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The technique and use of urografin as a contrast medium in hysterosalpingography
108
JOURNAL
OF
THE
FACULTY
OF
RADIOLOGISTS
The Technique and Use of Urografin as a Contrast Medium in Hysterosalpingography R. W. McNABB, M.R.C.S., L.R.C.P., D.M.R.D.
Consultant Radiologist, West Herts Hospital, Hemel Hempstead; Senior Registrar, Edgware General Hospital WITH the d e v e l o p m e n t of n e w n o n - o i l y contrast m e d i a it was felt, in 1955, t h a t a n a t t e m p t s h o u l d be m a d e to find w h i c h of those available was m o s t suitable for h y s t e r o s a l p i n g o g r a p h y . T h e decision to change f r o m the oily c o n t r a s t m e d i u m used u n t i l
I. S a l p i x . - - T h i s was f o u n d to b e of satisfactory radiographic d e n s i t y a n d w i t h n o side-effects. T h e s e findings agreed w i t h t h o s e of Czyzewski, w h o described its use in 1956. H o w e v e r , t h e p r e s e n t w r i t e r f o u n d it difficult to h a n d l e w i t h small syringes
Fig. i.--Case 1. Bdateral tubal filling and immedlate spill.
Fig. z.--Case I. Spread of m e d i u m from bilateral spili
Fig. 3.--Case z.
Umlateral tubal filling and spill outlining the ovary.
t h e n was m a d e w i t h some regret, b u t its c o n t i n u e d use, w i t h its k n o w n a t t e n d a n t dangers, d i d n o t appear to be justified. T h e s e dangers have b e e n stressed f r o m time to t i m e in the literature, a n d as recently as 1957 a case of p u l m o n a r y oil e m b o l i s m was described b y G r a n t , Callarn, a n d D a v i d s o n . Before t h e choice of urografin was m a d e several o t h e r contrast m e d i a were t r i e d a n d t h e following is a b r i e f description of these trials.
( I o - m m . film).
Opaque m e d i u m in vagina and spread of unilateral spili ( i o - m m . film).
Fig. 4.--Case a.
a n d cannulae. T h e s e were t i r e s o m e to fill a n d injection was hard. Finally o w i n g to these technical reasons it was discarded. 2. V i s k i o s o l S i x . - - T h i s p r o v e d a m o s t satisfactory m e d i u m , easy to h a n d l e a n d of good radiographic density. Side-effects were absent. T h e r e was excellent r e t e n t i o n of t h e m e d i u m , w i t h delayed a b s o r p t i o n in cases of hydrosalpinx. T h i s agreed w i t h the findings of Bligh, w h o in 1955 discussed the
U ROGtlAFIN
IN
HYSTEROSALPINGOGRAPHY
IO9
investigation of h y d r o s a l p i n x u s i n g this m e d i u m in 90 cases. Viskiosol Six was used b y us u n t i l it was w i t h d r a w n b y the makers. 3. E n d o g r a f i n . - - T h i s was f o u n d to be satisfactory in m o s t respects, b u t it h a d a serious d r a w back w h i c h led to it eventually b e i n g a b a n d o n e d . E v e r y p a t i e n t h a d pain arising 4 to 8 h o u r s after t h e
b e e n f o u n d to b e necessary in this series of cases. I t is i m p o r t a n t , however, to explain the p r o c e d u r e carefully to t h e p a t i e n t in order to get c o m p l e t e co-operation. T h i s is d o n e w h e n the p a t i e n t is seen b y the gynsecologist and, as a f u r t h e r check, again w h e n t h e p a t i e n t comes u p for the h y s t e r o s a l p i n g o gram.
Ftg. 5.--Case 3. Irregular filhng of the right fallopian tube
Fig. &--Case 3. Thirty-mm. film showing non-absorbed
examination. T h i s s y m p t o m is a feature n o t e d b y o t h e r users of this p r e p a r a t i o n , a n d c o m m e n t e d o n in some detail b y Davies, Fisher, a n d Rocker in I957. T h e y divided t h e pain experienced into two groups: (1) W i t h i n 24 h o u r s ; (2) A f t e r 24 hours. T h o s e in o u r series h a d pain in 4 to 8 hours, i.e., in G r o u p I. As t h e foregoing m e d i a did n o t p r o v e satisfactory f u r t h e r research proceeded, a n d in D e c e m b e r , 1956, urografin was first used. 4- U r o g r a f i n . - - T h i s is a m i x t u r e of t h e s o d i u m a n d m e t h y l g l u c a m i n e salts of N : N ' - d i a c e t y l - 3 : 5 d i a m i n o - 2 : 4 : 6 - t r i o d o b e n z o i c acid. The strength used in this series was 76 p e r cent. E x p e r i m e n t a l l y it was f o u n d b y Langecker, H a r w a r t , a n d J u n k m a n , in 1954, to be of relatively low toxicity. Viscosity is n o t high, b u t this has p r o v e d n o disadvantage. H a n d l i n g is easy a n d reflux has n o t b e e n a p r o b l e m . C o m p a r i s o n w i t h endografin has given t h e following figures : - Endografin 7° per cent, 18 Centlpoise Urografin 76 per cent, 7"3 Centlpoise R a d i o g r a p h i c d e n s i t y is satisfactory b o t h for screening a n d for films (Figs. I - 4 ) . It is i n t e r e s t i n g to note t h a t Massell, G r e e n s t o n e , a n d H e r i n g m a n , in 1957, claimed t h a t t h e m i x t u r e of s o d i u m a n d m e t h y l g l u c a m i n e salts gave b e t t e r density t h a n t h e s o d i u m salt alone ( H y p a q u e ) w h e n u s e d for angiography. T h e r e is satisfactory r e t e n t i o n of u n a b s o r b e d m e d i u m in cases of h y d r o s a l p i n x ; deffsity b e i n g p r e s e n t for as long as 3 0 - 9 o m i n . I t is a m e d i u m w h i c h is u s e d for n u m e r o u s examinations, n o t a b l y i n t r a v e n o u s pyelography, p e r i p h e r a l arteriography, a n d cerebral angiography. Its use a n d suitability for h y s t e r o s a l p i n g o g r a p h y has b e e n r e p o r t e d recently b y Reiss a n d G r o s s m a n , 1958 , i n a series of 148 cases.
T h e urografin is i n t r o d u c e d u n d e r screen control, u s i n g a n i n t r a - u t e r i n e syringe w i t h a t t a c h e d softr u b b e r cone. O n l y t h e smallest a m o u n t necessary for diagnosis is used. T h i s m a y be as little as 2 c.c. ; occasionally 1"5 c.c. has b e e n f o u n d sufficient. T h e use of a v o l s e l l u m is avoided as m u c h as possible. I t is used only i n t h e small p r o p o r t i o n of cases w h e r e reflux occurs w i t h o u t it. O n e film is t a k e n i m m e d i a t e l y t u b a l filling is observed, or after an interval if n o filling is seen. T h e c a n n u l a is t h e n w i t h d r a w n a n d r a p i d s c r e e n i n g is p e r f o r m e d to check the rate of e m p t y i n g of t h e uterus. T h e p a t i e n t t h e n gets off t h e table, a n d a second film is t a k e n i o min. later, after t h e p a t i e n t has b e e n a m b u l a n t . I n cases of h y d r o s a l p i n x a t h i r d film is usually t a k e n at 30 min. Sereenlng.--This is kept to a m i n i m u m w i t h t h e d i a p h r a g m s closed d o w n so t h a t first t h e u t e r i n e a n d t h e n t h e u t e r i n e a n d t u b a l areas only are s c r e e n e d ; b o t h t u b e s are visualized simultaneously, as it h a s b e e n f o u n d i n o u r h a n d s to be quicker t h a n s c r e e n i n g first one t u b a l area a n d t h e n t h e other. T h i s latter m e t h o d was suggested b y B a r n e t t and Bewley ( B a r n e t t a n d Bewley, 1955; B a r n e t t , i955). S c r e e n i n g t i m e has b e e n f o u n d to be v e r y m u c h d e p e n d e n t o n co-operation b e t w e e n t h e gyn~ecologist a n d radiologist. A n e n d e a v o u r is m a d e n o t to exceed i rain. p e r case. S t o p - w a t c h trials have s h o w n t h a t large variations can o c c u r a n d t h a t t h e s h o r t e s t times are o b t a i n e d w h e n t h e same gyn~ecologist a n d radiologist work t o g e t h e r routinely. U n d e r t h e s e c o n d i t i o n s screening times of 3 0 - 5 0 sec. have b e e n consistently recorded. T h e X - r a y factors used for screening were 85 kV. a n d 2 ma. R a d l o l o g y . - - T h e two films were t a k e n u s i n g t h e u n d e r - c o u c h tube. X - r a y factors used were 85-9o kV. a n d 3 ° M a . S . T h e focus-table t o p distance was 54"6 cm., a n d 2 ram. of a l u m i n i u m filtration was used.
with a collection of opaque medium.
TECHNIQUE T e c h n i q u e has b e e n p l a n n e d to r e d u c e radiation to a m i n i m u m . Ansesthesia or p r e m e d i c a t i o n has n o t
medium m a right hydrosalpinx.
IIO
JOURNAL
OF
THE
FACULTY
OF
RADIOLOGISTS
I m a g e intensification w h i c h is shortly to be used will reduce the r a d i a t i o n dose to the ovaries d u r i n g screening. It is n o t e d t h a t Reiss a n d G r o s s m a n (1958) d i d n o t screen t h e i r cases; it is, however, t h o u g h t b y us to b e a useful p a r t of the examination.
incapacitating. W h e n it did occur it was w i t h i n 4 hours. (All p a t i e n t s were seen, w i t h i n a few days of the examination, b y .the gyn~ecologist, a n d specifically q u e s t i o n e d o n t h e o c c u r r e n c e or otherwise of pain.)
RESULTS
T h e successful use of urografin in h y s t e r o g r a p h y is r e p o r t e d a n d t h e t e c h n i q u e discussed. W h i l s t it is n o t claimed t h a t u r o g r a f i n is the ideal c o n t r a s t m e d i u m , it has in o u r experience p r o v e d to b e t h e m o s t satisfactory m e d i u m yet used.
U p to N o v e m b e r , 1958 , 181 h y s t e r o g r a m s have b e e n p e r f o r m e d on 167 patients, u s i n g urografin as contrast m e d i u m . T h e e x a m i n a t i o n s have b e e n done for a variety of reasons, infertility b e i n g the m o s t usual. A n analysis is given in Table I a n d t h e results o b t a i n e d are given in Table I_7.
Table/.--REASON FOR EXAMINATION Infertility Repeated miscarriages and/or suspected uterine malformation Check of sterilization *Local:zing of a G r a f e n b e r g ring
15 I II 4 I
TOTAL PATIENTS * F o u n d to be extra-uterine.
Acknowledgements.--My m o s t grateful t h a n k s are due to Dr. M. Rose, of t h e O b s t e t r i c a n d G y n m c o logical D e p a r t m e n t , a n d to Dr. E. T o p h a m , S e n i o r Radiologist, X - r a y D e p a r t m e n t , E d g w a r e G e n e r a l Hospital, for p e r m i s s i o n to p u b l i s h this report. REFERENCES
x67
Fac. Radiol., 7, 115. - - - - and BEWLEY, D. K. (I955), Ibid., 6, 186. BLIGH, A. S. (I955) , Brit. J. Radiol., 28, 30. CZYZEWSKI, W. J. J. (I956), ]bid., 29, 679. DAVIES, D. K. L., FISHER, H. J., and ROCKER, I. (I957), Brit. med. ff., 2, 859. G R A N T , I . W . B., CALLAM, W . , and DAVIDSON, J . K . (I957) , J. Fac. Radiol., 8, 4io. LANGECKER, H., HARWART, A., and JUNKMAN, K. (I954), Arch. exper. Path. Pharmack., 22, 584. MASSELL, T. B., GREENSTONE, S. M., and HERINGMAN, E. C. (I957), J. Amer. reed. Ass., 22, 584. REISS, H. E., and GROSSMAN, MARIA E. 0958), J. Obstet. Gynec., 65, 782. BARNETT, E . ( i 9 5 5 ) , J .
Table H . - - R E S U L T
OF EXAMINATIONS Unilateral or bilateral tubal spill I4 o N o tubal spill 24 Hydrosalpinx Io Reflux 7 TOTAL EXAMINATIONS
SUMMARY
ISI
Side-effects d u r i n g t h e e x a m i n a t i o n have n o t b e e n n o t e d in any of t h e cases. I n 2 e x a m i n a t i o n s v e n o u s intravasation was seen. T h e r e were n o i m m e d i a t e or late complications. P a i n has o c c u r r e d only very occasionally. It was m i n i m a l in degree a n d n e v e r
JOURNAL
OF
THE
FACULTY
OF
RADIOLOGISTS
The Technique and Use of Urografin as a Contrast Medium in Hysterosalpingography R. W. McNABB, M.R.C.S., L.R.C.P., D.M.R.D.
Consultant Radiologist, West Herts Hospital, Hemel Hempstead; Senior Registrar, Edgware General Hospital WITH the d e v e l o p m e n t of n e w n o n - o i l y contrast m e d i a it was felt, in 1955, t h a t a n a t t e m p t s h o u l d be m a d e to find w h i c h of those available was m o s t suitable for h y s t e r o s a l p i n g o g r a p h y . T h e decision to change f r o m the oily c o n t r a s t m e d i u m used u n t i l
I. S a l p i x . - - T h i s was f o u n d to b e of satisfactory radiographic d e n s i t y a n d w i t h n o side-effects. T h e s e findings agreed w i t h t h o s e of Czyzewski, w h o described its use in 1956. H o w e v e r , t h e p r e s e n t w r i t e r f o u n d it difficult to h a n d l e w i t h small syringes
Fig. i.--Case 1. Bdateral tubal filling and immedlate spill.
Fig. z.--Case I. Spread of m e d i u m from bilateral spili
Fig. 3.--Case z.
Umlateral tubal filling and spill outlining the ovary.
t h e n was m a d e w i t h some regret, b u t its c o n t i n u e d use, w i t h its k n o w n a t t e n d a n t dangers, d i d n o t appear to be justified. T h e s e dangers have b e e n stressed f r o m time to t i m e in the literature, a n d as recently as 1957 a case of p u l m o n a r y oil e m b o l i s m was described b y G r a n t , Callarn, a n d D a v i d s o n . Before t h e choice of urografin was m a d e several o t h e r contrast m e d i a were t r i e d a n d t h e following is a b r i e f description of these trials.
( I o - m m . film).
Opaque m e d i u m in vagina and spread of unilateral spili ( i o - m m . film).
Fig. 4.--Case a.
a n d cannulae. T h e s e were t i r e s o m e to fill a n d injection was hard. Finally o w i n g to these technical reasons it was discarded. 2. V i s k i o s o l S i x . - - T h i s p r o v e d a m o s t satisfactory m e d i u m , easy to h a n d l e a n d of good radiographic density. Side-effects were absent. T h e r e was excellent r e t e n t i o n of t h e m e d i u m , w i t h delayed a b s o r p t i o n in cases of hydrosalpinx. T h i s agreed w i t h the findings of Bligh, w h o in 1955 discussed the
U ROGtlAFIN
IN
HYSTEROSALPINGOGRAPHY
IO9
investigation of h y d r o s a l p i n x u s i n g this m e d i u m in 90 cases. Viskiosol Six was used b y us u n t i l it was w i t h d r a w n b y the makers. 3. E n d o g r a f i n . - - T h i s was f o u n d to be satisfactory in m o s t respects, b u t it h a d a serious d r a w back w h i c h led to it eventually b e i n g a b a n d o n e d . E v e r y p a t i e n t h a d pain arising 4 to 8 h o u r s after t h e
b e e n f o u n d to b e necessary in this series of cases. I t is i m p o r t a n t , however, to explain the p r o c e d u r e carefully to t h e p a t i e n t in order to get c o m p l e t e co-operation. T h i s is d o n e w h e n the p a t i e n t is seen b y the gynsecologist and, as a f u r t h e r check, again w h e n t h e p a t i e n t comes u p for the h y s t e r o s a l p i n g o gram.
Ftg. 5.--Case 3. Irregular filhng of the right fallopian tube
Fig. &--Case 3. Thirty-mm. film showing non-absorbed
examination. T h i s s y m p t o m is a feature n o t e d b y o t h e r users of this p r e p a r a t i o n , a n d c o m m e n t e d o n in some detail b y Davies, Fisher, a n d Rocker in I957. T h e y divided t h e pain experienced into two groups: (1) W i t h i n 24 h o u r s ; (2) A f t e r 24 hours. T h o s e in o u r series h a d pain in 4 to 8 hours, i.e., in G r o u p I. As t h e foregoing m e d i a did n o t p r o v e satisfactory f u r t h e r research proceeded, a n d in D e c e m b e r , 1956, urografin was first used. 4- U r o g r a f i n . - - T h i s is a m i x t u r e of t h e s o d i u m a n d m e t h y l g l u c a m i n e salts of N : N ' - d i a c e t y l - 3 : 5 d i a m i n o - 2 : 4 : 6 - t r i o d o b e n z o i c acid. The strength used in this series was 76 p e r cent. E x p e r i m e n t a l l y it was f o u n d b y Langecker, H a r w a r t , a n d J u n k m a n , in 1954, to be of relatively low toxicity. Viscosity is n o t high, b u t this has p r o v e d n o disadvantage. H a n d l i n g is easy a n d reflux has n o t b e e n a p r o b l e m . C o m p a r i s o n w i t h endografin has given t h e following figures : - Endografin 7° per cent, 18 Centlpoise Urografin 76 per cent, 7"3 Centlpoise R a d i o g r a p h i c d e n s i t y is satisfactory b o t h for screening a n d for films (Figs. I - 4 ) . It is i n t e r e s t i n g to note t h a t Massell, G r e e n s t o n e , a n d H e r i n g m a n , in 1957, claimed t h a t t h e m i x t u r e of s o d i u m a n d m e t h y l g l u c a m i n e salts gave b e t t e r density t h a n t h e s o d i u m salt alone ( H y p a q u e ) w h e n u s e d for angiography. T h e r e is satisfactory r e t e n t i o n of u n a b s o r b e d m e d i u m in cases of h y d r o s a l p i n x ; deffsity b e i n g p r e s e n t for as long as 3 0 - 9 o m i n . I t is a m e d i u m w h i c h is u s e d for n u m e r o u s examinations, n o t a b l y i n t r a v e n o u s pyelography, p e r i p h e r a l arteriography, a n d cerebral angiography. Its use a n d suitability for h y s t e r o s a l p i n g o g r a p h y has b e e n r e p o r t e d recently b y Reiss a n d G r o s s m a n , 1958 , i n a series of 148 cases.
T h e urografin is i n t r o d u c e d u n d e r screen control, u s i n g a n i n t r a - u t e r i n e syringe w i t h a t t a c h e d softr u b b e r cone. O n l y t h e smallest a m o u n t necessary for diagnosis is used. T h i s m a y be as little as 2 c.c. ; occasionally 1"5 c.c. has b e e n f o u n d sufficient. T h e use of a v o l s e l l u m is avoided as m u c h as possible. I t is used only i n t h e small p r o p o r t i o n of cases w h e r e reflux occurs w i t h o u t it. O n e film is t a k e n i m m e d i a t e l y t u b a l filling is observed, or after an interval if n o filling is seen. T h e c a n n u l a is t h e n w i t h d r a w n a n d r a p i d s c r e e n i n g is p e r f o r m e d to check the rate of e m p t y i n g of t h e uterus. T h e p a t i e n t t h e n gets off t h e table, a n d a second film is t a k e n i o min. later, after t h e p a t i e n t has b e e n a m b u l a n t . I n cases of h y d r o s a l p i n x a t h i r d film is usually t a k e n at 30 min. Sereenlng.--This is kept to a m i n i m u m w i t h t h e d i a p h r a g m s closed d o w n so t h a t first t h e u t e r i n e a n d t h e n t h e u t e r i n e a n d t u b a l areas only are s c r e e n e d ; b o t h t u b e s are visualized simultaneously, as it h a s b e e n f o u n d i n o u r h a n d s to be quicker t h a n s c r e e n i n g first one t u b a l area a n d t h e n t h e other. T h i s latter m e t h o d was suggested b y B a r n e t t and Bewley ( B a r n e t t a n d Bewley, 1955; B a r n e t t , i955). S c r e e n i n g t i m e has b e e n f o u n d to be v e r y m u c h d e p e n d e n t o n co-operation b e t w e e n t h e gyn~ecologist a n d radiologist. A n e n d e a v o u r is m a d e n o t to exceed i rain. p e r case. S t o p - w a t c h trials have s h o w n t h a t large variations can o c c u r a n d t h a t t h e s h o r t e s t times are o b t a i n e d w h e n t h e same gyn~ecologist a n d radiologist work t o g e t h e r routinely. U n d e r t h e s e c o n d i t i o n s screening times of 3 0 - 5 0 sec. have b e e n consistently recorded. T h e X - r a y factors used for screening were 85 kV. a n d 2 ma. R a d l o l o g y . - - T h e two films were t a k e n u s i n g t h e u n d e r - c o u c h tube. X - r a y factors used were 85-9o kV. a n d 3 ° M a . S . T h e focus-table t o p distance was 54"6 cm., a n d 2 ram. of a l u m i n i u m filtration was used.
with a collection of opaque medium.
TECHNIQUE T e c h n i q u e has b e e n p l a n n e d to r e d u c e radiation to a m i n i m u m . Ansesthesia or p r e m e d i c a t i o n has n o t
medium m a right hydrosalpinx.
IIO
JOURNAL
OF
THE
FACULTY
OF
RADIOLOGISTS
I m a g e intensification w h i c h is shortly to be used will reduce the r a d i a t i o n dose to the ovaries d u r i n g screening. It is n o t e d t h a t Reiss a n d G r o s s m a n (1958) d i d n o t screen t h e i r cases; it is, however, t h o u g h t b y us to b e a useful p a r t of the examination.
incapacitating. W h e n it did occur it was w i t h i n 4 hours. (All p a t i e n t s were seen, w i t h i n a few days of the examination, b y .the gyn~ecologist, a n d specifically q u e s t i o n e d o n t h e o c c u r r e n c e or otherwise of pain.)
RESULTS
T h e successful use of urografin in h y s t e r o g r a p h y is r e p o r t e d a n d t h e t e c h n i q u e discussed. W h i l s t it is n o t claimed t h a t u r o g r a f i n is the ideal c o n t r a s t m e d i u m , it has in o u r experience p r o v e d to b e t h e m o s t satisfactory m e d i u m yet used.
U p to N o v e m b e r , 1958 , 181 h y s t e r o g r a m s have b e e n p e r f o r m e d on 167 patients, u s i n g urografin as contrast m e d i u m . T h e e x a m i n a t i o n s have b e e n done for a variety of reasons, infertility b e i n g the m o s t usual. A n analysis is given in Table I a n d t h e results o b t a i n e d are given in Table I_7.
Table/.--REASON FOR EXAMINATION Infertility Repeated miscarriages and/or suspected uterine malformation Check of sterilization *Local:zing of a G r a f e n b e r g ring
15 I II 4 I
TOTAL PATIENTS * F o u n d to be extra-uterine.
Acknowledgements.--My m o s t grateful t h a n k s are due to Dr. M. Rose, of t h e O b s t e t r i c a n d G y n m c o logical D e p a r t m e n t , a n d to Dr. E. T o p h a m , S e n i o r Radiologist, X - r a y D e p a r t m e n t , E d g w a r e G e n e r a l Hospital, for p e r m i s s i o n to p u b l i s h this report. REFERENCES
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Fac. Radiol., 7, 115. - - - - and BEWLEY, D. K. (I955), Ibid., 6, 186. BLIGH, A. S. (I955) , Brit. J. Radiol., 28, 30. CZYZEWSKI, W. J. J. (I956), ]bid., 29, 679. DAVIES, D. K. L., FISHER, H. J., and ROCKER, I. (I957), Brit. med. ff., 2, 859. G R A N T , I . W . B., CALLAM, W . , and DAVIDSON, J . K . (I957) , J. Fac. Radiol., 8, 4io. LANGECKER, H., HARWART, A., and JUNKMAN, K. (I954), Arch. exper. Path. Pharmack., 22, 584. MASSELL, T. B., GREENSTONE, S. M., and HERINGMAN, E. C. (I957), J. Amer. reed. Ass., 22, 584. REISS, H. E., and GROSSMAN, MARIA E. 0958), J. Obstet. Gynec., 65, 782. BARNETT, E . ( i 9 5 5 ) , J .
Table H . - - R E S U L T
OF EXAMINATIONS Unilateral or bilateral tubal spill I4 o N o tubal spill 24 Hydrosalpinx Io Reflux 7 TOTAL EXAMINATIONS
SUMMARY
ISI
Side-effects d u r i n g t h e e x a m i n a t i o n have n o t b e e n n o t e d in any of t h e cases. I n 2 e x a m i n a t i o n s v e n o u s intravasation was seen. T h e r e were n o i m m e d i a t e or late complications. P a i n has o c c u r r e d only very occasionally. It was m i n i m a l in degree a n d n e v e r