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Salpix as a Medium in Hysterosalpingography
Salpix as a Medium in Hysterosalpingography Herbert H. Thomas, M.D., and David Dunn, M.D.
important studies in a sterility survey is the tubal patency test. Until Rubin and Cary devised a satisfactory method of tubal examination in 1914 very little progress had been made in developing a scientific approach to the problem of infertility. Over the years both carbon dioxide insufHation and x-ray methods of tubal study have had many advocates. Many investigators use a combination of the two methods to suit their individual needs. Carbon dioxide insufHation of the tubes is an excellent screening procedure, but when there is any question of tubal blockage or any reason to believe that intrauterine or intrapelvic pathology exists, then an x-ray method of diagnostic study should be used. In the past many radiopaque substances have been employed with variable results. Within the past few years a satisfactory radiopaque medium has been developed under the name of Salpix. 4 This medium is a combination of a nontoxic blood-expanding substance (P.V.P.) and sodium acetrizoate. Extensive laboratory and clinical tests have revealed these substances to be harmless.
ONE OF THE
TECHNIC OF HYSTEROSALPINGOGRAPHY
The optimal amount of Salpix is 4-8 cc. This will outline the uterine cavity and tubes and be sufficient for a good pelvic-scatter film. When less than 4 cc. is used the pelvic scatter is not always reliable even though the tubes may be patent. More than 8 cc. is rarely needed and is probably inadvisable. Presented on the scientific program of the Eleventh Annual Meeting of the American Society for the Study of Sterility, Atlantic City, N. J., June 4-5, 1955. From the Department of Obstetrics and Gynecology, Medical College of Alabama, Birmingham, Alabama. 155
156
THOMAS & DUNN
Fertility & Sterility
The added help of a fluoroscope is considerable but not essential. With the fluoroscope fewer x-ray pictures are necessary and greater control in
Fig.!.
Normal hysterosalpingogram demonstrating good pelvic scatter using only one x-ray picture taken 5 minutes after injection of Salpix.
timing the picture is obtained. Where filling of the uterus and both tubes is seen under the fluoroscope, an x-ray picture taken within 5 minutes usually will tell whether tubal spillage occurred and the extent of any pelvic scatter (Fig. 1). When tubal patency is in question, or there is a possibility that adhesions between the pelvic organs may prevent the scatter
Vol. 7. No.2. 1956
SALPIX IN HYSTEROSALPINGOGRAPHY
157
of Salpix, a tampon may be inserted into the vagina for 10 minutes to absorb the returning medium (Fig. 2). An x-ray picture taken immediately
Fig. 2.
Insertion of tampon to absorb Salpix draining into vagina.
after removal of the tampon will clearly reveal any Salpix that is present . in the pelvic cavity (Fig. 3). DIFFERENCES BETWEEN SALPIX AND OIL-BASED MEDIA The results were disappointing in our early use of Salpix as a medium in hysterosalpingography because it was used like, and the results compared with, oil-based media.
158
THOMAS & DUNN
Fertility & Sterility
Oil-based media must be injected slowly because of their high viscosity. Because of their slow spread throughout the pelvic cavity, speed is not so essential in getting good x-ray pictures. A 6- to 24-hour delay is usually
.
.
Fig. 3.
Removal of tampon reveals clear picture of Salpix in peritoneal cavity without interference of vaginal spill.
necessary to get a good pelvic-scatter film for visualization of possible pelvic adhesions. In fluid such as is found in a hydrosalpinx or in the cul-de-sac, the oil assumes spherical forms resembling grape clusters without clearly outlining the area covered by the fluid (Figs. 4 and 5).
•
,.
.
..
•
Vol. 7, No.2, 1956
SALPIX IN HYSTEROSALPINGOGRAPHY
159
The slow absorption of oil-based media from the pelvis, especially in damaged structures such as partially closed fallopian tubes, may lead to foreign-body granuloma formation and permanent tubal closure. I. 4 A water-soluble medium such as Salpix is easily and quickly injected with immediate scatter throughout the pelvis. Salpix is best handled by careful fluoroscopic visualization during its injection with the x-ray pictures taken as quickly as possible once the desired filling of the uterus and tubes is observed. Rapid absorption and dispersal of the medium makes prolonged observation impOSSible. Salpix mixes with the fluid present in the hydrosalpinx and the cul-de-sac to form more distinct outlines of the pelvic picture than are obtained with an oil-based medium. COMPARISON WITH OTHER AQUEOUS CONTRAST MEDIA
In some aqueous contrast media the viscosity is so low that sufficient concentrations cannot be obtained to properly outline the uterus and tubes or to take a good pelvic-scatter film. Urticarious reactions frequently result from substances added to certain aqueous contrast media to increase viscosity.2 Also, abdominal pain or cramps are frequent when some aqueous contrast media first come into contact with the peritoneum. Salpix has sufficient viscosity and density to allow use of the fluoroscope and to take good x-ray pictures. REACTIONS ENCOUNTERED WITH SALPIX
In general, little discomfort has been noticed with Salpix. However, 3 in a group of nearly one hundred patients developed abdominal cramps of a moderate to severe degree from 30 minutes to 1 hour after the procedure was completed. It should be pointed out that no sedation, analgesic, or antispasmodic had been given any patient. The injection of Salpix was carefully and gently done. Upon any increase in abdominal pain or cramps the injection was immediately stopped until the discomfort disappeared. Case 1 This was a 29-year-old white married female, para 1-1-0-0, who had an x-ray tubal-patency test with Salpix on Day 9 of the cycle. About 10 cc. of Salpix was injected. Mild cramping pains occurred when the Salpix reached the peritoneum but soon disappeared. X-ray pictures revealed the right tube patent with
160
THOMAS & DUNN
Fertility & Sterility
a good pelvic spill, but the left tube was closed at the fimbrial end. Forty-five minutes after the procedure was over the patient developed a severe cramping pain in the right lower abdomen that was relieved within 1 hour by 75 mg. of
Figs. 4 and 5.
Distinct margins of circumscribed collection of Salpix as contrasted with the grapelike, globular clusters of oil-based medium.
intravenous Demerol. She continued to have lower abdominal tenderness for 24 hours.
Case 2 This was a SO-year-old white married female, para 0, who had an x-ray tubal-
_
Vol. 7. No.2. 1956
SALPIX IN HYSTEROSALPINGOGRAPHY
161
patency test with Salpix on Day 11 of the cycle. Because of a large uterine cavity a total of 16 cc. of Salpix was used. The left tube was closed at the uterine cornu, but the right tube was patent with a good pelvic spill. Cramping across
Fig. 5.
the lower abdomen began about 45 minutes after the procedure ended. This pain persisted unreported until the next morning, at which time 4 mg. of Chlortrimeton, taken orally every 4 hours, was prescribed. Within 2 hours the patient felt better and the cramping ceased. She became pregnant during the following cycle.
162
THOMAS & DUNN
Fertility & Sterility
Case 3 This was a 29-year-old white married female, para 0, who had an x-ray tubalpatency test with Salpix on Day 11 of the cycle. X-ray pictures revealed both
•
Fig. 6.
Entrapped oil-base medium localized by injection of Salpix, revealing limits of free peritoneal cavity.
tubes patent with a good pelvic spill. Thirty minutes later the patient developed severe bilateral lower-abdominal cramping pains. Relief was obtained in 20-40 minutes with 50 mg. of Chlortrimeton given intramuscularly. The patient did not complain of any discomfort the following day.
.
...
Vol. 7. No.2. 1956
SALPIX IN HYSTEROSALPINGOGRAPHY
163
Comment
Possibly these 3 patients had more Salpix injected into the abdominal cavity than normally needed for the usual hysterosalpingogram. Excessive amounts of sodium acetrizoate may have caused a peritoneal irritation. Two of the 3 patients were quickly relieved of discomfort by oral and intramuscular Chlortrimeton, while the first patient, who was given a narcotic preparation, still had abdominal discomfort 24 hours later. For the past 6 months the amount of Salpix used for hysterosalpingograms has been limited to a maximum of 8 cc., with the average amount ranging around 6 cc. All patients are tested for sensitivity by placing a drop of Salpix sublingually at least 30 minutes before the hysterosalpingogram is begun. With these precautions, no further trouble with abdominal cramps has been experienced.
DISCUSSION Uterotubal insufHation in expert hands and with intricate expensive equipment may give considerable information about tubal status. For the general practitioner who sees the occasional sterility problem, a hysterosalpingogram is more practical and easy to interpret, and most doctors have access to an x-ray machine and the few simple instruments needed. In clinical practice it is important to obtain accurate conclusions in a minimum of time. This makes the use of Salpix attractive, as frequently the entire procedure can be concluded at one visit with the use of one or two x-ray films. Thus not only time but also money is saved. When the patient has had a previous hysterosalpingogram, a preliminary pelvic x-ray picture should be taken, as it may reveal residual medium still present. When many months have elapsed since the retained medium was injected, there is the possibility that pelvic damage has occurred, such as pelvic adhesions, oil granulomas, or damaged tubes. Because of the difference in density of the two media, the injection of Salpix may aid in accurately locating these collections of retained medium (Fig. 6). Even when patency is demonstrated in one or both tubes, it should be remembered that factors may still exist in the pelvis to prevent the ovum from leaving the ovary or reaching the tubal ostium. The characteristics of the pelvic scatter as seen on the x-ray film may reveal some of these difficulties, such as unusual collections of the medium that do not disperse
1THOMAS & DUNN
164
Fertility & Sterility
immediately or failure of the medium to spread over the entire pelvic cavity. Since Salpix is an aqueous contrast medium it adheres closely to the surfaces of the uterine cavity, so that the ragged edges of abnormal endometrial tissue are often clearly revealed. Frequently a curettage to clean this tissue away is followed by a pregnancy.
SUMMARY Salpix is a satisfactory, quickly absorbed aqueous contrast medium. An amount beyond that needed to obtain a good x-ray picture of the uterine cavity, tubal outlines, and pelvic scatter (~ cc.) is not recommended. REFERENCES 1. BROWN, W. E., JENNINGS, A. F., and BRADBURY, J. I. Am.]. Obst. & Gynee. 58: 1041,1949. 2. GRAY, L. A. Radiology 61: 189, 1953. 3. RUBIN, I. Uterotubal Insufflation. St. Louis, Mo., Mosby, 1947. 4. RUBIN, I. C., MYLLER, E., and HARTMAN, C. Fertil. & Steril. 4:357, 1953. 5. KANTOR, H. I., KAMHOLZ, J. H., and SMITH, ALICE L. Foreign-body granulomas following the use of Salpix: Report of a case simulating intra-abdominal tuberculosis.
Obst. & Gynee. 7: 171, 1956.
DISCUSSION DR. HERMAN I. KANTOR, Dallas, Texas: As a resident under Dr. I. C. Rubin, I was "brought up" to use water-soluble media in the gynecologic study. Its rapid absorption provides an outstanding advantage over the oil-base media. When the solution is injected with adequate controls, the need for delayed films is infrequent. Many gynecologists think of carbon-dioxide insuffiation and hysterosalpingography as somehow competing with each other in the sterility study. We Sincerely believe that unless both examinations are carried out the work-up is incomplete. Both make distinct contributions, and in no sense should they be considered competitive. We have used Salpix in more than 50 patients. The radiograph of a true uterus didelphys, demonstrated in one of our patients, was sent to the Ortho Pharmaceutical Corporation in an enthusiastic moment and has since been used by them to proclaim the merits of Salpix. We can confirm the rapid absorption, the satisfactory radiographs, and the infrequent incidence of even minor reactions. However, a recent experience indicates that Salpix may excite a foreign-body granulomatous reaction similar to the oil-base media: 5 We performed hysterography with 5 cc. of Salpix on a patient in 1954. On two occasions before this, it had been demonstrated that her tubes were normally
..
,
·
.
.
Vol. 7, No.2, 1956
SALPIX IN HYSTEROSALPINGOGRAPHY
165
patent. She did have several fibroids, and therefore we were primarily interested in the intrauterine pathology. Unfortunately, fluoroscopic control was not used. However, the right tube was partially visualized. There was no immediate reaction to the procedure. A year later we elected to remove the fibroids with hope of solving the infertility problem. At operation, the abdominal cavity and its contents were studded with many firm, gray-white nodules, thought to be tuberculosis. A frozen section of several confirmed this initial impression. Since the process seemed to originate in the pelvis, the uterus, tubes, and ovaries were removed. When the tissue was studied in better-stained preparations, the doubly refractile central portions of the nodules revealed their true nature, a typical foreignbody granuloma. Because we did not demonstrate the passage of the Salpix into the abdominal cavity, the evidence remains circumstantial, to be sure. However, since the tubes were proved to be patent both before the x-ray and afterward in the pathology laboratory, Salpix appears to be the responsible agent. We were unable to reproduce this syndrome in our animal work, and it must surely be rare. On the whole, we have found Salpix to be a satisfactory diagnostic medium for hysterosalpingography. I am pleased to confirm the essayists' report.
important studies in a sterility survey is the tubal patency test. Until Rubin and Cary devised a satisfactory method of tubal examination in 1914 very little progress had been made in developing a scientific approach to the problem of infertility. Over the years both carbon dioxide insufHation and x-ray methods of tubal study have had many advocates. Many investigators use a combination of the two methods to suit their individual needs. Carbon dioxide insufHation of the tubes is an excellent screening procedure, but when there is any question of tubal blockage or any reason to believe that intrauterine or intrapelvic pathology exists, then an x-ray method of diagnostic study should be used. In the past many radiopaque substances have been employed with variable results. Within the past few years a satisfactory radiopaque medium has been developed under the name of Salpix. 4 This medium is a combination of a nontoxic blood-expanding substance (P.V.P.) and sodium acetrizoate. Extensive laboratory and clinical tests have revealed these substances to be harmless.
ONE OF THE
TECHNIC OF HYSTEROSALPINGOGRAPHY
The optimal amount of Salpix is 4-8 cc. This will outline the uterine cavity and tubes and be sufficient for a good pelvic-scatter film. When less than 4 cc. is used the pelvic scatter is not always reliable even though the tubes may be patent. More than 8 cc. is rarely needed and is probably inadvisable. Presented on the scientific program of the Eleventh Annual Meeting of the American Society for the Study of Sterility, Atlantic City, N. J., June 4-5, 1955. From the Department of Obstetrics and Gynecology, Medical College of Alabama, Birmingham, Alabama. 155
156
THOMAS & DUNN
Fertility & Sterility
The added help of a fluoroscope is considerable but not essential. With the fluoroscope fewer x-ray pictures are necessary and greater control in
Fig.!.
Normal hysterosalpingogram demonstrating good pelvic scatter using only one x-ray picture taken 5 minutes after injection of Salpix.
timing the picture is obtained. Where filling of the uterus and both tubes is seen under the fluoroscope, an x-ray picture taken within 5 minutes usually will tell whether tubal spillage occurred and the extent of any pelvic scatter (Fig. 1). When tubal patency is in question, or there is a possibility that adhesions between the pelvic organs may prevent the scatter
Vol. 7. No.2. 1956
SALPIX IN HYSTEROSALPINGOGRAPHY
157
of Salpix, a tampon may be inserted into the vagina for 10 minutes to absorb the returning medium (Fig. 2). An x-ray picture taken immediately
Fig. 2.
Insertion of tampon to absorb Salpix draining into vagina.
after removal of the tampon will clearly reveal any Salpix that is present . in the pelvic cavity (Fig. 3). DIFFERENCES BETWEEN SALPIX AND OIL-BASED MEDIA The results were disappointing in our early use of Salpix as a medium in hysterosalpingography because it was used like, and the results compared with, oil-based media.
158
THOMAS & DUNN
Fertility & Sterility
Oil-based media must be injected slowly because of their high viscosity. Because of their slow spread throughout the pelvic cavity, speed is not so essential in getting good x-ray pictures. A 6- to 24-hour delay is usually
.
.
Fig. 3.
Removal of tampon reveals clear picture of Salpix in peritoneal cavity without interference of vaginal spill.
necessary to get a good pelvic-scatter film for visualization of possible pelvic adhesions. In fluid such as is found in a hydrosalpinx or in the cul-de-sac, the oil assumes spherical forms resembling grape clusters without clearly outlining the area covered by the fluid (Figs. 4 and 5).
•
,.
.
..
•
Vol. 7, No.2, 1956
SALPIX IN HYSTEROSALPINGOGRAPHY
159
The slow absorption of oil-based media from the pelvis, especially in damaged structures such as partially closed fallopian tubes, may lead to foreign-body granuloma formation and permanent tubal closure. I. 4 A water-soluble medium such as Salpix is easily and quickly injected with immediate scatter throughout the pelvis. Salpix is best handled by careful fluoroscopic visualization during its injection with the x-ray pictures taken as quickly as possible once the desired filling of the uterus and tubes is observed. Rapid absorption and dispersal of the medium makes prolonged observation impOSSible. Salpix mixes with the fluid present in the hydrosalpinx and the cul-de-sac to form more distinct outlines of the pelvic picture than are obtained with an oil-based medium. COMPARISON WITH OTHER AQUEOUS CONTRAST MEDIA
In some aqueous contrast media the viscosity is so low that sufficient concentrations cannot be obtained to properly outline the uterus and tubes or to take a good pelvic-scatter film. Urticarious reactions frequently result from substances added to certain aqueous contrast media to increase viscosity.2 Also, abdominal pain or cramps are frequent when some aqueous contrast media first come into contact with the peritoneum. Salpix has sufficient viscosity and density to allow use of the fluoroscope and to take good x-ray pictures. REACTIONS ENCOUNTERED WITH SALPIX
In general, little discomfort has been noticed with Salpix. However, 3 in a group of nearly one hundred patients developed abdominal cramps of a moderate to severe degree from 30 minutes to 1 hour after the procedure was completed. It should be pointed out that no sedation, analgesic, or antispasmodic had been given any patient. The injection of Salpix was carefully and gently done. Upon any increase in abdominal pain or cramps the injection was immediately stopped until the discomfort disappeared. Case 1 This was a 29-year-old white married female, para 1-1-0-0, who had an x-ray tubal-patency test with Salpix on Day 9 of the cycle. About 10 cc. of Salpix was injected. Mild cramping pains occurred when the Salpix reached the peritoneum but soon disappeared. X-ray pictures revealed the right tube patent with
160
THOMAS & DUNN
Fertility & Sterility
a good pelvic spill, but the left tube was closed at the fimbrial end. Forty-five minutes after the procedure was over the patient developed a severe cramping pain in the right lower abdomen that was relieved within 1 hour by 75 mg. of
Figs. 4 and 5.
Distinct margins of circumscribed collection of Salpix as contrasted with the grapelike, globular clusters of oil-based medium.
intravenous Demerol. She continued to have lower abdominal tenderness for 24 hours.
Case 2 This was a SO-year-old white married female, para 0, who had an x-ray tubal-
_
Vol. 7. No.2. 1956
SALPIX IN HYSTEROSALPINGOGRAPHY
161
patency test with Salpix on Day 11 of the cycle. Because of a large uterine cavity a total of 16 cc. of Salpix was used. The left tube was closed at the uterine cornu, but the right tube was patent with a good pelvic spill. Cramping across
Fig. 5.
the lower abdomen began about 45 minutes after the procedure ended. This pain persisted unreported until the next morning, at which time 4 mg. of Chlortrimeton, taken orally every 4 hours, was prescribed. Within 2 hours the patient felt better and the cramping ceased. She became pregnant during the following cycle.
162
THOMAS & DUNN
Fertility & Sterility
Case 3 This was a 29-year-old white married female, para 0, who had an x-ray tubalpatency test with Salpix on Day 11 of the cycle. X-ray pictures revealed both
•
Fig. 6.
Entrapped oil-base medium localized by injection of Salpix, revealing limits of free peritoneal cavity.
tubes patent with a good pelvic spill. Thirty minutes later the patient developed severe bilateral lower-abdominal cramping pains. Relief was obtained in 20-40 minutes with 50 mg. of Chlortrimeton given intramuscularly. The patient did not complain of any discomfort the following day.
.
...
Vol. 7. No.2. 1956
SALPIX IN HYSTEROSALPINGOGRAPHY
163
Comment
Possibly these 3 patients had more Salpix injected into the abdominal cavity than normally needed for the usual hysterosalpingogram. Excessive amounts of sodium acetrizoate may have caused a peritoneal irritation. Two of the 3 patients were quickly relieved of discomfort by oral and intramuscular Chlortrimeton, while the first patient, who was given a narcotic preparation, still had abdominal discomfort 24 hours later. For the past 6 months the amount of Salpix used for hysterosalpingograms has been limited to a maximum of 8 cc., with the average amount ranging around 6 cc. All patients are tested for sensitivity by placing a drop of Salpix sublingually at least 30 minutes before the hysterosalpingogram is begun. With these precautions, no further trouble with abdominal cramps has been experienced.
DISCUSSION Uterotubal insufHation in expert hands and with intricate expensive equipment may give considerable information about tubal status. For the general practitioner who sees the occasional sterility problem, a hysterosalpingogram is more practical and easy to interpret, and most doctors have access to an x-ray machine and the few simple instruments needed. In clinical practice it is important to obtain accurate conclusions in a minimum of time. This makes the use of Salpix attractive, as frequently the entire procedure can be concluded at one visit with the use of one or two x-ray films. Thus not only time but also money is saved. When the patient has had a previous hysterosalpingogram, a preliminary pelvic x-ray picture should be taken, as it may reveal residual medium still present. When many months have elapsed since the retained medium was injected, there is the possibility that pelvic damage has occurred, such as pelvic adhesions, oil granulomas, or damaged tubes. Because of the difference in density of the two media, the injection of Salpix may aid in accurately locating these collections of retained medium (Fig. 6). Even when patency is demonstrated in one or both tubes, it should be remembered that factors may still exist in the pelvis to prevent the ovum from leaving the ovary or reaching the tubal ostium. The characteristics of the pelvic scatter as seen on the x-ray film may reveal some of these difficulties, such as unusual collections of the medium that do not disperse
1THOMAS & DUNN
164
Fertility & Sterility
immediately or failure of the medium to spread over the entire pelvic cavity. Since Salpix is an aqueous contrast medium it adheres closely to the surfaces of the uterine cavity, so that the ragged edges of abnormal endometrial tissue are often clearly revealed. Frequently a curettage to clean this tissue away is followed by a pregnancy.
SUMMARY Salpix is a satisfactory, quickly absorbed aqueous contrast medium. An amount beyond that needed to obtain a good x-ray picture of the uterine cavity, tubal outlines, and pelvic scatter (~ cc.) is not recommended. REFERENCES 1. BROWN, W. E., JENNINGS, A. F., and BRADBURY, J. I. Am.]. Obst. & Gynee. 58: 1041,1949. 2. GRAY, L. A. Radiology 61: 189, 1953. 3. RUBIN, I. Uterotubal Insufflation. St. Louis, Mo., Mosby, 1947. 4. RUBIN, I. C., MYLLER, E., and HARTMAN, C. Fertil. & Steril. 4:357, 1953. 5. KANTOR, H. I., KAMHOLZ, J. H., and SMITH, ALICE L. Foreign-body granulomas following the use of Salpix: Report of a case simulating intra-abdominal tuberculosis.
Obst. & Gynee. 7: 171, 1956.
DISCUSSION DR. HERMAN I. KANTOR, Dallas, Texas: As a resident under Dr. I. C. Rubin, I was "brought up" to use water-soluble media in the gynecologic study. Its rapid absorption provides an outstanding advantage over the oil-base media. When the solution is injected with adequate controls, the need for delayed films is infrequent. Many gynecologists think of carbon-dioxide insuffiation and hysterosalpingography as somehow competing with each other in the sterility study. We Sincerely believe that unless both examinations are carried out the work-up is incomplete. Both make distinct contributions, and in no sense should they be considered competitive. We have used Salpix in more than 50 patients. The radiograph of a true uterus didelphys, demonstrated in one of our patients, was sent to the Ortho Pharmaceutical Corporation in an enthusiastic moment and has since been used by them to proclaim the merits of Salpix. We can confirm the rapid absorption, the satisfactory radiographs, and the infrequent incidence of even minor reactions. However, a recent experience indicates that Salpix may excite a foreign-body granulomatous reaction similar to the oil-base media: 5 We performed hysterography with 5 cc. of Salpix on a patient in 1954. On two occasions before this, it had been demonstrated that her tubes were normally
..
,
·
.
.
Vol. 7, No.2, 1956
SALPIX IN HYSTEROSALPINGOGRAPHY
165
patent. She did have several fibroids, and therefore we were primarily interested in the intrauterine pathology. Unfortunately, fluoroscopic control was not used. However, the right tube was partially visualized. There was no immediate reaction to the procedure. A year later we elected to remove the fibroids with hope of solving the infertility problem. At operation, the abdominal cavity and its contents were studded with many firm, gray-white nodules, thought to be tuberculosis. A frozen section of several confirmed this initial impression. Since the process seemed to originate in the pelvis, the uterus, tubes, and ovaries were removed. When the tissue was studied in better-stained preparations, the doubly refractile central portions of the nodules revealed their true nature, a typical foreignbody granuloma. Because we did not demonstrate the passage of the Salpix into the abdominal cavity, the evidence remains circumstantial, to be sure. However, since the tubes were proved to be patent both before the x-ray and afterward in the pathology laboratory, Salpix appears to be the responsible agent. We were unable to reproduce this syndrome in our animal work, and it must surely be rare. On the whole, we have found Salpix to be a satisfactory diagnostic medium for hysterosalpingography. I am pleased to confirm the essayists' report.