&0EtJ§ tbc ctonpltmeiite nf tbe torttcr. THE . ...■ Relief of Salpingitis Dy Dilatation and Drainage of trie Uterus. BY CHARLES P. STRONG, M. D„ Assistant Surgeon, Free Hospital for Women ; Physician to Out- Patients, Massachusetts General Hospital; Assistant in Gynecology, Harvard Medical School. Reprinted from the Boston Medical and Surgical Journal of March 17, 1892. BOSTON: DAMRELL & UPHAM, Publishers, 283 Washington Street. 1892. S. J PARKHILL & CO., PRINTERS BOSTON THE RELIEF OF SALPINGITIS BY DILATATION AND DRAINAGE OF THE UTERUS.1 BY CHARLES P. STRONG, M.D., Assistant Surgeon, Free Hospital for Women; Physician to Out- Patients, Massachusetts General Hospital; Assistant in Gynecology, Harvard Medical School. The treatment of salpingitis is divisible into two general classes: operative, that is, ablation of the tubes, and non-operative. Of the former I say noth- ing except that the larger the experience of the operator -the less the percentage of cases will be found which demand this radical measure. Of the lat- ter class we have still in daily practice the use of alter- ative applications and vaginal tamponades, as the common and routine measures. There will be found, however, many cases in which this antiphlogistic treat- ment is unsatisfactory, securing only temporary allevi- ation, or, from other necessities of circumstance being impracticable. I wish to present for consideration an interme- diate measure which does not embody the objection- able features of either of the two methods sketched above. Considering for a moment the etiology of salpingitis, exclusive of malignant and tuberculous diseases, or di- rect violence, it is from the uterus the causative agent extends into the tubes, whether this be of a highly septic, or mildly irritant, nature. This is especially true of those cases where the marked characteristic is alternating periods of quiescence and activity of inflam- matory symptoms. These cases are distinguished by the presence of more or less profuse uterine discharge, and 1 Bead before the Boston Society for Medical Improvement, Janu- ary 11, 1892. 2 examination will always reveal endometritis existing in some one of its several forms. Obviously, if this endometrial condition be restored to normal before the tubes become in themselves hopelessly diseased, and before the co-existing salpingitis has induced peritoneal adhesions, a return to healthful conditions may he ex- pected. The local treatment of endometritis by applications through the barely patent cervical canal, must always be both dangerous and unsatisfactory. This has been demonstrated too often, clinically, to require further comment. The treatment by drainage of the uterus following free dilatation, has much to commend it as a safe and conservative measure. That it is practised by but few is due, I think, not to non-success following its procedure, but rather to the glamour attendant upon a primarily successful laparotomy. I have selected four cases among the number in which I have per- formed it, to illustrate the various phases of cure, pal- liation and temporary improvement, and one case of acute endometritis and salpingitis, to show the freedom with which the measure may be employed in cases which we are prone to consider dangerous, if meddled with. The first three cases were operated upon sufficiently long ago to make the present report of value, the most recent one having been under observation considerably over a year. To avoid unnecessary confusion, I have selected only those cases with symptoms which would be materially affected by improvement in the salpingi- tis or endometritis; also, statements with regard to local conditions are based upon the results of examina- tions made with the patient angesthetized. Case I. Mrs. K. This patient was referred to me for operation upon the cervix and perineum, for relief of the symptoms of backache, constant pain in ovarian 3 region, and repeated attacks of slight pelvic peritonitis, subsiding coincidently with the establishment of pro- fuse purulent discharge from the vagina. The patient was a complete invalid, and had been bed-ridden most of the time. October, 1889. I found, by examination, the left Fallopian tube enlarged quite uniformly to the size of an ordinary sausage ; the right tube about one-half that size—numerous peritoneal adhesions which were not dense enough to prevent mobility of the tubes. Both ovaries apparently normal. The uterus the seat of a decidedly puriform endometritis, and in a hyperplastic condition. I rapidly dilated the uterus, removing the thickened mucous membrane, which was very rich in its glandu- lar elements : thoroughly disinfected the cavity, and packed with iodoform gauze. Drainage was continued one week. November 22d. Examination showed that the right tube had diminished one-third in size. The left tube was practically normal. The uterine discharge was re- commencing. The operation and treatment was re- peated. May 6th. There had been great improvement in the symptoms of six mouths previous, and it was only at my request that the patient had reported. Upon the right there was still a distinctly enlarged tube. Operation repeated. August, 1891. Twenty-two months had elapsed since the first operation, during which period there had been no local treatment. I found the right tube still slightly enlarged; the left normal. No evidence of endometritis. The uterus involuted to its proper size, and the cervical laceration not requiring operation. During the two years there had been no attack of per- itoneal inflammation, and the symptoms of pelvic dis- 4 turbance had been so alleviated that the patient had resumed all her household duties, and considered her- self well. I, however, have classed this case at present as one of complete relief rather than cure, as the slightly enlarged tube may possibly, but not probably, at some future time give trouble. Case II. Mrs. F., married eighteen months, and confined to bed during the past six months by pain in the left side. Had for sometime previous to marriage a slight discharge from vagina, which is steadily in- creasing. Examination, under ether, shows decided enlarge- ment of left tube, possibly also of right. Ovaries normal. December 11, 1889. Treatment as in Case I. January 9th. One month later, more comfortable than at any time for a year. Only two attacks of pain since the operation, each one less than thirty minutes’ duration; can walk about fifteen minutes, and stand five minutes, without inducing more than a temporary feeling of pain in the side. Operation and treatment repeated. At this examination the enlargement of the tube could hardly be recognized as pathological. January 5, 1892. One year from the lasc operation. Patient is perfectly well; is totally free from any pain or discomfort in the pelvis. Examination can detect no enlargement or tenderness of the tubes on either side. Walks several miles daily; no endometritis whatever. This case I consider a cure. Case III. Mrs. Mary K., nurse. Pain in both ovarian regions, steadily increasing for several years, despite replacement of a retroflexed and adherent ute- rus. Chronic and profuse purulent endometrial dis- charge. Not able to work. 5 October 14, 1890. Examination shows a decided mass on left side — less upon right side; ovaries not felt. Implicated in the mass were the tubes, possibly the ovaries ; certainly, there existed an abundance of strong peritoneal adhesions. Operation and treatment as in previous cases. Hypertrophied mucous membrane, and numerous mucous polypi removed. Immediately upon leaving the hospital this patient went to work in the violent ward of an insane hospital, needless to say, against advice. She re-entered the hospital three months’ later. I could not see that the local condi- tion had been improved, and operated, removing the tubes and ovaries on both sides, which were so firmly imbedded in adhesions that they were torn away piece- meal. This case I consider a failure. I have reported it as illustrative of those cases in which this palliative treatment does not afford reasonable prospect of suc- cess. At the time of the operation, I did not regard it at all as a hopeful case, and so stated ; but as a pos- sibly conservative measure, I decided to try what might be accomplished. Case IV. Mrs. F. F. This case was one of acute salpingitis accompanying acute gonorrhoeal endometri- tis. There was great dilatatiou of the tubes. I op- erated three times in two weeks. At the conclusion of the attack both tubes remained enlarged. There was a re-lighting of the salpingitis after the interval of a year, when I repeated the operation. Three years ago, that is, five years after the first operation, there could be detected only some slight thickening about the broad ligaments, which was not at all tender, and to-day the patient is, so far as symptoms are indica- tive, perfectly well. I am aware that my course in operating upon this case in the height of an attack of acute gonorrhoeal salpingitis, exposes me to criticism : 6 but it was necessary to do something as the patient’s condition was becoming decidedly worse hourly. Lap- arotomy could not be considered; other palliative measures had been tried in vain. The course I adopted seemed the only one possible. As to the methods of procedure. The aim should be to render the operation thoroughly aseptic, oper- ating with the patient upon the side in the Sim’s posi- tion, avoiding any downward traction of the uterus, by which the tubes might be put upon the stretch, and possibly a portion of their contents forced out upon the peritoneum ; the cardinal point in the whole operation being to avoid lighting up fresh salpingitis or peritoni- tis by mechanical violence. Dilate slowly and stead- ily with steel forceps until the canal will readily admit a No. 36 sound. Thoroughly scrape away by sharp curette and curette forceps the entire uterine mucous membrane, both cervical and fundal: especially en- deavoring to free the opening at the uterine end of the tubes, it being at this point that they are frequently occluded by a slight hyperplastic enlargement. Dis- infect the uterine cavity. Insert a twisted roll of iodoform gauze, about the size of a goose-quill, to the fundus. Along side of this roll insert others until the cervical canal is firmly filled. Leave the protruding ends within the vagina, and protect the vulva by an antiseptic pad. Change these rolls of gauze every two or three days for ten days, and keep the patient in bed a week. The time of election for the operation is one week subsequent to the menstrual flow. Examine, under ether, after a month has gone by, and if there is still evidence of salpingitis or endometritis, repeat the treat- ment. Should the tubes be enlarged when the uterine interior shows no evidence of disease either by muco- purulent discharge or hyperplasia, do not operate, but 7 rely upon douches and alterative applications to the vaginal vault, to effect reduction in their size, which may, very possibly, be due to the results of the perito- neal inflammation, rather than to any increase in the contents of the tubes. Selection of cases for operation. Success depends upon a proper appreciation of the pathological condi- tions which are to be relieved. Acute cases are best treated, for a time, at least, by palliative measures, or by radical operation. Chronic cases in which the tubes are tied down by many adhesions, and in which the symptoms are dependent upon immobility of the tubes, or of the uterus, do not afford a hopeful prospect of cure. In all other forms I consider the operation not dan- gerous, and capable of accomplishing far more in the way of radical cure than any of the absolutely pallia- tive measures, and, of course, free from the one great objection of a radical operation. The symptoms are indicative, in a measure, of what you may expect to find by examination. Pain, which is the constant and prominent symptom, is usually constantly present in those cases where peritoneal adhesions are thick and strong. These are not promising cases. The dura- tion of the disease is also of importance. Those of more recent origin, other points being equal, yield more readily. Mobility of the tubes, and patency of the uterine end of the canal, are absolutely essential. It will be noticed that none of my cases have been cured by a single treatment. I think this is due to the prac- tical difficulty of removing entirely the affected uterine mucous membrane. Whether a longer period of drain- age would accomplish this, I am unable to say. I have made it a rule to limit my drainage to eight or ten days. The suffering caused by the operation and the treat- 8 ment is practically nil. An incidental point gained is that it tends very strongly to relieve menstrual pain, especially in those cases where the pain is due to me- chanical obstruction to free menstrual discharge. With regard to the dangers of the operation, there are none if properly planned, properly executed, and proper judgment employed in guiding the convales- cence. THE BOSTON MedicalandSurgical Journal. 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