Fig. 149.—Hydrosalpinx, showing complete inversion of the fimbriæ.
Fig. 149.—Hydrosalpinx, showing complete inversion of the fimbriæ.
It seems probable that if the woman survive the dangers to which she is exposed from a pyosalpinx, the tumor may in time become converted into a hydrosalpinx. The solid constituents of the fluid become absorbed or deposited upon the cyst-walls, and a clear watery fluid remains. In hydrosalpinx the recesses of the tube are often found to contain cheesy material and cholesterin—remnants of the old purulent accumulation. The tubo-ovarian cyst is formed in this way from a former tubo-ovarian abscess.
Hydrosalpinx.—The fluid in a hydrosalpinx may becolorless, slightly yellow, or brownish or chocolate colored from the presence of blood. As the accumulation increases, the walls of the cyst atrophy and become very thin. The epithelium and the mucous membrane atrophy and in time disappear, until nothing but a thin-walled transparent cyst remains (Fig. 149). The cyst-wall in hydrosalpinx is always thinner and more transparent than that in pyosalpinx. On the inner wall of the cyst delicate ridges corresponding to the plicæ or folds of mucous membrane may be traced. There may often be discovered, at the distal end of the retort-shaped tumor, a slight depression that marks the position of the abdominal ostium, while upon the inner aspect of this depression may be found the remains of the invaginated fimbriæ. The size of the tube in hydrosalpinx varies from that of the little finger to a tumor as large as the fetal head. Large hydrosalpinx tumors are very unusual, because the fluid probably leaks slowly through the thin cyst-wall, and because the secreting surface of the cyst becomes destroyed by pressure. The fluid from a hydrosalpinx is sterile, unirritating to the peritoneum, and is readily absorbed. The cyst may rupture spontaneously or as the result of some slight accident; the fluid will be absorbed by the peritoneum, and only the shrivelled, atrophied sac will remain. In old cases of this kind the Fallopian tube is represented by an impervious cord. Such specimens have often been found in old prostitutes who have survived the dangers of their calling.
Hematosalpinx.—True hematosalpinx, a closed Fallopian tube distended with blood, is a rare condition. Tubal pregnancy is the usual cause of an accumulation of blood in the Fallopian tube, but the term hematosalpinx should not be applied to this condition. True hematosalpinx occurs when, from any cause, hemorrhage takes place into a tube that had previously been closed by inflammatory action. Such an accident may be caused by traumatism or by torsion of the pedicle of a tubal cyst. Slight hemorrhages of this kind occur in pyosalpinx andin hydrosalpinx, and cause the brownish discoloration that is sometimes seen in the contents of these tumors.
The various forms of inflammatory disease of the tubes that have been described under names which designate the gross appearance of the disease are all really but different manifestations of the same primary condition. Gonorrheal or septic infection may produce any of the forms of tubal disease that have been mentioned. Interstitial salpingitis without closure of the ostium, pyosalpinx, hydrosalpinx, hematosalpinx, tubo-ovarian abscess, etc. are not distinct diseases, but are different manifestations of the same disease, representing different stages of progress or different methods of development. Several of these different forms are often found in the same woman. On one side there may be a hydrosalpinx, on the other a pyosalpinx, both caused by a primary chronic gonorrhea; the distal end of one tube may be distended by a clear watery fluid, forming a hydrosalpinx, while the isthmus may be distended with pus, forming a pyosalpinx; a hematosalpinx may be formed on one side, while a tubo-ovarian abscess exists on the other; and so through a great variety of combinations.
Pyosalpinx with active septic contents represents the early stages of tubal disease, or it represents a chronic condition in which reinfection has occurred. Pyosalpinx with sterile pus is like a chronic abscess anywhere else, and represents a chronic form of salpingitis that had been active and purulent in the beginning. Hydrosalpinx represents the disease less violent and septic in the beginning, and slow in progress; or it represents the last stages of an old pyosalpinx; while, finally, hematosalpinx represents a condition of salpingitis in which some accident has befallen the cystic tube and caused hemorrhage into its cavity.
The description given shows the progress, the dangers, and the terminations of salpingitis.
The disease is caused by extension of inflammation from the endometrium. The usual causes of this inflammationare gonorrhea, or infection after a criminal abortion, a labor, or a miscarriage. The gonorrheal salpingitis is usually slow or insidious from the beginning. The symptoms of the disease are often not troublesome until many months after the primary gonorrheal infection. The closure of the tube is slow, and it is sometimes not until the tube becomes distended with pus that the woman experiences much suffering and is placed in imminent danger. There are cases, however, of acute gonorrheal salpingitis in which the disease is virulent and active from the beginning. Infection may traverse the tube, reach the peritoneum through the open ostium, and produce general peritonitis within a few days of the primary attack of gonorrhea. In such cases it is probable that the infection is a mixed one, other organisms accompanying the gonococcus. In other cases the abdominal ostium becomes quickly closed and a gonorrheal tubal abscess is rapidly formed.
The septic variety of salpingitis, as has already been said, is more frequently acute from the beginning. Within ten days or two weeks after a criminal abortion, or after a miscarriage or labor, a large tubal abscess may be formed; or the septic organisms may pass through the tube before the ostium has been closed, and produce within a few days a general fatal peritonitis.
On the other hand, septic salpingitis is often slow, a mild attack of puerperal sepsis being the beginning of years of invalidism, of gradually increasing suffering, until gross tubal disease is produced.
The slowest forms of salpingitis are those that result from chronic endometritis, such as accompanies subinvolution, laceration of the cervix, retro-displacements, or uterine fibroid. Simple catarrhal salpingitis is often found in these diseases; or the abdominal ostium may be closed, and a small hydrosalpinx will be present; or the isthmus may be sufficiently open for drainage, and no tubal distention result. Hydrosalpinx is very often found with uterine fibroids.
Cancer of the cervix or the body of the uterus is a frequent cause of salpingitis, of hydrosalpinx, and of pyosalpinx. The endometrial inflammation secondary to the cancer extends into the tubes.
The progress of salpingitis is beset with danger.
Fig. 150.—Chronic salpingitis with general adhesions of tubes, ovaries, and uterus (Bandl).
Fig. 150.—Chronic salpingitis with general adhesions of tubes, ovaries, and uterus (Bandl).
At any time a pyosalpinx may rupture and a rapid fatal peritonitis result. Unusual effort, vaginal examination, or slight operations upon the cervix or body of the uterus may cause this accident. Not infrequently, such rupture has been produced by even gentle bimanual examination. I have seen a fatal peritonitis occur from rupture of a pyosalpinx during the replacement of a prolapsed uterus.
For this reason the operator should always determine by careful examination the presence or absence of tubal disease in every case before performing any of the minor gynecological operations or manipulations, such as trachelorrhaphy or the replacement of a retroverted uterus.Purulent disease of the tubes is a contraindication to all such procedures, unless an immediate subsequent celiotomy is to be performed. Great care must be exercised in any of the less dangerous forms of salpingitis. In any case of salpingitis, however mild, an acute attack may be excited by reinfection or by rough manipulation.
Fig. 151.—Chronic salpingitis: both Fallopian tubes are closed and adherent.
Fig. 151.—Chronic salpingitis: both Fallopian tubes are closed and adherent.
Rupture into the peritoneum is not the only danger to which the woman is exposed in salpingitis. The gradually formed adhesions in the pelvis impede the motion of the pelvic intestines and may cause intestinal obstruction. Obstruction of the ureters has occurred from pelvic inflammation. The Fallopian tube may discharge its contents through the bladder and produce violent cystitis, or it may discharge through the rectum or intestine, or adhere to the side of the vagina and discharge through this channel; or it may be evacuated through the abdominal parietes. Such fistulous openings rarely, if ever, close spontaneously and permanently. Temporary closure may occur, but the tube will refill and discharge as before.
Fistulæ of this kind persist for many years, becomingseats of tuberculosis or exhausting the woman by the continuous suppuration.
If the patient escape these dangers, the disease may become quiescent. Some of the less dangerous forms of salpingitis are produced, until finally, when the woman has reached middle life, a hydrosalpinx remains, or an adherent, atrophied, cord-like remnant of the tube. Though then freed from the various dangers that had threatened her life, she is not restored to health, but remains a suffering invalid.
Salpingitis may be unilateral or bilateral. It is more likely to be unilateral in the acute cases than in the chronic, for, as the primary focus of the disease exists in the body of the uterus, it will extend in time to the second tube in case only one had at first been involved. If the endometrial disease is cured before the second tube has been attacked, the salpingitis may remain unilateral. Double salpingitis is especially likely to occur in those diseases of the endometrium that are difficult or impossible to eradicate—diseases like chronic gonorrhea, where the infection lurks in the distal ends of the utricular glands and defies our methods of treatment. Operators have repeatedly removed a unilateral pyosalpinx, leaving the second tube apparently perfectly healthy, and yet, after the lapse of a few months, a second operation has been necessary for the relief of a similar pyosalpinx on the other side.
Symptoms of Acute and Chronic Salpingitis.—The symptoms of acute salpingitis are usually obscured by the accompanying symptoms of endometritis, ovarian congestion and inflammation, and localized peritonitis. The woman complains of pelvic pain and tenderness, which are most severe in one or both ovarian regions. There are elevation of temperature and rapid pulse. The knees are often drawn up as in peritonitis.
Bimanual examination reveals marked tenderness upon pressure in the vaginal fornices. There is an indistinct sense of fulness in the region of the tubes. If the pelvicperitoneum and cellular tissue are involved, the whole vaginal vault will feel full and resistant. The tissues lying to the sides and behind the uterus are thickened and resistant. If the woman is thin and there is not much surrounding inflammation, it is sometimes possible to palpate the enlarged tender tube between the vaginal finger and the abdominal hand. Usually, however, the tenderness is too great to permit this. The tube, from its increase in weight, may fall below its normal level, and may be felt lying behind the uterus in Douglas’s pouch.
Usually, in cases of acute salpingitis, the examiner is obliged to content himself with the determination of an indistinct fulness and marked tenderness in the region of the Fallopian tubes.
Before the true pathology of salpingitis was known these cases were described as pelvic peritonitis or pelvic cellulitis. It was supposed that the inflammation involved the peritoneum of the pelvis or the cellular tissue of the broad ligaments. It is true that this is often the case, and that inflammation of these structures accompanies the salpingitis, but it is the tubal inflammation which is the primary disease.
The most pronounced symptom of chronic salpingitis ispain. The pain is referred to one or to both ovarian regions as the disease is unilateral or bilateral. It is due not only to the salpingitis, but to the accompanying ovaritis. The pain is continuous. It is relieved by the recumbent posture, and is increased whenever the woman is upon her feet or is performing any work. The pain is increased by a jolt or sudden movement, by defecation, often by urination and by coitus. The pain during coitus, from direct pressure, is often so great that marital relations are abolished. I have seen a woman with salpingitis who was obliged to take a dose of morphine before every act of defecation. The pain from the jolting of a carriage often renders riding impossible.
The pain is dull and aching in character or sharp andlancinating. It may extend down the anterior aspect of the thighs.
The pain is very much worse at each menstrual period. All the genital structures become congested and swollen at this time, and such phenomena, occurring in the adherent inflamed tubes and ovaries, often cause unbearable pain. The dysmenorrhea in salpingitis is usually very characteristic. It begins several days—sometimes a week—before the bleeding appears. It starts in one or both ovarian regions, and radiates thence throughout the pelvis and down the thighs. It will be remembered that the dysmenorrhea of anteflexion begins only a few hours before the bleeding—that the pain is usually situated in the center of the lower abdomen, in the region of the uterus, is expulsive in character, and is relieved when the bleeding has become well established.
The dysmenorrhea of salpingitis usually lasts throughout the whole of the period.
The pain of salpingitis persists throughout the whole course of the disease. It is common to all forms of salpingitis, and seems to bear no relation to the gross character of the lesions of the tubes. The pain and the dysmenorrhea are often as marked in a case of salpingitis without cystic distention as in a case of large pyosalpinx.
The pain persists after the dangerous stages of the disease have been passed. Relief begins only with the cessation of menstruation, when general atrophy takes place in the genital organs.
The pain of salpingitis is often obvious from the expression and the posture of the woman. She walks with the body slightly flexed forward; she sits down gently upon a chair; she protects herself, by support with the hand, from the jolting of a carriage or a car.
The woman frequently suffers with marked exacerbations of the pain, which occur independently of the menstrual periods, and are caused by leakage from the tube and the resulting local peritonitis. The woman often describes such attacks as attacks of “inflammation of thebowels.” They occur usually during the early stages of the disease. Each attack, if survived, results in a more perfect closure of the ostium abdominale, and diminishes the risk of subsequent attacks. At these times all the symptoms of local peritonitis are present: elevated temperature, rapid pulse, local or general distention, and tenderness. In any case of pyosalpinx or of old chronic salpingitis close questioning of the patient will elicit a history of this kind.
Acute attacks of pain, fever, and other disturbance also occur in cases of chronic salpingitis from acute reinfection of the diseased tube. The disease may have been quiescent for a long time, and yet active reinfection may take place by way of the uterine cavity or by the passage of the colon bacillus through an adherent intestinal wall; or infection may occur through an adherent bladder.
Salpingitis is usually accompanied by menorrhagia. It is impossible to determine how much of this is to be attributed to the tubal disease. There is always an accompanying endometritis which is sufficient to account for it.
Sterility is the rule in cases of salpingitis. The disease of the mucous membrane and the destruction of the ciliæ render the passage of the ovum into the uterus difficult. For this reason tubal pregnancy may occur in salpingitis, impregnation and attachment of the ovum taking place within the tube. Inflammation of the ovary, which prevents the rupture of the ripened ovarian follicles, is another cause of the sterility. When the abdominal ostia are closed absolute sterility is present.
In chronic salpingitis the condition of the Fallopian tubes is revealed by bimanual examination. The tube usually falls below its normal level, and may be felt by the vaginal finger lying beside the uterus, or behind it, in Douglas’s pouch. By careful palpation the connection of the tubal tumor with the uterus may be traced. Bimanual examination is most satisfactory in the quiescentstages of the disease. During an exacerbation or during one of the acute attacks of inflammation the tenderness prohibits thorough palpation, and the surrounding inflammatory infiltration masks the condition of the tube. The tube may be felt as a hard cord, or as a cystic tumor with the ovary lying in its concavity, or as a tortuous, sausage-shaped mass.
In old chronic cases the tube and ovary may be felt as a hard, knot-like mass adherent to the side of the uterus or coiled about the cornu (Fig. 151).
In nearly every case the isthmus is rendered hard and cord-like by inflammatory infiltration. This indurated condition of the isthmus is a feature of tubal disease that is usually readily determined, and it is of decided diagnostic value. The connection, by such a cord, of the mass felt in the pelvis with the uterine cornu is the most valuable proof that the tumor is tubal in character.
Diagnosis.—The diagnosis of chronic disease of the Fallopian tubes must be made from a study of the history, the symptoms, and by physical examination.
The history is always of value. Careful questioning will usually show that the ovarian pain dates from a criminal abortion, from an attack of fever after a miscarriage or labor, or from a suspicious coitus. Women who have been infected with chronic gonorrhea by their husbands attribute the origin of the disease to their marriage. The woman will often say that for some days after marriage she suffered with irritation and burning of the external genitals, with dysuria, perhaps with a slight vaginal discharge, and that after this, very gradually, the ovarian pain developed. She may have had one child or a miscarriage, but with this exception is usually sterile.
The history of attacks of local peritonitis, confining the women to bed for several days or weeks, can also usually be obtained.
The character and the situation of the pain and the character of the dysmenorrhea usually point strongly tosalpingitis. The physical examination is not by any means always satisfactory. The small flaccid tubal tumors are often difficult to palpate, especially in fat women, and the gross forms of the disease may be obscured by surrounding adhesions and inflammation. The examination, however, when taken in connection with the history and the symptoms, will usually enable one to make the diagnosis. Inflammatory tumors in the female pelvis are very generally tubal in origin.
It is difficult to estimate the mortality of salpingitis. It is certainly a frequent cause of death—not only immediately, by some of the acute accidents that may occur, but as a result of gradual exhaustion from prolonged suppuration. Acute salpingitis, and the purulent forms of the disease, should always be viewed with anxiety. As appendicitis is the usual cause of peritonitis in man, so is salpingitis the usual cause of this disease in the woman. In every case of peritonitis in a woman, therefore, careful examination of the pelvic organs should be made.
Salpingitis is an exceedingly common disease. It occurs in all classes of society, but most frequently in the lower walks of life. Salpingitis is the rule in prostitutes, and in them is caused by gonorrhea or by septic infection at criminal abortion.
Treatment.—The treatment of acute salpingitis in its early stage should be expectant: absolute rest in the recumbent position, vaginal douches of a gallon of hot sterile water (100°-110° F.) two or three times a day, small doses of saline purgatives (Rochelle salts, ʒss-ʒj every one or two hours) until mild purgation is produced, should be prescribed, and should be continued as required. Relief of pain is afforded by hot fomentations over the lower abdomen. It is best to administer no opium, as it is very important to watch these cases closely, and the symptoms that demand operation might be masked by the administration of an anodyne. Examinations should be made with great care and gentleness, and no oftener than is necessary to determine the progress ofthe disease. If the patient is progressing satisfactorily, repeated examinations are contraindicated.
A chill followed by a rapid high elevation of temperature (105°-106° F.) is often caused by even gentle manipulation of the upper organs of generation in cases of acute inflammation.
The case must be watched carefully and continuously. In the gonorrheal and septic forms of the disease there is great danger of extension to the peritoneum, or of the formation of a tubal or other form of pelvic abscess that will imperil the life of the woman.
As a general rule, it may be said that, unless there are well-marked symptoms of extensive pelvic peritonitis, or unless a distinct tumor can be felt in the pelvis, operation is not indicated. As resolution undoubtedly takes place even after severe acute attacks of salpingitis, it is right to treat the woman with this end in view rather than to resort to an immediate mutilating operation.
If, under the expectant plan of treatment, the patient does not improve; if the area of pelvic tenderness increases; if the local tympany (which may at first be present only on one or both sides of the pelvis, and which indicates merely local peritoneal irritation or inflammation) extends upward; if the temperature and pulse-rate increase; if constipation appears; if, in fact, indications of extension of the peritonitis are present,—celiotomy should be immediately performed. The diseased tube or tubes should be removed, and, if necessary, the abdomen should be drained.
Fatal peritonitis sometimes results within three or four days after the onset of acute salpingitis. As soon, therefore, as the physician realizes the imminence of this complication in any case, he should not delay in removing the source of infection.
The other acute termination of salpingitis, the formation of an abscess in the pelvis, likewise demands operative interference. This condition is readily recognized. The woman has one or more chills. The temperaturebecomes more elevated and the pulse more rapid. The pelvic tenderness and pain may become more distinctly localized to one or both ovarian regions. Defecation and urination increase the pain. Bimanual examination reveals an exceedingly tender mass, either indurated or perhaps soft and fluctuating, lying to either side of, or behind the uterus. The character, upon palpation, of the mass depends upon the nature and extent of the peritoneal adhesions that surround it. The diagnosis of a pelvic abscess resulting from acute salpingitis is usually easy.
There is some difference of opinion among operators in regard to the best treatment for this condition. Some advise evacuation of the abscess by way of the vagina; others advise celiotomy, with removal of the abscess and the Fallopian tube that caused it, followed, if necessary, by abdominal or vaginal drainage. I prefer the latter method of treatment, for reasons that will appear under the consideration of the technique of operation.
Treatment of Chronic Salpingitis.—Cases of simple chronic catarrhal salpingitis undoubtedly recover after the cure of the endometrial disease of which the salpingitis forms a part. The tube may be restored perfectly to its normal condition; or there may remain an atrophic condition of the mucous membrane; or the fimbriæ may be left somewhat distorted, crumpled, or slightly drawn within the tube; or there may be a few fine peritoneal adhesions, like cobwebs, between the distal end of the tube, the broad ligament, and the ovary. Such slight lesions may cause no trouble beyond interfering a little with the fecundity of the woman.
When, however, the adhesions are more extensive, treatment for their relief may be demanded, even though all inflammatory action has disappeared from the body of the uterus and the tubes. Treatment in such cases is demanded, not to cure the salpingitis or on account of any danger that threatens the woman’s life, but to relieve the pain caused by the results of the inflammation.
It may be necessary to perform celiotomy in order to free or break up adhesions that bind down the ovary in an abnormal position, or to liberate an adherent intestine, or to replace a uterus that has been displaced by the traction of adhesions.
The degree of suffering experienced by the woman is the guide in advising such operative interference.
Pelvic massage has been used for the relief of pelvic adhesions of this kind, the uterus, tubes, and ovaries being manipulated between the fingers in the vagina and a hand upon the abdomen. The results of this treatment have not been encouraging.
In discussing the treatment of chronic salpingitis the cases may be divided into two classes: those in which palliative treatment may be followed, and those in which operation is demanded.
There are a great number of cases of chronic salpingitis in which there is no gross disease of the tubes, and in which operation upon the tubes is not immediately indicated. It is proper in such cases to try milder palliative treatment first.
Salpingitis is always preceded, and usually accompanied, by inflammation of the endometrium, and in every chronic case attention should first be directed to the cure of the endometritis.
If there is no tubal and ovarian displacement—that is, if the ovary is not prolapsed; if the uterus has not been retroverted; if there are no extensive tubal adhesions; and if there is no gross disease of the tube, such as pyosalpinx, hydrosalpinx, hematosalpinx, a thorough curetting of the uterus, or, if necessary, a trachelorrhaphy or an amputation of the cervix, will often relieve the woman of her suffering, and it may not be necessary to operate for the damaged tubes.
In all such cases, however, the operator must be very careful to exclude active or purulent tubal disease. If he overlooks a pyosalpinx, the curettage or the trachelorrhaphy may be followed by an active peritoneal inflammation that will destroy the woman.
If there is ovarian or uterine displacement, we cannot expect relief until these conditions have been treated, and such treatment usually requires celiotomy.
The pain and dysmenorrhea of chronic tubal disease may be relieved by rest in the recumbent position during the menstrual period; by the administration of saline laxatives (the pain is always increased by constipation); by vaginal douches of large quantities of hot water (one gallon at 110° F.) administered two or three times a day in the recumbent posture; and by applications of Churchill’s tincture of iodine to the vaginal vault, and the use of the glycerin tampon. The directions for this treatment have been given under the preparatory treatment of laceration of the cervix.
Such treatment is only palliative: it relieves the pain, but it will not cure well-established chronic salpingitis.
In many cases the woman experiences little, if any, relief from this treatment. In other cases, though the pain may be very much relieved while she is taking treatment, yet it returns as soon as the treatment is stopped, and she becomes unwilling to lead the life of an invalid under constant medical care, with but little prospect of relief until the menopause is reached. It is then necessary to consider operation.
The second class of cases referred to—those in which immediate operation is demanded, and in which it is dangerous to delay and useless to try the palliative treatment—includes a great variety. Such cases are—the gross forms of tubal disease, hydrosalpinx, hematosalpinx, and pyosalpinx; salpingitis with prolapsed and adherent tube and ovary; salpingitis with retrodisplacement of the uterus; all the milder forms of salpingitis which have resisted palliative treatment.
The operative treatment of salpingitis usually demands celiotomy. Some operators, however, prefer to reach the uterine appendages by way of the vagina.
The details of the operative technique of salpingo-oöphorectomy will be given in a subsequent chapter. Asa rule, the operation of celiotomy for salpingitis should always be immediately preceded by thorough curetting of the uterus and, if necessary, by trachelorrhaphy or an amputation of the cervix.
After the abdomen has been opened the operation consists in freeing adhesions, rendering patulous the abdominal ostium of the tube, replacing the uterus, and, if necessary, removing the tube and ovary on one or on both sides.
Removal of the tubes and ovaries—salpingo-oöphorectomy—is usually necessary. In pyosalpinx this operation should always be performed. If the woman is young and is very anxious to have children, every attempt should be made to save, at any rate, one tube and ovary. Remarkable cases of conception have occurred after conservative operations upon badly diseased tubes.
The adhesions about the abdominal ostium may be broken and the imprisoned fimbriæ freed; or if the ostium is firmly closed, an incision may be made in the wall of the tube, the peritoneum stitched to the mucous coat, and a new ostium produced. In one case conception followed such an operation in which the ovary was sutured in the artificial opening made in the tube. Conception has occurred after both tubes had been amputated at the uterine cornua.
In all such conservative operations, however, the woman should be told of the probability of failure and the probable necessity for a subsequent radical operation. The successful cases show the possibilities of surgery, but, unfortunately, they are exceptional. Sterility usually continues, the pain is usually unrelieved, and a second radical operation becomes necessary.
Such conservative operations upon badly diseased tubes should be performed, therefore, only when the woman is young and anxious for children. Whenever the abdominal ostium is closed and the ovary is adherent, it is safest to perform a complete salpingo-oöphorectomy. This is always indicated when the woman is near themenopause or when immediate certain relief is demanded from prolonged suffering.
In some cases the question arises as to whether both tubes should be removed when only one is grossly diseased. In the early stages of chronic pyosalpinx it often happens that but one tube is found diseased, while the other is apparently perfectly healthy or is only slightly adherent. Experience has shown that in a great many cases of tubal disease in which only one tube was removed, the second tube has become similarly affected, often within a short time, and a second operation has been required. This disaster is not likely to occur if the endometrial disease is eradicated by thorough curetting at the time of the first operation. But in some forms of salpingitis, as the gonorrheal, the infection is so deeply seated in the distal ends of the utricular glands that the most vigorous curetting fails to remove it, and the second tube will become infected from the original focus in the uterus.
So common is such occurrence that many women, profiting by the experience of their friends, request the operator to remove both tubes, even though he finds but one diseased. The advice already given in regard to conservative operation applies here also. It is safest in all forms of pyosalpinx to remove both appendages. In the less serious forms of salpingitis—hydrosalpinx and adherent tubes without cystic distention—there is less danger of recurrence, and the unilateral operation may be more safely performed. The importance of thorough treatment of the endometritis at the same time is emphasized by these considerations.
In many cases in which double salpingo-oöphorectomy is performed it is often advisable to remove the uterus at the same time. The uterus may be amputated at any convenient point of the cervix, or it may be completely removed at the vaginal junction. This operation ensures more certain and speedy relief from suffering, and is attended by but little, if any, greater mortality than thesimple salpingo-oöphorectomy. The uterus without the tubes and ovaries is a useless structure. The operation is advisable if the uterus is retroverted and adherent, when the uterus is large and subinvoluted, when the disease of the endometrium is severe and is likely to persist—in any case, in fact, in which the physician fears that the uterus may be a subsequent source of trouble.
Pus in the female pelvis, to which condition the vague term of pelvic abscess has been applied, is usually the result of salpingitis producing a pyosalpinx, of ovarian abscess, or of suppuration of an ovarian cyst, very often a dermoid. The disease may also occur from infection of a broad-ligament hematoma or from a pelvic hematocele caused by a ruptured tubal pregnancy.
Following these conditions the cellular tissue of the pelvis may become affected, so that the purulent accumulation may make its way between the layers of the broad ligament or in some other part of the pelvis.
Before the days of modern abdominal surgery these accumulations of pus were evacuated through the vagina, the rectum, or the abdominal wall, according to the direction in which the abscess seemed to point or in which it seemed to be most accessible. The sinuses thus formed often persisted for years or during the remaining life of the woman. There were many theories in regard to the origin of the suppuration, it being impossible to determine its true nature without opening the abdomen. Now we know that the great majority of such pelvic abscesses originated in septic infection of the Fallopian tubes, and that infection of the pelvic cellular tissue was secondary.
There are, however, rare cases in which the suppuration occurs primarily in the cellular tissue of the pelvis, without any involvement whatever of the tubes or ovaries. Such an accumulation of pus is usually found in the cellular tissue of the broad ligaments; it sometimesoccurs in the utero-vesical tissue, and rarely in the tissue back of the cervical neck.
The cause of such suppuration is usually infection, by way of the lymphatics, from the uterus, or by the passage of septic organisms directly through the uterine wall. The condition is most frequently the result of puerperal sepsis. I have on one occasion seen it occur in connection with extensive venereal ulceration of the external genitals. It seems probable that a pelvic lymphatic gland, becoming infected, may break down and suppurate, forming the starting-point of the abscess.
The symptoms of this form of pelvic abscess are those characteristic of any other kind of suppuration in the pelvis.
The purulent accumulation may be detected by bimanual examination. It usually bulges into the vagina at the lateral fornices or before or behind the cervix. The abscess-mass is in close relationship with the uterus. In this respect it differs from a simple tubal or an ovarian abscess, in which cases a distinct separation of the tubal or ovarian tumor from the uterus may be determined, at any rate, before the pelvic cellular tissue has become involved.
If the abscess bulge in the anterior vaginal fornix, it is very probably of neither tubal nor ovarian origin, as tubal and ovarian abscesses lie to the side of, or behind, the uterus.
The sense of fluctuation is often difficult or impossible to determine. The infiltration of the surrounding structures gives to the mass a dense hard feeling that obscures fluctuation. To the experienced finger, however, this indurated condition of the tissues is characteristic of pelvic suppuration, as is the sense of fluctuation elsewhere.
The treatment of pelvic suppuration of this nature is evacuation by way of the vagina. The incision should be made into the most prominent part of the mass. When made into the lateral fornices, the operator shouldremember the position of the ureters and the uterine arteries. The ureters lie a little over half an inch from the cervix. In every case it is safest to make the incision close to the cervix and to work carefully into the abscess-cavity. The pus should be evacuated, and a double drainage-tube should be introduced for subsequent washing.
In most cases, however, the physician cannot determine with any certainty that the abscess is simply confined to the pelvic cellular tissue and did not originate in the Fallopian tube. If there is any doubt of this kind, celiotomy should be performed and the true nature of the condition determined. If a pyosalpinx or an ovarian abscess is present, as is usually the case, the condition may be dealt with as has already been advised. If the uterine adnexa are healthy, the abdomen may be closed and a subsequent vaginal incision may be made.
Indiscriminate evacuation of collections of pus in the pelvis by way of the vagina has resulted in a great deal of harm. The abscess, being usually of tubal origin, often persists indefinitely. Intestine, ureters, bladder, and blood-vessels have often been injured; and when subsequent celiotomy is performed the operation is attended with great danger from the presence of the fistulous opening.
Tuberculosis attacks the Fallopian tubes much more frequently than any other part of the genital apparatus. The disease may be associated with tuberculosis of the peritoneum or with tuberculosis of the ovaries and the uterus. As has already been said, tuberculosis of the uterus often originates in the tubes and extends thence to the endometrium.
The tubercular Fallopian tube varies much in appearance according to the nature and stage of the disease. The strictly tubercular lesions may be masked by those of ordinary inflammation. There may be peritoneal adhesions, often very dense and widespread, between the tube and adjacent organs, and the ostium abdominale may be closed, as in non-tubercular salpingitis.
In some cases these simple inflammatory adhesions probably existed before the tubercular infection took place, the tuberculosis occurring in an old diseased tube. In other cases it is probable that the inflammatory adhesions and products occurred as a result of the tuberculosis, which attacked a tube previously healthy. In the latter case such adhesions may be viewed as a conservative process.
The tubercular tube is often very much enlarged from infiltration of its walls and dilatation of its lumen. It may be filled with typical caseous material, and when this is removed the mucous membrane will be found the seat of deep, jagged, ulcerated areas.
If the abdominal ostium is not entirely closed, the cheesy material may project into the abdominal cavity.If the disease has extended to the peritoneal coat, the covering of the tube will be found studded with typical tubercles (Fig. 152). Such tuberculosis of the peritoneum may be confined to that covering the tube, or it may extend to the uterus and throughout the abdominal cavity.
In peritoneal tuberculosis that has originated in the tube the lesions are found to be most widespread in the pelvic peritoneum.
Fig. 152.—Tuberculosis of the Fallopian tubes. The disease has extended to the peritoneum, which is covered with tubercles.
Fig. 152.—Tuberculosis of the Fallopian tubes. The disease has extended to the peritoneum, which is covered with tubercles.
In some cases the ostium becomes closed, and the tubes are found distended with pus, forming tubercular pyosalpinx. Such tubes sometimes attain enormous size, containing a quart or more of purulent material.
In less extreme cases than those just described the tubercular area may be limited to a portion of the tube, and gives rise to one or more nodular enlargements (Fig. 153). In other cases there is no gross change in the shape or size of the tube, and only a few miliary tubercles are found scattered throughout the mucous membrane.
In a very large number of the cases of tuberculosis of the Fallopian tubes, the lesions resemble in all respects those of ordinary salpingitis, and are not in any way recognizable by the naked eye as characteristic of tuberculosis.There are no cheesy contents; there are no tubercles upon the peritoneum; the mucous membrane shows no macroscopical changes that would lead to the suspicion of tuberculosis. In these cases the tubes are usually closed at the abdominal ostium; there may or may not be cystic distention; and the adhesions, which are usually very firm, distort the shape of the tube and bind it to the posterior aspect of the broad ligament, the uterus, or other pelvic structure. Until recent years such cases were supposed to be simple cases of salpingitis. Careful microscopic examination, however, has shown that this forms one variety of tubal tuberculosis, and that a certain proportion of such cases of salpingitis are tubercular. The term “unsuspected tuberculosis” has been applied by Williams to such cases.
Fig. 153.—Tuberculosis of the Fallopian tubes:A, tubercular nodules.
Fig. 153.—Tuberculosis of the Fallopian tubes:A, tubercular nodules.
Cases of tuberculosis of the Fallopian tubes may be divided into three classes: Miliary tuberculosis; chronic diffuse tuberculosis (cheesy tubes); and chronic fibroid tuberculosis.
Miliary tuberculosisof the tubes may be a part of a general miliary tuberculosis, or it may occur primarily in the tube. Microscopic examination shows giant epithelioid cell-tubercles scattered throughout the mucous membrane.
Miliary tuberculosis is the first stage of tuberculosis of the tubes. The process may progress no farther, or it may become converted into one of the other varieties.
Inchronic diffuse tuberculosisthe mucous membrane is infiltrated with epithelioid cells, miliary tubercles, and areas of caseation. The tube may be filled with cheesy material or with pus, and in time the mucous membrane becomes completely destroyed. In this form of tuberculosis the gross appearances are usually characteristic, and are those which have already been described.
Inchronic fibroid tuberculosisthere is a great increase of connective tissue between the tubercles. The lumen of the tube is distorted, and a few miliary tubercles are found scattered through the mucous membrane. This form of the disease is very slow and chronic, and represents a usual method of spontaneous cure.
Since the discovery of so-called unsuspected tuberculosis of the Fallopian tubes the disease has been found to be much more frequent than was formerly supposed.
Williams found tuberculosis of the tubes in one out of every twelve operations for the removal of tubes and ovaries that were the seat of past or present inflammatory disease.
Dr. Beyea and I have found tuberculosis of the tubes present in 18 per cent. of the cases that were subjected to the operation of salpingo-oöphorectomy for inflammatory disease of the tubes.
It may be said, therefore, that tuberculosis is present in from 8 to 18 per cent. of all cases of inflammatory disease of the uterine appendages. It is impossible, however, to say whether or not tuberculosis is the cause of the disease in all cases, or whether tuberculosis has been grafted upon a previous non-tubercular affection. Other organisms, along with the tubercle bacillus, are frequently found in the Fallopian tube.
Tuberculosis of the Fallopian tubes may be primary or secondary.
In primary tuberculosis the tubes are the primary seatof the disease, being affected before other structures of the body.
In secondary tuberculosis the tubes are affected from a tubercular focus in some other part of the body.
Tuberculosis of the tubes is usually secondary.
Infection takes place in a variety of ways. Infection through the blood is the most usual way.
Infection may take place from a tubercular ulcer of the intestine or bladder becoming adherent to the tube. The tube may become involved by extension of tuberculosis of the peritoneum to it. In many cases the reverse order happens: the tube is first involved by the tuberculosis, and the disease extends thence to the peritoneum. In other cases it is the peritoneum that is primarily affected. It seems probable that tubercle bacilli, having gained entrance to the peritoneum from a tuberculous mesenteric gland or from an intestinal ulceration, fall to the pelvis and are drawn into the Fallopian tubes, there producing tuberculous lesions without first affecting the peritoneum.
It seems probable that in a good many cases of tuberculosis of the tubes the infection takes place from without by way of the genital tract. Dirty instruments, syringes, or the examining finger may cause it in this way. Infection may also occur from clothing or bed-sheets soiled by sputum or other tubercular discharge. Coitus with men affected with genito-urinary tuberculosis or any other form of tuberculosis may be an occasional cause. It has been shown that tubercle bacilli may be present in the testes and prostate glands of consumptives without any evidence of genito-urinary tuberculosis being present.
Tubal tuberculosis may occur by way of the genital tract from infection from the discharges from some other tubercular focus in the woman, as in the lungs, bladder, or intestinal tract.
Thesymptomsof tuberculosis of the Fallopian tubes are not at all characteristic. Most cases of tubal tuberculosishave been discovered at the autopsy or have been unexpectedly found at operation.
The symptoms resemble those of non-tubercular salpingitis. There is the same ovarian pain and dysmenorrhea. Bimanual examination reveals the enlarged or nodular and distorted condition of the tube. The adhesions are often very firm and dense, and the tubal tumor is often of stony hardness.
Thediagnosisof uncomplicated tubal tuberculosis is difficult, and in many cases impossible. If the peritoneal covering of the tube is involved, the small tubercles may sometimes be felt by vaginal or rectal palpation. Or, if the condition has extended to the posterior aspect of the uterus, the tubercles may be felt here, by dragging the cervix down with a tenaculum and palpating the posterior uterine surface with a finger in the vagina or the rectum. The association of salpingitis with pulmonary tuberculosis would lead the physician to suspect that the salpingitis might be tubercular. If the woman has tuberculosis of the peritoneum, and the tubes are found enlarged, it is most probable that they are tubercular. A knowledge of a genito-urinary lesion of tubercular nature in the husband should lead us to fear tubal tuberculosis in the wife.
Prognosis.—Tubal tuberculosis is a dangerous disease. There are several methods of termination. It very often leads to tuberculosis of the peritoneum. For this reason peritoneal tuberculosis is more common in women than in men.
A tubercular abscess may be formed in the pelvis, and the woman may die as the result of prolonged discharge and suppuration, as in the case of non-tubercular pyosalpinx. General tubercular infection may arise from the tubercular focus in the tubes.
Tuberculosis of the tubes may, and probably often does, undergo spontaneous cure. The fibroid changes that have been described lead to this end. In some cases calcification occurs, as in tuberculosis elsewhere, and thedisease is cured in this way.Fig. 154represents an old tubercular pyosalpinx that was filled with calcified plates.
Even though these conservative changes take place and all danger from the tuberculosis has disappeared, the woman will continue to suffer pain and dysmenorrhea from the tubal and ovarian adhesions.
Treatment.—The treatment of tubal tuberculosis is celiotomy, with removal of the tubes and ovaries. If the uterus is involved, it should also be removed. Removal of the tubes, however, is the important feature of the operation. I have seen perfect and permanent recovery occur after removing the tubes, even though the disease had extended into the uterine cornua. As the disease very rarely extends below the internal os, the uterus may be amputated at any convenient point of the cervix.