Pathology.—Inflammation of the tubes occurs in the form of acute and chronic inflammation. Chronic inflammation re sults in salpingitis, perisalpingitis, ac cumulation of fluid in the tube forming an hydrosalpinx, pyosalpinx, or hatmato salpinx, according to the activity of the inflammation and infectious character of the germs. Inflammation consists in, first, thickening of the mucous mem brane, frequently desquamation of its epithelium, and enlargement of the tube. The longitudinal folds of mucous mem brane, becoming abraded and lying in apposition, infrequently become adher ent, forming what appear to be cysts. At other points, particularly in the isthmus of the tube, thickening of the membrane occurs, forming pea- to bean- sized nod ules, which are spherical in form, with sharp margins, and give the impression of tumor-formations. They are firm in consistence, thick, vascular structures, sometimes also double sided, and sym metrical. This inflammation has been denominated the salpingitis nodosa isth mica. With the extension of the inflam mation to the mucous membrane, in creased secretion follows, portions of which are discharged into the peritoneal cavity, and cause an inflammatory con dition, which causes the plastic material ' to be thrown out, and close up the end of the tube. With inflammation and thickening of the mucous membrane, it becomes contracted and leads to retrac tion of the fimbrim, or by the contraction of the muscular layer it pushes the peritoneum over the abdominal orifice, which becomes agglutinated and closes the opening. Occasionally one or more fimbrile may protrude, thus leaving a track by which fluid subsequently may escape into the peritoneal cavity. With the closure of the tube the increase of contents causes an obtuse-ended tumor, which gradually fills with fluid, forming occasionally a pear-shaped mass, or, n here its walls are in places constricted by an increased amount of fibrous tissue, a sausage-shaped tumor is formed. This sac, when its contents are serous, is an hydrosalpinx, and occasionally becomes greatly distended, forming a sac as large as a child's head, which increases in size toward the abdominal end, and presents a thin-walled tumor which is more or less free, and about which adhesions may be entirely absent. In a more acute infec tion the contents become purulent, and with pus-contents we have an inflamma tion extending through the wall of the tumor, involving its peritoneal surface, and not infrequently causing extensive peritoneal inflammation by which every thing in the pelvis is matted together. Such a sac may subsequently rupture, spread out the broad ligament, and form a pelvic abscess of considerable dimen sions. If the adhesions are firm between the intestine or bladder and sac, rupture may occur either in the intestine or blad der and decrease the tumor from the dis charge of pus; or the wall may become so thinned as to permit its discharge through the abdominal walls, into the vagina, or more seriously into the peri toneal cavity, when it is followed by rapidly fatal septic peritonitis. When the sac empties into the bladder or in testine, it does so at a level which does not permit the entire sac to be drained, and consequently it is only the overflow that escapes. The patient is subjected to a long-continued drain, which results in increased anemia and debility.
Treatment. — Palliative treatment in these conditions is of no avail. If the patient is in an acute attack one may prefer to bring about a subsidence from the acute symptoms. Place the patient in bed, administer purgatives, and apply an ice-bag. No hope for permanent re lief can be asserted until the sac is evac uated or removed. The method of treat ment, however, will depend somewhat upon its situation and size. A large col lection filling up Douglas's pouch, or dis tinctly recognized through the vagina, is preferably attacked by vaginal in order to remove the large quantity of infectious material without bringing it in contact with the peritoneal cavity.
Collections of pus may be evacuated by free vaginal incision, through the poste rior vaginal fornix: expose the sac and make an incision into it through which its contents are evacuated. The sac is thoroughly irrigated, and an examination made as to the existence of further col lections. If any exist, they are broken open and evacuated. Where the sac is readily separable it may be gradually drawn down and removed through the vagina. If, however, there is more or less fixation of the thoroughly opened and irrigated sac, it is packed with iodo form gauze, which is permitted to remain the greater part of the week, the cavity being irrigated, after its removal, with formalin solution (1 to 2000) and re packed. The procedure should be con tinued every few days until the sac has contracted, when it may be omitted. Oc casionally this operation will result in obliteration of the sac and cure of the patient. It should always precede an ab dominal section whenever there is a large collection of pus that can be reached per vaginam. The only objection to the plan of treatment is that it is not al ways curative; the secreting surface re mains and the sac may again close and refill. The effective operation is to open the abdomen, break up the adhesions, and remove the infected tube and ovary. This operation is greatly enhanced by placing the patient in the Trendelen burg posture, by which the sight as well as touch may be eXereised in the enuclea tion and removal of the mass.
While extirpation of a tubal sac is the proper treatment in large collections, whether of blood, pus, or serum, abdom inal section should not be considered as required in every case of tubal inflamma tion. In the slighter forms of disease, and in the early stages, the hygienic measures already indicated, supplemented by palliative curettement and the drain age of the uterus, will often be sufficient to establish a resolution of the slighter forms. The maintenance of uterine drainage will often be sufficient to estab lish a cure, both clinically and function ally. In other words, patients who have had extensive tubal inflammation of gon orrhceal origin have recovered and sub sequently given birth to children. I have observed this sufficiently frequently in my own practice to make this assertion without question. Occasionally the uter ine end of the tube remains patulous, permitting, in certain positions of the body or in overaccumulation, the evacua tion of the sac through the uterus and its disappearance until it again refills. This condition is known as hydrops tubm pro fluens.
The extension of inflammation from the uterus to the tubes and the existence of inflammatory products in that organ after the removal of the tubes, which not infrequently causes nervous and other manifestations, led Nan and his follow ers to advocate the removal of the uterus per vaginanz whenever the condition was such as to require the removal of both ovaries. This operation may be done either by clamp or ligature. The clamp operation is the more expeditious. The ligature, while longer, is safer.
The operative procedure consists, first, in thorough cleansing and disinfection of the vagina. The cervix is seized with a double tenaculum, and the vagina in cised with scissors, knife, or—preferably —with a thermocautery-knife. Incision with the latter prevents hemorrhage from the vaginal wall and promotes drainage through the longer duration re quired in the union of the vaginal wound. The incision completely encircles the neck of the uterus and may extend one half to three-fourths of an inch on a line posteriorly to the broad ligament. Pus collections in either the tube or Douglas's pouch should now be opened and thor oughly evacuated, and the cavity irri gated before the adhesions are broken up, which removes an extensive source of infection.