypophysis instead of from menopausal urine as we have done, our observations may be regarded as not strictly comparable. But, on the basic issue of the stage at which gonadotrophins influence human spermatogenesis, it is clear from our findings that complete hypophysectomy,
designed. Denis Browne’s tonsil-holding
Above: the instrument. Below: underside view of shank, sucker control.
Department of Surgery, Cornell University Medical College, New York
showing
JOHN MACLEOD B.A.,
M.S.
PH.D.
New York, Cornell
ARTEMIS PAZIANOS B.A. Wellesley, M.D.
Cornell
BRONSON S. RAY M.D. Northwestern, D.SC.
Franklin
College
This has ideal jaws for seizing this kind of tissue with leverage, and its angled form makes sure that the operator’s hand does not obstruct his view. In the lower handle of this instrument has been incorporated a sucker tubing which passes on into the upper jaw in which has been incorporated a sucker end. The steel tube projects about two inches behind the handle of the instrument, so that it may be connected to rubber tubing without impeding its use. At the distal end, the upper part of the sucker portion is hinged in order to allow it to be opened for cleaning, and it clicks back into place when in use. The sucker tubing is cleaned conveniently by passing the stilette from a Gibbon catheter. Since it is irritating to have the sucker screaming on shreds of tissue while it is not required, a control has been incorporated in the handle. This consists of a hole leading into the sucker tubing which is normally occluded by the index finger. When suction is not required the finger can be elevated. In order to allow the tubing to pass across the joint, the box has been made deeper than the standard instrument and the pivot has been placed off centre. This instrument has now been used in a large number of transvesical prostatectomies, and has been found extremely useful. It enables one to get a firm grip on the bladder neck for diathermy excision, to seize tags and residual adenomas, and to stretch the prostatic capsule, while hasmostatsis is obtained either by diathermy or by the insertion of sutures with the boomerang needle. While this is being done, the suction is quite adequate to keep the prostatic cavity free from diathermy smoke and blood unless the haemorrhage is excessive. This means that at no time is it necessary to have more than two instruments in this rather confined space, and these manoeuvres are made very much easier.
excellent
INSTRUMENT FOR PROSTATECTOMY IN the modern form of transvesical prostatectomy, after the adenoma has been enucleated it is often difficult to obtain a good enough view to remove any tags or residual adenomas, to excise the bladder neck, and to secure haemostasis. It is usually necessary to have a sucker working in the prostatic cavity to keep it clear of blood and to aspirate any smoke from the diathermy. The sucker, forceps, diathermy point, and boomerang needle or similar instrument in this small cavity at the bottom of a deep, dark hole often obscure the view. In order to avoid this, the instrument illustrated here has been on
Cornell University Medical College, New York Department of Endocrinology and Metabolism, Memorial Center for Cancer and Allied Diseases, New York
forceps.
New Inventions
The instrument is based
Department of Anatomy,
1198 Since this instrument is based on a tonsil-holding forceps, it seemed reasonable to try it in tonsillectomy. The widening of the instrument which has been necessary to incorporate the suction tube makes it rather a clumsy instrument in the small mouth of a child; but in adults it has been used quite effectively, and it serves to hold the tonsil and keep the pharynx clear of blood at the same time.
We have latterly increased the flow-rate to 5 litres or more per minute in adult patients. Postoperative metabolic acidosis has been greatly reduced, probably because of improved perfusion of muscle. At this rate of flow the reservoirs could empty in five or six seconds if the venous flow were com-
This instrument has been made for me by Messrs. Down Bros., Mayer & Phelps, and I thank Mr. S. Bonas for his extremely helpful technical advice.
Merthyr and Aberdare General Hospitals, Glamorgan
H. KER M.B.
Lond.,
F.R.C.S.
CANNULÆ FOR PROFOUND HYPOTHERMIA THE cannulae shown in the accompanying figure have been used with success in 110 open-heart operations by the profound
hypothermia technique.1 Left atrial cannulation is especially difficult in the surgery of aortic stenosis or tetralogy of Fallot. The J-shaped cannula on the extreme left of the figure is suitable if the left Fig. 1-Automatic
cut-out circuit.
obstructed. To avoid a tragedy the operator would have to throw the switches very rapidly to stop the pumps. We have devised a cut-out which automatically switches off both pumps when the blood-level falls in either reservoir.
pletely
When the apparatus is assembled, a photo-cell is clipped to each reservoir by means of a ’Terry ’ clip approximately opposite the 200 ml. mark. Each photo-cell faces inwards towards a 15 W ’ Pygmy ’ lamp on the opposite side of the reservoir. If the blood level drops below the 200 ml. mark, light falls on the photo-cell and produces a current which closes the relay Rl (fig. 1). This in turn operates the relay R2 which interrupts the current to both pumps. The second relay is energised by a 50 V D.C. supply from a small transformer and rectifier bridge.
As soon as venous return is re-established and the reservoir blood rises above the level of the photo-cell, the pumps are automatically restarted. The device is mounted in a Atrial cannulae (above) and pulmonary-artery cannulae (below).
atrial atrial
appendage itself is to be cannulated. But when the left appendage is inaccessible, the cannula can be more introduced into the left atrium on the right side of the easily behind the interatrial heart groove. In this event, one of the two curved cannula: shown on the right of the figure is preferable. For the pulmonary artery the straight cannula is usually satisfactory. But, if the approach is by a right thoracotomy extended across the sternum (as in an operation for atrial septal defect), the angled cannula is more suitable. These cannulse (4 and 6 mm. in diameter) may be obtained from the Genito-Urinary Company, 28a, Devonshire Street, London, W.1.
Department of Thoracic Surgery, St. Bartholomew’s Hospital, London, E.C.1
R. L. HURT M.B.
Lond.,
F.R.C.S.
AUTOMATIC SAFETY CUT-OUT FOR CARDIAC BYPASS MACHINE WE have been using Hurt’s cardiac bypass apparatus2 in Drew’s techniqueof producing profound hypothermia for about two years. It has proved efficient and reliable in over 100 operations. Nevertheless, there was a possible source of danger. In the event of sudden failure or obstruction of left or right venous return the roller pumps would empty the reservoirs of the 400-500 ml. of blood which they ordinarily contain during perfusion. If both pumps were not switched off in time, a fatal air embolus could result. 1. 2.
Drew, C. E. Brit. med. Bull. 1961, 17, Hurt, R. L. Lancet, 1962, i, 763.
37.
Fig. 2-Unit mounted on switch above jack-plugs.
box attached
to
necessary, it
can
cardiac
bypass machine: overriding
the side of the perfusion apparatus; if be overridden by a separate external switch (fig. 2). The unit could be constructed in any hospital workshop and adapted to control most types of extracorporeal circulation. I am indebted to Mr. P. Vainker and Mr. F. Fernandes, of the Standard Telephone and Cable Co., Ltd., for considerable technical helo and for constructing the final orototvoe. Department of Thoracic Surgery, St. Bartholomew’s Hospital, London, E.C.1
P. V. COLE M.B.
St. And., F.F.A. R.C.S.
presumably is followed by absolute withdrawal of luteinising hormone (L.H.), produces involution of spermatogenesis to the level of spermatogonia. It is equally clear from our findings that the administration of
which F.s.H.
and
gonadotrophin at this stage initiates division of the spermatogonia, followed by maturation of daughter cells through every stage of spermatogenesis. What we have not determined is whether spermatogenesis, once started at the level of spermatogonia, is thereafter autonomous. Plainly, however, the claim of Gemzell and Kjessler that the influence of gonadotrophins is mainly restricted to the maturation process of transforming early spermatids into mature spermatozoa " is not tenable. We cannot argue the relative merits of gonadotrophin extracts of the pituitary and extracts derived from menopausal urine, both of which seem to be highly potent in Fig. 2-Seminiferous tubule after 64 days of menopausal gonadoproducing ovulation. Nor can we discuss the possible role trophin. of L.H. (pergonal does have some L.H. activity) in initiating are and present spermatozoa Primary spermatocytes and maintaining human spermatogenesis. The important therapy was begun. Only the right testis (in which only conclusions are that complete hypophysectomy produces spermatogonia had been previously found) was biopsied. involution of human spermatogenesis to the level of The testes seemed larger and firmer. Microscopy clearly spermatogonia within 31/2 months, and that gonadodemonstrated all stages of spermatogenesis (primary spermatotrophins obtained from menopausal urine will reactivate cytes, early and mature spermatids, and spermatozoa which spermatogenesis at that level. seemed ready for exfoliation, if some cells had not already been "
exfoliated) (fig. 2). The interstitial tissue showed of development.
no
evidence
We are indebted to Dr. Hayes, of the Cutter Laboratories, Berkeley, California, for a liberal supply of’Pergonal’.
DISCUSSION
Since the
patient described by Gemzell and Kjessler was
only partly hypophysectomised and since these workers used pituitary gonadotrophins obtained from extracts of the hypophysis instead of from menopausal urine as we have done, our observations may be regarded as not strictly comparable. But, on the basic issue of the stage at which gonadotrophins influence human spermatogenesis, it is clear from our findings that complete hypophysectomy,
designed. Denis Browne’s tonsil-holding
Above: the instrument. Below: underside view of shank, sucker control.
Department of Surgery, Cornell University Medical College, New York
showing
JOHN MACLEOD B.A.,
M.S.
PH.D.
New York, Cornell
ARTEMIS PAZIANOS B.A. Wellesley, M.D.
Cornell
BRONSON S. RAY M.D. Northwestern, D.SC.
Franklin
College
This has ideal jaws for seizing this kind of tissue with leverage, and its angled form makes sure that the operator’s hand does not obstruct his view. In the lower handle of this instrument has been incorporated a sucker tubing which passes on into the upper jaw in which has been incorporated a sucker end. The steel tube projects about two inches behind the handle of the instrument, so that it may be connected to rubber tubing without impeding its use. At the distal end, the upper part of the sucker portion is hinged in order to allow it to be opened for cleaning, and it clicks back into place when in use. The sucker tubing is cleaned conveniently by passing the stilette from a Gibbon catheter. Since it is irritating to have the sucker screaming on shreds of tissue while it is not required, a control has been incorporated in the handle. This consists of a hole leading into the sucker tubing which is normally occluded by the index finger. When suction is not required the finger can be elevated. In order to allow the tubing to pass across the joint, the box has been made deeper than the standard instrument and the pivot has been placed off centre. This instrument has now been used in a large number of transvesical prostatectomies, and has been found extremely useful. It enables one to get a firm grip on the bladder neck for diathermy excision, to seize tags and residual adenomas, and to stretch the prostatic capsule, while hasmostatsis is obtained either by diathermy or by the insertion of sutures with the boomerang needle. While this is being done, the suction is quite adequate to keep the prostatic cavity free from diathermy smoke and blood unless the haemorrhage is excessive. This means that at no time is it necessary to have more than two instruments in this rather confined space, and these manoeuvres are made very much easier.
excellent
INSTRUMENT FOR PROSTATECTOMY IN the modern form of transvesical prostatectomy, after the adenoma has been enucleated it is often difficult to obtain a good enough view to remove any tags or residual adenomas, to excise the bladder neck, and to secure haemostasis. It is usually necessary to have a sucker working in the prostatic cavity to keep it clear of blood and to aspirate any smoke from the diathermy. The sucker, forceps, diathermy point, and boomerang needle or similar instrument in this small cavity at the bottom of a deep, dark hole often obscure the view. In order to avoid this, the instrument illustrated here has been on
Cornell University Medical College, New York Department of Endocrinology and Metabolism, Memorial Center for Cancer and Allied Diseases, New York
forceps.
New Inventions
The instrument is based
Department of Anatomy,
1198 Since this instrument is based on a tonsil-holding forceps, it seemed reasonable to try it in tonsillectomy. The widening of the instrument which has been necessary to incorporate the suction tube makes it rather a clumsy instrument in the small mouth of a child; but in adults it has been used quite effectively, and it serves to hold the tonsil and keep the pharynx clear of blood at the same time.
We have latterly increased the flow-rate to 5 litres or more per minute in adult patients. Postoperative metabolic acidosis has been greatly reduced, probably because of improved perfusion of muscle. At this rate of flow the reservoirs could empty in five or six seconds if the venous flow were com-
This instrument has been made for me by Messrs. Down Bros., Mayer & Phelps, and I thank Mr. S. Bonas for his extremely helpful technical advice.
Merthyr and Aberdare General Hospitals, Glamorgan
H. KER M.B.
Lond.,
F.R.C.S.
CANNULÆ FOR PROFOUND HYPOTHERMIA THE cannulae shown in the accompanying figure have been used with success in 110 open-heart operations by the profound
hypothermia technique.1 Left atrial cannulation is especially difficult in the surgery of aortic stenosis or tetralogy of Fallot. The J-shaped cannula on the extreme left of the figure is suitable if the left Fig. 1-Automatic
cut-out circuit.
obstructed. To avoid a tragedy the operator would have to throw the switches very rapidly to stop the pumps. We have devised a cut-out which automatically switches off both pumps when the blood-level falls in either reservoir.
pletely
When the apparatus is assembled, a photo-cell is clipped to each reservoir by means of a ’Terry ’ clip approximately opposite the 200 ml. mark. Each photo-cell faces inwards towards a 15 W ’ Pygmy ’ lamp on the opposite side of the reservoir. If the blood level drops below the 200 ml. mark, light falls on the photo-cell and produces a current which closes the relay Rl (fig. 1). This in turn operates the relay R2 which interrupts the current to both pumps. The second relay is energised by a 50 V D.C. supply from a small transformer and rectifier bridge.
As soon as venous return is re-established and the reservoir blood rises above the level of the photo-cell, the pumps are automatically restarted. The device is mounted in a Atrial cannulae (above) and pulmonary-artery cannulae (below).
atrial atrial
appendage itself is to be cannulated. But when the left appendage is inaccessible, the cannula can be more introduced into the left atrium on the right side of the easily behind the interatrial heart groove. In this event, one of the two curved cannula: shown on the right of the figure is preferable. For the pulmonary artery the straight cannula is usually satisfactory. But, if the approach is by a right thoracotomy extended across the sternum (as in an operation for atrial septal defect), the angled cannula is more suitable. These cannulse (4 and 6 mm. in diameter) may be obtained from the Genito-Urinary Company, 28a, Devonshire Street, London, W.1.
Department of Thoracic Surgery, St. Bartholomew’s Hospital, London, E.C.1
R. L. HURT M.B.
Lond.,
F.R.C.S.
AUTOMATIC SAFETY CUT-OUT FOR CARDIAC BYPASS MACHINE WE have been using Hurt’s cardiac bypass apparatus2 in Drew’s techniqueof producing profound hypothermia for about two years. It has proved efficient and reliable in over 100 operations. Nevertheless, there was a possible source of danger. In the event of sudden failure or obstruction of left or right venous return the roller pumps would empty the reservoirs of the 400-500 ml. of blood which they ordinarily contain during perfusion. If both pumps were not switched off in time, a fatal air embolus could result. 1. 2.
Drew, C. E. Brit. med. Bull. 1961, 17, Hurt, R. L. Lancet, 1962, i, 763.
37.
Fig. 2-Unit mounted on switch above jack-plugs.
box attached
to
necessary, it
can
cardiac
bypass machine: overriding
the side of the perfusion apparatus; if be overridden by a separate external switch (fig. 2). The unit could be constructed in any hospital workshop and adapted to control most types of extracorporeal circulation. I am indebted to Mr. P. Vainker and Mr. F. Fernandes, of the Standard Telephone and Cable Co., Ltd., for considerable technical helo and for constructing the final orototvoe. Department of Thoracic Surgery, St. Bartholomew’s Hospital, London, E.C.1
P. V. COLE M.B.
St. And., F.F.A. R.C.S.