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Lipiodol as a diagnostic aid
LIPIODOL
AS A DIAGNOSTIC
IN FIBROMATA
AID
OF THE FEMALE GENITAL TRACT* ALBERT MATHIEU,
M.D.,
F.A.C.S.
PORTLAND, OREGON
T
HE vaIue of IipiodoI as a diagnostic aid in gynecology has been we11 substantiated. In competent hands, this method of visuaIizing cavities of the genita1 tract has been proved to be an artfu1 aid, suffrcientIy free from harm to be of rea1 practica1 vaIue. Its r&son d’etre is as rationa as that of the visuaIization of the urinary tract; the frequency of genital abnormalities in the femaIe gives it much academic as we11 as practica1 vaIue. Notwithstanding these facts, this aid to gynecoIogica1 diagnosis has not been suff~cientIy used to establish mass information or reIiabIe acumen in reading the roentgenograms; hence, any new materia1 shouId be weIcome. The wiIIingness of the femaIe patient to submit to operation and the interest of the surgeon in operation shouId not stand in the way of our best efforts toward exactness in preoperative gynecoIogic diagnosis. The foIIowing cases are iIIustrative : A singIe woman, aged twenty-two, presented the classic picture of ectopic pregnancy; exposure, missed period with uterine bIeeding three weeks later, and a doughy, rather fixed, mass in the region of the right tube. By means of IipiodoI, the cavities of both tubes were visualized and shown to be normaI. Because of the fact that at a previous operation the right ovarv had been removed, the diagnosis of intraiigamentary cyst was made and the indication for operation was changed from an emergency to that of one of eIection. Later, the diagnosis of intraIigamentary cyst was proved at operation. In another case, that of a young gir1 of fifteen, who had had an amenorrhea of five months and a mass in the Iower abdomen, just the shape and size of a five months’ pregnancy, Iipiodol proved extremety usefu1. This patient’s mother had been toId by the interne that her
daughter was pregnant. I saw this patient the foIIowing day and on bimanual examination made out a smaI1 mass in the right side of the pelvis, which seemed to have been pushed up near the symphysis by the larger mass. I feIt that this might be the infantiIe uterus. The patient absoIuteIy denied the possibiIity of pregnancy, no feta1 heart couId be heard and no fetus couId be paIpated. The cervix was smaI1 and showed no signs of pregnancy. The uterus was then very carefully sounded and found to be of Iess than normaI depth. LipiodoI was then injected and the skiagram showed the uterus to be infantiIe, both tubes fiIIing normaIIy, and the uterus pushed considerabIy to the right side. The temperature record, the white bIood ceI1 count, and the sedimentation test pointed toward abscess, and this diagnosis was made and proved at 0peration.l Two appIications of this method of diagnosis seem to be missing from the Iiterature; the one, of visuaIizing Iibromata in the vagina, uterus and peIvis, and the other, of the prognostic value of this method in subacute and chronic saIpingitis. Out of a mass of materia1 coIIected from the injection of 150 patients under my supervision,* I submit 6 cases of fibromata of the femaIe genita1 tract visuaIized by IipiodoI and the roentgen ray. The question of the use of IipiodoI as a prognostic aid in saIpingitis wiI1 be discussed in a subsequent paper. CASE REPORTS AND DISCUSSION OF ILLUSTRATIONS CASE I (Fig. I). This patient, aged nineteen, came to the hospita1 in October, 1927, with a condition in which differentiation between appendicitis and right saIpingitis was diffkult. 1This patient was from the service of and was ooerated upon by Dr. Raymond Watkins. 2 Some of this materia1 has been reported in Norfbwest Med., 27: 222, 1928.
* From the Department of Gynecology, University of Oregon Medical SchooI, and the GynecoIogicaI Service of the MuItnomah HospitaI. Submitted for publication March 30, 1929. 720
NEW SERIES VOL. VI, No. 6
Mathieu-Lipiodol
This skiagram, taken after the injection of Iipiodol, showed a normal uterine cavity (there is a defect on the right side, due no doubt, to
FIG. I. Skiagram of Case I, shown, primarily, as one of normal uterine cavity and tubes to be used as contrast in the pIates that folIow.
the cannula) and norma tubes. A constriction in the tubouterine junction on each side was
American
Journal
of Surgery
721
of subacute appendicitis, disease of the right tube having been eliminated by the roentgen ray. The appendix was found considerably
FIG. 2. Case 11. Skiagram showing tumor with pedicle.
swoIIen and inffamed. She made an uneventfu1 recovery, became pregnant in three months, and within a year after the injection of IipiodoI I deIivered her of a normal living baby, weigh-
3B. Case III. Photograph of the specimen after a supravagina1 hysterectomy, showing the uterine cavity and the large fibromyoma, cut into.
FIG.
FIG. 3~. Case III. Skiagram showing elongated cavity and large crescent-shaped filling Uterine fibroid.
uterine defect.
aIso seen. (This has been described by Rubin as caused by sphincteric action). The patient was operated on the same day, with a diagnosis
ing 3394 gm. This case suggested that the use of Iipiodol in the tubes does not jeopardize the chance of future pregnancy. Here, then, is a case in which injection of IipiodoI was an aid in the differentia1 diagnosis between right salpingitis and acute appendicitis; in which a constriction, probably
722
American Journd
of Surgery
Mathieu-LipiodoI
sphincteric, is shown in both tubouterine junctions and in which a pregnancy and deIivery of a normaI baby ensued within the year.
be feIt. LipiodoI was injected a11 around the tumor with a soft rubber catheter, and the skiagram (Fig. 2) visualized the tumor with its
FIG. 48. Case
FIG. 4A. Case IV. Skiagram showing eIongated Iower uterine segment and Iarge MuItipIe fibroids of uterus.
concave
fiIIing defect.
IV.
Photograph
of specimen
removed.
pedicIe, which I presumed was attached inside the uterus. The tumor was deIivered through the vuIva, as a baby’s head wouId be, with a pair of obstetrica forceps. When the pedicIe was exposed, it was cIamped and the tumor was amputated. The pedicIe was cIosed with a continuous suture of chromic catgut. The uterus
FIG. 5~. Case v. Skiagram.
CASE II (Fig. 2). This patient, aged fortythree, compIained of metrorrhagia and Ioss of strength for two years and recentIy of a fou1, blood-tinged Ieucorrhea. Examination reveaIed a round, hard mass fiIIing the pelvis, as dose a baby’s head. The fingers couId not be passed around the tumor, and no attachment couId
FIG. 5~. Case v. PathoIogicaI specimen. Fibromata
of
ovary.
inverted as to be aImost saucer shaped. The cervica1 waI1 was about 3 cm. in thickness and the cervica1 opening was about 7 cm. in diameter. The eversion couId not be reduced was so
NEW SERIESVOL. VI, No. 6
Mathieu-LipiodoI
by pressure and was apparentIy one of Iong standing. The patient made an uneventfu1 recovery, and when seen six months after the
American Journal of Surgery
723
ing-down sensations. The peIvic examination was negative, except for the fact that, the corpus of the uterus was approximately three
FIG. 6~. Photograph of specimen after supravaginal hysterectomy and remova of right adnexa showing peduncutated fibroid and ovarian cyst.
times the norma size, and extremeIy hard. The skiagram (Fig. 3~) after oi1 injection showed considerable eIongation of the uterine cavity with a Iarge crescent-Iike fiIIing defect. Diagnosis by skiagram: uterine fibroid.
FIG. 6~. Case VI. Skiagram.
CASE IV (Figs. 4A and B). The patient, aged fifty, compIained of a tumor in the abdomen which was slow growing and gave
PLATE 7~. Photograph of specimen removed, showing the cyst of Ieft ovary and peduncutated fibroid. (Note how peduncurated fibroid causes widening of lower uterine segment in skiagram. Figure 7A.) FIG. 7~. Case VII. Skiagram.
operation, the uterus was gradually returning to norma shape, and the patient was free from bIeeding and discharge. The pathoIogica1 diagnosis was pedunculated submucous fibromyoma with hyaIine degeneration and secondary chronic infiammation. CASE III (Figs. 3~ and B). This patient, aged forty-eight, compIained of uterine bIeeding, a feeling of weight in the peIvis, and bear-
her considerabIe distress because of weight. The top of the growth couId be palpated at the IeveI of the umbilicus, and because of thick abdomina1 fat, the exact nature of the growth could not be ascertained nor couId the corpus of the uterus be exactly Iocated. A mass about the size of a norma uterine corpus couId be felt just above the cervix to the right. The skiagram (Fig. 4~), foIIowing the injection of IipiodoI, shows an enormous elongation of the Iower uterine segment, and a Iarge concave fiII-
724
American Journd
of Surgery
Mathieu-Lipiodol
ing defect on the Ieft side of the uterine cavity. Diagnosis: muItipIe fibroids of the uterus. A photograph of the specimen (Fig. 4B) after supravagina1 hy.sterectomy, shows that the mass near the cervtx which I thought might be the fundus was one of the muItipIe fibromyomata of the uterine corpus. The crescentlike fiIIing defect is expIained by the Iarge fibromyomata shown in the opened specimen. CASE v (Figs. 5~ and B). In this case3 as iIIustrated the Iipiodol appears to have been injected with more than the usua1 force, and is scattered rather widely in the peIvis. The tumor is cIearIy outlined. The oil, being warm and thin, readiIy accommodates itseIf to the outer surface of a growth on which it faIIs. The uterus is seen sharpIy antiffexed. The fimbriated end of the tube apparentIy lies near the top of the tumor. Diagnosis: fibromata of the ovary. CASE VI (Figs. 6~ and B). This woman, aged thirty-five, compiained of almost constant bIood-tinged spotting with no other iII-heaIth. BimanuaI examination was negative except that the uterine corpus was Iarger than normal, and there was feIt a mass in the right adnexa which feIt Iike an ovarian cyst the size of a hen’s egg. After injection of IipiodoI, the skiagram (Fig. 6~) reveaIed (I) a widening of the lower segment of the uterine cavity, (z) a concave fiIIing defect in the fundus of the uterine cavity, and (3) at the point marked “x” (the origina fiIm showed this pIainIy) another fiIIing defect with the concavity upwards, of the sort one wouId expect to find at the Iower pole of a peduncuIated fibroid. A diagnosis of pedunculated fibroid was made. CASE VII (Figs. 7~ and B). This patient, coIored, aged twenty-six, compIained of almost continuous uterine hemorrhage for twenty days, foIIowing seven weeks of amennorrhea. During the Iast two weeks of this time she had nausea and vomiting and cramp-Iike pains in the Ieft Iower quadrant. Examination: There was free bIood in the vagina and the cervix was slightIy softened. The corpus of the uterus was anterior and sIightIy enIarged. There was a mass paIpabIe in the Ieft adnexa approximateIy 6 cm. in diameter and Auctuating. The history pointed definiteIy to ectopic pregnancy but the mass feIt like an ovarian cyst. After the injection of oiI, the skiagram (Fig. 7~) showed (I) marked evidence of disease of both tubes with almost compIete obIiteration of the 3This patient was from the service of, and was operated on, by Dr. Raymond
Watkins.
right tube, (2) a marked widening of the lower segment of the uterine cavity (cf. Fig. I), (3) a HIing defect near the fundus of the uterus on the right side. This was the first of its kind that I had seen, and I was unabIe to account for the widening of the lower segment and the fiIIing defect. At operation there was found biIatera1 subacute saIpingitis, a cyst of the left ovary and multipIe fibroids of the corpus of the uterus. Both tubes, the cyst of the Ieft ovary, and the corpus of the uterus were removed. This patient had a temperature of IOO’F. for several days but Ieft the hospita1 on the twentieth day in exceIIent condition. Pathologica diagnosis: sub-acute purulent salpingitis; simple cyst of the ovary; peduncuIated submucous fibromyoma with secondary chronic inflammation and multipIe intramura1 fibromyomata. SUMMARY The presence of fibroids in the uterus is nearIy aIways indicated by a deformity of the uterine canaI. The presence of intrauterine peduncuIated fibroids can be ascertained by the shadow of the tumor itseIf and by the distortion of the uterine cana and the fiIIing defects. IntravaginaI tumors may be outlined by the iodized oi1 and intra-abdominal tumors may occasionaIIy be visuaIized in the same way. In cases of large submucous myomata the uterine cavity often takes the shape of a crescent and in muItipIe tumors of the uterus the cavity is visuahzed in irreguIar form and sometimes enormousIy enIarged. Since myomectomy is the procedure of choice in a11 but the exceptiona case where the woman is under forty, it wiI1 seem important to be abIe to foresee, at Ieast in the possibiIity of a a certain measure, conservative operation. RadioIogic expIoration of the uterus after the injection of iodized oil, in case of myomata, gives one a cIear view of the reIationship between the myomata and the cavity of the uterus and aIso estabIishes the fact as to the permeabiIity of the tubes. This last fact is of importance since one wouId not want to conserve the uterine corpus unless the tubes were permeabIe.
AS A DIAGNOSTIC
IN FIBROMATA
AID
OF THE FEMALE GENITAL TRACT* ALBERT MATHIEU,
M.D.,
F.A.C.S.
PORTLAND, OREGON
T
HE vaIue of IipiodoI as a diagnostic aid in gynecology has been we11 substantiated. In competent hands, this method of visuaIizing cavities of the genita1 tract has been proved to be an artfu1 aid, suffrcientIy free from harm to be of rea1 practica1 vaIue. Its r&son d’etre is as rationa as that of the visuaIization of the urinary tract; the frequency of genital abnormalities in the femaIe gives it much academic as we11 as practica1 vaIue. Notwithstanding these facts, this aid to gynecoIogica1 diagnosis has not been suff~cientIy used to establish mass information or reIiabIe acumen in reading the roentgenograms; hence, any new materia1 shouId be weIcome. The wiIIingness of the femaIe patient to submit to operation and the interest of the surgeon in operation shouId not stand in the way of our best efforts toward exactness in preoperative gynecoIogic diagnosis. The foIIowing cases are iIIustrative : A singIe woman, aged twenty-two, presented the classic picture of ectopic pregnancy; exposure, missed period with uterine bIeeding three weeks later, and a doughy, rather fixed, mass in the region of the right tube. By means of IipiodoI, the cavities of both tubes were visualized and shown to be normaI. Because of the fact that at a previous operation the right ovarv had been removed, the diagnosis of intraiigamentary cyst was made and the indication for operation was changed from an emergency to that of one of eIection. Later, the diagnosis of intraIigamentary cyst was proved at operation. In another case, that of a young gir1 of fifteen, who had had an amenorrhea of five months and a mass in the Iower abdomen, just the shape and size of a five months’ pregnancy, Iipiodol proved extremety usefu1. This patient’s mother had been toId by the interne that her
daughter was pregnant. I saw this patient the foIIowing day and on bimanual examination made out a smaI1 mass in the right side of the pelvis, which seemed to have been pushed up near the symphysis by the larger mass. I feIt that this might be the infantiIe uterus. The patient absoIuteIy denied the possibiIity of pregnancy, no feta1 heart couId be heard and no fetus couId be paIpated. The cervix was smaI1 and showed no signs of pregnancy. The uterus was then very carefully sounded and found to be of Iess than normaI depth. LipiodoI was then injected and the skiagram showed the uterus to be infantiIe, both tubes fiIIing normaIIy, and the uterus pushed considerabIy to the right side. The temperature record, the white bIood ceI1 count, and the sedimentation test pointed toward abscess, and this diagnosis was made and proved at 0peration.l Two appIications of this method of diagnosis seem to be missing from the Iiterature; the one, of visuaIizing Iibromata in the vagina, uterus and peIvis, and the other, of the prognostic value of this method in subacute and chronic saIpingitis. Out of a mass of materia1 coIIected from the injection of 150 patients under my supervision,* I submit 6 cases of fibromata of the femaIe genita1 tract visuaIized by IipiodoI and the roentgen ray. The question of the use of IipiodoI as a prognostic aid in saIpingitis wiI1 be discussed in a subsequent paper. CASE REPORTS AND DISCUSSION OF ILLUSTRATIONS CASE I (Fig. I). This patient, aged nineteen, came to the hospita1 in October, 1927, with a condition in which differentiation between appendicitis and right saIpingitis was diffkult. 1This patient was from the service of and was ooerated upon by Dr. Raymond Watkins. 2 Some of this materia1 has been reported in Norfbwest Med., 27: 222, 1928.
* From the Department of Gynecology, University of Oregon Medical SchooI, and the GynecoIogicaI Service of the MuItnomah HospitaI. Submitted for publication March 30, 1929. 720
NEW SERIES VOL. VI, No. 6
Mathieu-Lipiodol
This skiagram, taken after the injection of Iipiodol, showed a normal uterine cavity (there is a defect on the right side, due no doubt, to
FIG. I. Skiagram of Case I, shown, primarily, as one of normal uterine cavity and tubes to be used as contrast in the pIates that folIow.
the cannula) and norma tubes. A constriction in the tubouterine junction on each side was
American
Journal
of Surgery
721
of subacute appendicitis, disease of the right tube having been eliminated by the roentgen ray. The appendix was found considerably
FIG. 2. Case 11. Skiagram showing tumor with pedicle.
swoIIen and inffamed. She made an uneventfu1 recovery, became pregnant in three months, and within a year after the injection of IipiodoI I deIivered her of a normal living baby, weigh-
3B. Case III. Photograph of the specimen after a supravagina1 hysterectomy, showing the uterine cavity and the large fibromyoma, cut into.
FIG.
FIG. 3~. Case III. Skiagram showing elongated cavity and large crescent-shaped filling Uterine fibroid.
uterine defect.
aIso seen. (This has been described by Rubin as caused by sphincteric action). The patient was operated on the same day, with a diagnosis
ing 3394 gm. This case suggested that the use of Iipiodol in the tubes does not jeopardize the chance of future pregnancy. Here, then, is a case in which injection of IipiodoI was an aid in the differentia1 diagnosis between right salpingitis and acute appendicitis; in which a constriction, probably
722
American Journd
of Surgery
Mathieu-LipiodoI
sphincteric, is shown in both tubouterine junctions and in which a pregnancy and deIivery of a normaI baby ensued within the year.
be feIt. LipiodoI was injected a11 around the tumor with a soft rubber catheter, and the skiagram (Fig. 2) visualized the tumor with its
FIG. 48. Case
FIG. 4A. Case IV. Skiagram showing eIongated Iower uterine segment and Iarge MuItipIe fibroids of uterus.
concave
fiIIing defect.
IV.
Photograph
of specimen
removed.
pedicIe, which I presumed was attached inside the uterus. The tumor was deIivered through the vuIva, as a baby’s head wouId be, with a pair of obstetrica forceps. When the pedicIe was exposed, it was cIamped and the tumor was amputated. The pedicIe was cIosed with a continuous suture of chromic catgut. The uterus
FIG. 5~. Case v. Skiagram.
CASE II (Fig. 2). This patient, aged fortythree, compIained of metrorrhagia and Ioss of strength for two years and recentIy of a fou1, blood-tinged Ieucorrhea. Examination reveaIed a round, hard mass fiIIing the pelvis, as dose a baby’s head. The fingers couId not be passed around the tumor, and no attachment couId
FIG. 5~. Case v. PathoIogicaI specimen. Fibromata
of
ovary.
inverted as to be aImost saucer shaped. The cervica1 waI1 was about 3 cm. in thickness and the cervica1 opening was about 7 cm. in diameter. The eversion couId not be reduced was so
NEW SERIESVOL. VI, No. 6
Mathieu-LipiodoI
by pressure and was apparentIy one of Iong standing. The patient made an uneventfu1 recovery, and when seen six months after the
American Journal of Surgery
723
ing-down sensations. The peIvic examination was negative, except for the fact that, the corpus of the uterus was approximately three
FIG. 6~. Photograph of specimen after supravaginal hysterectomy and remova of right adnexa showing peduncutated fibroid and ovarian cyst.
times the norma size, and extremeIy hard. The skiagram (Fig. 3~) after oi1 injection showed considerable eIongation of the uterine cavity with a Iarge crescent-Iike fiIIing defect. Diagnosis by skiagram: uterine fibroid.
FIG. 6~. Case VI. Skiagram.
CASE IV (Figs. 4A and B). The patient, aged fifty, compIained of a tumor in the abdomen which was slow growing and gave
PLATE 7~. Photograph of specimen removed, showing the cyst of Ieft ovary and peduncutated fibroid. (Note how peduncurated fibroid causes widening of lower uterine segment in skiagram. Figure 7A.) FIG. 7~. Case VII. Skiagram.
operation, the uterus was gradually returning to norma shape, and the patient was free from bIeeding and discharge. The pathoIogica1 diagnosis was pedunculated submucous fibromyoma with hyaIine degeneration and secondary chronic infiammation. CASE III (Figs. 3~ and B). This patient, aged forty-eight, compIained of uterine bIeeding, a feeling of weight in the peIvis, and bear-
her considerabIe distress because of weight. The top of the growth couId be palpated at the IeveI of the umbilicus, and because of thick abdomina1 fat, the exact nature of the growth could not be ascertained nor couId the corpus of the uterus be exactly Iocated. A mass about the size of a norma uterine corpus couId be felt just above the cervix to the right. The skiagram (Fig. 4~), foIIowing the injection of IipiodoI, shows an enormous elongation of the Iower uterine segment, and a Iarge concave fiII-
724
American Journd
of Surgery
Mathieu-Lipiodol
ing defect on the Ieft side of the uterine cavity. Diagnosis: muItipIe fibroids of the uterus. A photograph of the specimen (Fig. 4B) after supravagina1 hy.sterectomy, shows that the mass near the cervtx which I thought might be the fundus was one of the muItipIe fibromyomata of the uterine corpus. The crescentlike fiIIing defect is expIained by the Iarge fibromyomata shown in the opened specimen. CASE v (Figs. 5~ and B). In this case3 as iIIustrated the Iipiodol appears to have been injected with more than the usua1 force, and is scattered rather widely in the peIvis. The tumor is cIearIy outlined. The oil, being warm and thin, readiIy accommodates itseIf to the outer surface of a growth on which it faIIs. The uterus is seen sharpIy antiffexed. The fimbriated end of the tube apparentIy lies near the top of the tumor. Diagnosis: fibromata of the ovary. CASE VI (Figs. 6~ and B). This woman, aged thirty-five, compiained of almost constant bIood-tinged spotting with no other iII-heaIth. BimanuaI examination was negative except that the uterine corpus was Iarger than normal, and there was feIt a mass in the right adnexa which feIt Iike an ovarian cyst the size of a hen’s egg. After injection of IipiodoI, the skiagram (Fig. 6~) reveaIed (I) a widening of the lower segment of the uterine cavity, (z) a concave fiIIing defect in the fundus of the uterine cavity, and (3) at the point marked “x” (the origina fiIm showed this pIainIy) another fiIIing defect with the concavity upwards, of the sort one wouId expect to find at the Iower pole of a peduncuIated fibroid. A diagnosis of pedunculated fibroid was made. CASE VII (Figs. 7~ and B). This patient, coIored, aged twenty-six, compIained of almost continuous uterine hemorrhage for twenty days, foIIowing seven weeks of amennorrhea. During the Iast two weeks of this time she had nausea and vomiting and cramp-Iike pains in the Ieft Iower quadrant. Examination: There was free bIood in the vagina and the cervix was slightIy softened. The corpus of the uterus was anterior and sIightIy enIarged. There was a mass paIpabIe in the Ieft adnexa approximateIy 6 cm. in diameter and Auctuating. The history pointed definiteIy to ectopic pregnancy but the mass feIt like an ovarian cyst. After the injection of oiI, the skiagram (Fig. 7~) showed (I) marked evidence of disease of both tubes with almost compIete obIiteration of the 3This patient was from the service of, and was operated on, by Dr. Raymond
Watkins.
right tube, (2) a marked widening of the lower segment of the uterine cavity (cf. Fig. I), (3) a HIing defect near the fundus of the uterus on the right side. This was the first of its kind that I had seen, and I was unabIe to account for the widening of the lower segment and the fiIIing defect. At operation there was found biIatera1 subacute saIpingitis, a cyst of the left ovary and multipIe fibroids of the corpus of the uterus. Both tubes, the cyst of the Ieft ovary, and the corpus of the uterus were removed. This patient had a temperature of IOO’F. for several days but Ieft the hospita1 on the twentieth day in exceIIent condition. Pathologica diagnosis: sub-acute purulent salpingitis; simple cyst of the ovary; peduncuIated submucous fibromyoma with secondary chronic inflammation and multipIe intramura1 fibromyomata. SUMMARY The presence of fibroids in the uterus is nearIy aIways indicated by a deformity of the uterine canaI. The presence of intrauterine peduncuIated fibroids can be ascertained by the shadow of the tumor itseIf and by the distortion of the uterine cana and the fiIIing defects. IntravaginaI tumors may be outlined by the iodized oi1 and intra-abdominal tumors may occasionaIIy be visuaIized in the same way. In cases of large submucous myomata the uterine cavity often takes the shape of a crescent and in muItipIe tumors of the uterus the cavity is visuahzed in irreguIar form and sometimes enormousIy enIarged. Since myomectomy is the procedure of choice in a11 but the exceptiona case where the woman is under forty, it wiI1 seem important to be abIe to foresee, at Ieast in the possibiIity of a a certain measure, conservative operation. RadioIogic expIoration of the uterus after the injection of iodized oil, in case of myomata, gives one a cIear view of the reIationship between the myomata and the cavity of the uterus and aIso estabIishes the fact as to the permeabiIity of the tubes. This last fact is of importance since one wouId not want to conserve the uterine corpus unless the tubes were permeabIe.