The Uses of Lipiodol in Gynaecological Practice

When Rubin, in 1920, published his article on " Non-operative determination of patency of Fallopian tubes in sterility " in the Journal of the American Medical Association, the diagnostic equipment of the gynaecologist received an extremely valuable addition. His method of per-uterine inflation with oxygen and the production of an artificial pneumo-peritoneum was modified and improved step by step, so that in the course of a few years the relatively compact apparatus, as exemplified by the widely used Provis's modification of Currier's apparatus, became almost a standard part of the equipment of a gynaecological operating theatre. And carbon dioxide replaced oxygen or air as the gas used for insufflation since it is more rapidly absorbed from the peritoneal cavity than either of the other two. Shortly after Rubin's original observations various workers turned their attention to the possibility of demonstrating radiologically the patency or otherwise of the Fallopian tubes by means of injection via the uterine cavity of radio-opaque substances. This investigation had in fact been suggested as long ago as I914 by H. Cary (American J. Obst: and Gynaec.) and was performed in 1915 by Rubin. But there was no general adoption of the method-on the contrary it was rapidly abandoned because the substances employed-bismuth paste, argyrol, sodium bromide, etc.-were of uncertain value from the photographic point of view, and, worse, they were occasionally highly toxic. However, in I923 lipiodol* (a preparation containing iodine in poppy-seed oil) was put on the market and in this substance we have something which is radiographically suitable and, at the same time, nearly safe. Since its first application to the pelvic organs by Heuser in 1924 it has been very widely used in the investigation of cases of sterility. Its place in the diagnosis of other gynaecological conditions has not been so clearly established but it has been used to demonstrate cases of sub-mucous fibroids, carcinoma of the uterine body, etc., and some further remarks on this subject will be made later in this article. The method of tubal insufflation was at first a purely diagnostic measure but it was soon realised that it, and the methods evolved from it, possessed features of prognostic significance and of therapeutic value. For example, if tubes resisted the passage of gas until a pressure of, say, I50 mm. Hg. was reached and then permitted a free flow, it was quite reasonable to suppose that some minor obstruction had been overcome and that (providing the husband was fertile) the occurrence of conception in the course of the next few months was a distinct possibility. It is highly probable that in cases of partial obstruction a greater degree of patency may be established by insufflation with gas or with some radio-opaque substance under reasonable pressure. In some cases even of complete obstruction it has almost certainly happened that, following such treatment, tubal patency has been re-established in a few cases by the breakdown of adhesions, the straightening out of a kink or the expulsion of a plug of mucus. It is safe to say that after either method of investigation of a case of sterility the fairly frequent occurrence of a conception rapidly following, is strong presumptive evidence of its value as a therapeutic measure. The Choice between Infection of Gas or Lipiodol. There grew up a kind of rivalry between the two methods of investigating tubal patency-insufflation with carbon dioxide on the one hand and lipiodol injection plus X-rays on the other. It will be convenient here to consider the