PERFECTION OF
OF
THE
TECHNIQUE
AND
APPARATUS
HYSTEROSALPINGOGRAPHY
N. M. Pobedinskii, and M. V. Gudkova
A. I. Volobuev,
UDC 618.14+ 618.12]-0.73.755.4
In r e c e n t y e a r s h y s t e r o s a l p i n g o g r a p h y h a s found i n c r e a s i n g u s e in the gynecological clinic. The v i sualization of the method and the possibility of diagnosing pathological changes of the oviducts and u t e r u s by m e a n s of it b r o a d e n the indications f o r its u s e . The d e v e l o p m e n t of h y s t e r o s a l p i n g o g r a p h y p r o c e e d e d along t h r e e m a i n directions: 1) s e a r c h for i m p r o v e d c o n t r a s t m e d i a , 2) i m p r o v e m e n t of the technique, and 3) c r e a t i o n of i m p r o v e d a p p a r a t u s . P r i o r to 1924 such p r e p a r a t i o n s as Lugd's solution, bismuth paste, and sodium b r o m i d e w e r e u s e d for h y s t e r o s a l p i n o g o g r a p h y [1-4]; a f t e r 1924 iodized oils b e c a m e popular [5-8]. However, despite the good r e s u l t s (clear c o n t r a s t i n g r o e n t g e n o g r a m s ) a d v e r s e f e a t u r e s in using t h e s e c o n t r a s t m e d i a w e r e soon found: e n t r y into the blood v e s s e l s and subsequent p u l m o n a r y e m b o l i s m , slow r e s o r p t i o n by t i s s u e s , and p o s s i bility of the o c c u r r e n c e of an i n f l a m a t e r y p r o c e s s . The new stage in the development of h y s t e r o s a l p i n g o g r a p h y began a f t e r 1933 in connection with the u s e of w a t e r - s o l u b l e p r e p a r a t i o n s as c o n t r a s t m e d i a [9-12]. Good d e g r e e of contrast, rapid absorbability, and ability to be e x c r e t e d f r o m the body readily, a b s e n c e of i r r i t a t i o n of t i s s u e s , low v i s c o s i t y , safety - all these advantageously d l s t i n g u i s h e d w a t e r - s o l u b l e p r e p a r a t i o n s . The technique of h y s t e r o s a l p i n g o g r a p h y also changed along with i m p r o v e m e n t of the c o n t r a s t m e d i a . Thus, w h e r e a s both the open and closed method Of h y s t e r o s a l p i n g o g r a p h y w e r e used e a r l i e r , nowouly the closed method is used, in which the ostium u t e r i is closed tightly, as a r e s u l t of which the c o n t r a s t m e d i u m does not flow out into the vagina. This is e s pecially i m p o r t a n t when using w a t e r - s o l u b l e c o n t r a s t m e d i a . In the roentgenological d e p a r t m e n t of the All-Union Scientific R e s e a r c h - I n s t i t u t e of O b s t e t r i c s and Gynecology (VNIIAG), where between 800 and 1000 h y s t e r o s a l p i n g o g r a p h i e s a r e p e r f o r m e d y e a r l y , its t e c h nique has been i m p r o v e d continuously o v e r the p a s t 10 y e a r s . A cannula of the Shul'ts type, modified by d o c t o r s of the d e p a r t m e n t , w a s u s e d as the i n s t r u m e n t for hysterosalpingographyo A technique of h y s t e r o salpingography was developed which in the m a j o r i t y of c a s e s p e r m i t t e d establishing the c o r r e c t diagnosis. This technique c o n s i s t s of the following. H y s t e r o s a l p i n g o g r a p h y is p e r f o r m e d on the x - r a y a p p a r a t u s for u r o l o g i c a l investigations (universal r o e n t g e n o - u r o l o g i c a l table, model 2M70). The patient lies down on the edge of the table in a position for vaginal o p e r a t i o n s . A f t e r t r e a t i n g the e x t e r n a l genitalia with a solution of c h l o r a m i n e a b i m a n u a l gynecological examination is m a d e . Spoon-shaped specula a r e i n s e r t e d into the vagina. I t s walls a r e t r e a t e d with a cotton ball, at f i r s t dry, and then soaked with alcohol. The labium anterius ostii u t e r i i is g r a s p e d with bullet f o r c e p s . In so doing they a r e applied on the outer s u r f a c e of the labium a n t e r i u s ostii u t e r i without puncturing the i n t e r o c e p t e r - r i c h m u c o s a of the c e r v i c a l canal, b e t t e r tangentially, i.e., in a t r a n s v e r s e direction. It should be noted that the u s e of two or t h r e e bullet f o r c e p s for closing the c e r v i c a l canal with the use of the nozzle f r o m a Braun syringe c a u s e s s p a s m of the tubouterine s p h i n c t e r s in a c o n s i d e r a b l e
All-Union S c i e n t i f i c - R e s e a r c h Institute of O b s t e t r i c s and Gynecology, M i n i s t r y of Health of the USSR, Moscow. T r a n s l a t e d f r o m Meditsinskaya Tekhnika, No. 3, pp. 49-51, M a y - J u n e , 1974. Original a r ticle submitted M a r c h 12, 1973 . . . . .
© 1975 Consultants Bureau, a division of Plenum Publishing Corporation, 227 West 17th Street, New York, N. Y. 10011. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording or otherwise, without written permission of the publisher. A copy of this article is available from the publisher for $15.00.
174
Fig. 1
Fig. 2
Fig. I. Modified Shul'ts cannula used for hysterosalpingography. Conical cannula; 2) ~rider,'. Fig. 2. Remote-control
I)
attachment for introducing the contrast medium
into the uterine cavity. p e r c e n t a g e of investigations. The instrument, which is a slight modification of the Shul'ts cannula (Fig. 1), is filled with the c o n t r a s t m e d i u m heated to body t e m p e r a t u r e . After treating the ostium u t e r i with a l cohol (treatment of the c e r v i c a l canal and p r e l i m i n a r y probing of the u t e r u s a r e not p e r f o r m e d in o r d e r to avoid t r a u m a of its mucosa) the tip of the instrument, equipped with a r u b b e r conical cannula (Fig. 1), which c l o s e s the o s t i u m u t e r i well, is i n s e r t e d into the c e r v i c a l canal. The b r a n c h e s of the bullet f o r c e p s a r e mounted at an appropriate distance on a " r i d e r " which is fastened on the i n s t r u m e n t by a s c r e w (Fig. 1, 2). After checking the tightness of closing the ostium u t e r i by introducing a small amount of c o n t r a s t m e d i u m into the uterine cavity, the vaginal specula are removed, and the patient is placed on the table so that the c e n t r a l x r a y p a s s e s through the u p p e r edge of the s y m p h y s i s pubis. When using w a t e r - s o l u b l e c o n t r a s t m e d i a the photographs m u s t be taken at the m o m e n t of introducing the c o n t r a s t m e d i u m into the uterine cavity. T h e r e f o r e , to p r o t e c t the d o c t o r against x radiation, a m o v able lead shield p r o t e c t i n g additionally the trunk and legs of the d o c t o r is used along with a special apron attached on the x - r a y apparatus for u r o l o g i c a l investigations. While taking the x - r a y photographs the u t e r u s , by pulling the bullet f o r c e p s t o w a r d oneself, upward or downward, is placed in a surface position so as to attain the c o r r e c t image of the uterine cavity. F o r taking the f i r s t photograph 2-2.5 ml of cont r a s t m e d i u m is introduced in o r d e r to obtain a r e l i e f image of the uterine cavity. A f t e r p r o c e s s i n g and examining the f i r s t photograph an additional 3-4 ml of c o n t r a s t m e d i u m is introduced, and the second photograph is taken. In so doing a tighter filling of the uterine cavity is obtained and the c o n t r a s t medium usually e n t e r s the tubes and abdominal cavity. After examining the second photograph a third is taken if n e c e s s a r y . Usually f r o m 10 to 20 ml of c o n t r a s t medium a r e needed for the entire p r o c e d u r e . It should be noted that, depending on the purpose of the investigation and conjectural diagnosis, h y s t e r o s a l p i n g o g r a p h y should be done on different days of the m e n s t r u a l cycle. Thus, for determining the patency of the oviducts it is b e t t e r to p e r f o r m h y s t e r o s a l p i n g o g r a p h y in the second phase of the m e n s t r u a l cycle, w h e r e a s in the case of suspecting adenomyosis, this p r o c e d u r e should be done on the 7-8th day of the m e n s t r u a l cycle when the shed functional l a y e r of the uterine m u c o s a does not i n t e r f e r with penetration of the c o n t r a s t m e d i u m into the endometrioid p a s s a g e s , In the case of suspecting submucosal m y o m a of the u t e r u s , h y s t e r o s a l p i n g o g r a p h y can be p e r f o r m e d in any phase of the m e n s t r u a l c y c l e . H y s t e r o s a l p i n g o g r a p h y is p r e s e n t l y c a r r i e d out in the roentgenological department of VNIIAG on the TiR-10001 x - r a y apparatus with an i m a g e - c o n v e r t e r tube. So that the doctor can be outside the zone of action of the x r a y s , c o - w o r k e r s of the department p r o posed a device (Fig. 2) permitting introduction of the c o n t r a s t medium into the uterine cavity f r o m a d i s tance (N. M. Pobedinskii, A. I. Volobuev, M. I. Legat). This is done in the following way. The syringe t o g e t h e r with the cannula for h y s t e r o s a l p i n g o g r a p h y is fastened on a stand with a heavy metal base. The b r a n c h e s of the bullet f o r c e p s applied on the labium anterius ostii uteri and fixed by m e a n s of the " r i d e r " are fastened on the stand by a metal hook, which m a k e s possible, by moving the attachment away f r o m the patient, bringing the u t e r u s into the n e c e s s a r y position relative to the table. The plunger of the syringe is actuated by m e a n s of a flexible cable about 2 m long fastened on the stand, which allows the doctor to move away f r o m the x - r a y apparatus, behind the shield.
175
F o r r e m o t e control of the x - r a y apparatus itself (moving the c a s s e t t e with the tube up or down, etc.), an extended r e m o t e control panel was c r e a t e d which is placed at a distance of about 2 m f r o m the patient. After turning on the x - r a y apparatus and placing its tube in the n e c e s s a r y position (which is checked on a television screen), the plunger of the syringe is actuated by the flexible cable, and the contrast medium gradually p e n e t r a t e s the uterine cavity. On a television s c r e e n one can see the gradual filling of the uterine cavity, oviducts, and movement of the c o n t r a s t medium into the abdominal cavity. With this technique the doctor o b s e r v e s the entire p r o c e s s of hysterosalpingography f r o m s t a r t to end, detects and eliminates a r tefacts of the image, and follows the c h a r a c t e r of filling of the uterine cavity and oviducts. A s e r i e s of photographs can be taken during the investigation for documentary confirmation of the roentgenological picture. P e r f e c t i o n of hysterosalpingography c a r r i e d out in the department has improved the diagnosis of a number of d i s e a s e s (submucosal m y o m a of the uterus, pathological changes of the uterine mucosa, adenomyosis, etc.). The percent of patency of oviducts has i n c r e a s e d from 50 to 72. Irradiation of the medical personnel has d e c r e a s e d considerably. LITERATURE 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
176
CITED
M. Nemenov, Vestn. Renigenol., 3, No. 1, 25 (1924). Dartiques et Dimier, P a r i s . Chit., 8, 400 (1916). W . H . C a r r y , Am. J. Obstet. Dis. Women, 6_9, 462 (1914). W . T . Kennedy, Am. J. Obstet. Gynec., 6, 12 (1923). C. Henser, Lancet, 2, 1111 (1925). R. Gregoire, C. Darbois, and C. Becler6, Bull. M~m. Soc. Radiol. Mgd. F r . , 1._33,239 (1925). H. Nahmmacher, Zbl. Gyn~k., Bd 50_, 2238 (1926). J. Jarcho, Surg. Gynec. Obstet., 4__55,129 (1927). T. Neustaedter, D. E. Ehrlich, S. C. Du Bois, et al., Radiology, 21, 568 (1933). P. Titus, R. L. Tafel, R. McClellan, et al., Am. Jo Obstet. Gynec., 3.~3, 164 (1937). F . Z . Blinchevskii, Al~sh. i Gin., No. 4, 18 (1966); T r a n s a c t i o n of the 2nd Congress of Obstetricians and Gynecologists of the RSFSR [in Russian], Moscow (1967), p. 285. P . P . Nikulin, Ak~sh. i Gin., No. 7, 22 (1967).
OF
THE
TECHNIQUE
AND
APPARATUS
HYSTEROSALPINGOGRAPHY
N. M. Pobedinskii, and M. V. Gudkova
A. I. Volobuev,
UDC 618.14+ 618.12]-0.73.755.4
In r e c e n t y e a r s h y s t e r o s a l p i n g o g r a p h y h a s found i n c r e a s i n g u s e in the gynecological clinic. The v i sualization of the method and the possibility of diagnosing pathological changes of the oviducts and u t e r u s by m e a n s of it b r o a d e n the indications f o r its u s e . The d e v e l o p m e n t of h y s t e r o s a l p i n g o g r a p h y p r o c e e d e d along t h r e e m a i n directions: 1) s e a r c h for i m p r o v e d c o n t r a s t m e d i a , 2) i m p r o v e m e n t of the technique, and 3) c r e a t i o n of i m p r o v e d a p p a r a t u s . P r i o r to 1924 such p r e p a r a t i o n s as Lugd's solution, bismuth paste, and sodium b r o m i d e w e r e u s e d for h y s t e r o s a l p i n o g o g r a p h y [1-4]; a f t e r 1924 iodized oils b e c a m e popular [5-8]. However, despite the good r e s u l t s (clear c o n t r a s t i n g r o e n t g e n o g r a m s ) a d v e r s e f e a t u r e s in using t h e s e c o n t r a s t m e d i a w e r e soon found: e n t r y into the blood v e s s e l s and subsequent p u l m o n a r y e m b o l i s m , slow r e s o r p t i o n by t i s s u e s , and p o s s i bility of the o c c u r r e n c e of an i n f l a m a t e r y p r o c e s s . The new stage in the development of h y s t e r o s a l p i n g o g r a p h y began a f t e r 1933 in connection with the u s e of w a t e r - s o l u b l e p r e p a r a t i o n s as c o n t r a s t m e d i a [9-12]. Good d e g r e e of contrast, rapid absorbability, and ability to be e x c r e t e d f r o m the body readily, a b s e n c e of i r r i t a t i o n of t i s s u e s , low v i s c o s i t y , safety - all these advantageously d l s t i n g u i s h e d w a t e r - s o l u b l e p r e p a r a t i o n s . The technique of h y s t e r o s a l p i n g o g r a p h y also changed along with i m p r o v e m e n t of the c o n t r a s t m e d i a . Thus, w h e r e a s both the open and closed method Of h y s t e r o s a l p i n g o g r a p h y w e r e used e a r l i e r , nowouly the closed method is used, in which the ostium u t e r i is closed tightly, as a r e s u l t of which the c o n t r a s t m e d i u m does not flow out into the vagina. This is e s pecially i m p o r t a n t when using w a t e r - s o l u b l e c o n t r a s t m e d i a . In the roentgenological d e p a r t m e n t of the All-Union Scientific R e s e a r c h - I n s t i t u t e of O b s t e t r i c s and Gynecology (VNIIAG), where between 800 and 1000 h y s t e r o s a l p i n g o g r a p h i e s a r e p e r f o r m e d y e a r l y , its t e c h nique has been i m p r o v e d continuously o v e r the p a s t 10 y e a r s . A cannula of the Shul'ts type, modified by d o c t o r s of the d e p a r t m e n t , w a s u s e d as the i n s t r u m e n t for hysterosalpingographyo A technique of h y s t e r o salpingography was developed which in the m a j o r i t y of c a s e s p e r m i t t e d establishing the c o r r e c t diagnosis. This technique c o n s i s t s of the following. H y s t e r o s a l p i n g o g r a p h y is p e r f o r m e d on the x - r a y a p p a r a t u s for u r o l o g i c a l investigations (universal r o e n t g e n o - u r o l o g i c a l table, model 2M70). The patient lies down on the edge of the table in a position for vaginal o p e r a t i o n s . A f t e r t r e a t i n g the e x t e r n a l genitalia with a solution of c h l o r a m i n e a b i m a n u a l gynecological examination is m a d e . Spoon-shaped specula a r e i n s e r t e d into the vagina. I t s walls a r e t r e a t e d with a cotton ball, at f i r s t dry, and then soaked with alcohol. The labium anterius ostii u t e r i i is g r a s p e d with bullet f o r c e p s . In so doing they a r e applied on the outer s u r f a c e of the labium a n t e r i u s ostii u t e r i without puncturing the i n t e r o c e p t e r - r i c h m u c o s a of the c e r v i c a l canal, b e t t e r tangentially, i.e., in a t r a n s v e r s e direction. It should be noted that the u s e of two or t h r e e bullet f o r c e p s for closing the c e r v i c a l canal with the use of the nozzle f r o m a Braun syringe c a u s e s s p a s m of the tubouterine s p h i n c t e r s in a c o n s i d e r a b l e
All-Union S c i e n t i f i c - R e s e a r c h Institute of O b s t e t r i c s and Gynecology, M i n i s t r y of Health of the USSR, Moscow. T r a n s l a t e d f r o m Meditsinskaya Tekhnika, No. 3, pp. 49-51, M a y - J u n e , 1974. Original a r ticle submitted M a r c h 12, 1973 . . . . .
© 1975 Consultants Bureau, a division of Plenum Publishing Corporation, 227 West 17th Street, New York, N. Y. 10011. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording or otherwise, without written permission of the publisher. A copy of this article is available from the publisher for $15.00.
174
Fig. 1
Fig. 2
Fig. I. Modified Shul'ts cannula used for hysterosalpingography. Conical cannula; 2) ~rider,'. Fig. 2. Remote-control
I)
attachment for introducing the contrast medium
into the uterine cavity. p e r c e n t a g e of investigations. The instrument, which is a slight modification of the Shul'ts cannula (Fig. 1), is filled with the c o n t r a s t m e d i u m heated to body t e m p e r a t u r e . After treating the ostium u t e r i with a l cohol (treatment of the c e r v i c a l canal and p r e l i m i n a r y probing of the u t e r u s a r e not p e r f o r m e d in o r d e r to avoid t r a u m a of its mucosa) the tip of the instrument, equipped with a r u b b e r conical cannula (Fig. 1), which c l o s e s the o s t i u m u t e r i well, is i n s e r t e d into the c e r v i c a l canal. The b r a n c h e s of the bullet f o r c e p s a r e mounted at an appropriate distance on a " r i d e r " which is fastened on the i n s t r u m e n t by a s c r e w (Fig. 1, 2). After checking the tightness of closing the ostium u t e r i by introducing a small amount of c o n t r a s t m e d i u m into the uterine cavity, the vaginal specula are removed, and the patient is placed on the table so that the c e n t r a l x r a y p a s s e s through the u p p e r edge of the s y m p h y s i s pubis. When using w a t e r - s o l u b l e c o n t r a s t m e d i a the photographs m u s t be taken at the m o m e n t of introducing the c o n t r a s t m e d i u m into the uterine cavity. T h e r e f o r e , to p r o t e c t the d o c t o r against x radiation, a m o v able lead shield p r o t e c t i n g additionally the trunk and legs of the d o c t o r is used along with a special apron attached on the x - r a y apparatus for u r o l o g i c a l investigations. While taking the x - r a y photographs the u t e r u s , by pulling the bullet f o r c e p s t o w a r d oneself, upward or downward, is placed in a surface position so as to attain the c o r r e c t image of the uterine cavity. F o r taking the f i r s t photograph 2-2.5 ml of cont r a s t m e d i u m is introduced in o r d e r to obtain a r e l i e f image of the uterine cavity. A f t e r p r o c e s s i n g and examining the f i r s t photograph an additional 3-4 ml of c o n t r a s t m e d i u m is introduced, and the second photograph is taken. In so doing a tighter filling of the uterine cavity is obtained and the c o n t r a s t medium usually e n t e r s the tubes and abdominal cavity. After examining the second photograph a third is taken if n e c e s s a r y . Usually f r o m 10 to 20 ml of c o n t r a s t medium a r e needed for the entire p r o c e d u r e . It should be noted that, depending on the purpose of the investigation and conjectural diagnosis, h y s t e r o s a l p i n g o g r a p h y should be done on different days of the m e n s t r u a l cycle. Thus, for determining the patency of the oviducts it is b e t t e r to p e r f o r m h y s t e r o s a l p i n g o g r a p h y in the second phase of the m e n s t r u a l cycle, w h e r e a s in the case of suspecting adenomyosis, this p r o c e d u r e should be done on the 7-8th day of the m e n s t r u a l cycle when the shed functional l a y e r of the uterine m u c o s a does not i n t e r f e r with penetration of the c o n t r a s t m e d i u m into the endometrioid p a s s a g e s , In the case of suspecting submucosal m y o m a of the u t e r u s , h y s t e r o s a l p i n g o g r a p h y can be p e r f o r m e d in any phase of the m e n s t r u a l c y c l e . H y s t e r o s a l p i n g o g r a p h y is p r e s e n t l y c a r r i e d out in the roentgenological department of VNIIAG on the TiR-10001 x - r a y apparatus with an i m a g e - c o n v e r t e r tube. So that the doctor can be outside the zone of action of the x r a y s , c o - w o r k e r s of the department p r o posed a device (Fig. 2) permitting introduction of the c o n t r a s t medium into the uterine cavity f r o m a d i s tance (N. M. Pobedinskii, A. I. Volobuev, M. I. Legat). This is done in the following way. The syringe t o g e t h e r with the cannula for h y s t e r o s a l p i n g o g r a p h y is fastened on a stand with a heavy metal base. The b r a n c h e s of the bullet f o r c e p s applied on the labium anterius ostii uteri and fixed by m e a n s of the " r i d e r " are fastened on the stand by a metal hook, which m a k e s possible, by moving the attachment away f r o m the patient, bringing the u t e r u s into the n e c e s s a r y position relative to the table. The plunger of the syringe is actuated by m e a n s of a flexible cable about 2 m long fastened on the stand, which allows the doctor to move away f r o m the x - r a y apparatus, behind the shield.
175
F o r r e m o t e control of the x - r a y apparatus itself (moving the c a s s e t t e with the tube up or down, etc.), an extended r e m o t e control panel was c r e a t e d which is placed at a distance of about 2 m f r o m the patient. After turning on the x - r a y apparatus and placing its tube in the n e c e s s a r y position (which is checked on a television screen), the plunger of the syringe is actuated by the flexible cable, and the contrast medium gradually p e n e t r a t e s the uterine cavity. On a television s c r e e n one can see the gradual filling of the uterine cavity, oviducts, and movement of the c o n t r a s t medium into the abdominal cavity. With this technique the doctor o b s e r v e s the entire p r o c e s s of hysterosalpingography f r o m s t a r t to end, detects and eliminates a r tefacts of the image, and follows the c h a r a c t e r of filling of the uterine cavity and oviducts. A s e r i e s of photographs can be taken during the investigation for documentary confirmation of the roentgenological picture. P e r f e c t i o n of hysterosalpingography c a r r i e d out in the department has improved the diagnosis of a number of d i s e a s e s (submucosal m y o m a of the uterus, pathological changes of the uterine mucosa, adenomyosis, etc.). The percent of patency of oviducts has i n c r e a s e d from 50 to 72. Irradiation of the medical personnel has d e c r e a s e d considerably. LITERATURE 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
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CITED
M. Nemenov, Vestn. Renigenol., 3, No. 1, 25 (1924). Dartiques et Dimier, P a r i s . Chit., 8, 400 (1916). W . H . C a r r y , Am. J. Obstet. Dis. Women, 6_9, 462 (1914). W . T . Kennedy, Am. J. Obstet. Gynec., 6, 12 (1923). C. Henser, Lancet, 2, 1111 (1925). R. Gregoire, C. Darbois, and C. Becler6, Bull. M~m. Soc. Radiol. Mgd. F r . , 1._33,239 (1925). H. Nahmmacher, Zbl. Gyn~k., Bd 50_, 2238 (1926). J. Jarcho, Surg. Gynec. Obstet., 4__55,129 (1927). T. Neustaedter, D. E. Ehrlich, S. C. Du Bois, et al., Radiology, 21, 568 (1933). P. Titus, R. L. Tafel, R. McClellan, et al., Am. Jo Obstet. Gynec., 3.~3, 164 (1937). F . Z . Blinchevskii, Al~sh. i Gin., No. 4, 18 (1966); T r a n s a c t i o n of the 2nd Congress of Obstetricians and Gynecologists of the RSFSR [in Russian], Moscow (1967), p. 285. P . P . Nikulin, Ak~sh. i Gin., No. 7, 22 (1967).
