TUBERCULAR SALPINGITIS, WITH CASES TREATED BY OPERATION. BY J. W. ELLIOT, M.D., BostUfi"'*" | Reprinted from the American Journal of Obstetrics and Diseases of Women and Children, Vol. XXV., No. 2, 1892.] NEW YORK: WILLIAM WOOD & COMPANY, PUBLISHERS, 56 & 58 Lafayette Place. 1892. TUBERCULAR SALPINGITIS, WITH CASES TREATED BY OPERATION. BY J. W. ELLIOT, M.D., Boston. Reprinted from the American Journal of Obstetrics and Diseases of Women and Children, Vol. XXV., No. 2, 1892.] NEW YORK': WILLIAM WOOD & COMPANY, PUBLISHERS, 56 & 58 Lafayette Place. 1892. TUBERCULAR SALPINGITIS, WITH CASES TREATED BY OPERATION.1 According to Winckel the Fallopian tubes are always in- volved in tuberculosis of the genitals, and in about one half of all the cases they alone are affected. Primary tuberculo- sis of the tube is rare, the most common cause being coitus witli a tuberculous man or infection by instruments, fingers, etc. The germs may then spread through the genital tract, and the tubes are an especially favorable seat for infection on account of their numerous folds, their narrowness, and their delicate epithelium. The tubes may be secondarily affected by the spreading of the tuberculous process from other or- gans either through the blood or by direct extension. In this way intestinal tuberculosis may cause tubercular perito- nitis, and tubercular peritonitis may in turn cause tubercular salpingitis, or vice versa. Case I.-Miss D. entered the Massachusetts General Hos- pital in June, 1888, and gave the following history: She was 25 years old and a native of Nova Scotia. None of her brothers or sisters had had lung trouble, but there was con- sumption in her mother's family. The patient was pale and thin, and had grown rapidly. Menstruation began at 13. Seven years previous to entrance she had had amenorrhea lasting seven months, during which time she was weak and had indigestion with chronic diarrhea. When menstruation began again she had pain at each period. Three years before entrance she began to have pain in the region of the rectum and still more dysmenorrhea. This pain was most severe 1 Read before the Boston Obstetrical Society, December 12th, 1891. 4 ELLIOT: TUBERCULAR SALPINGITIS during the first day or two. It would cease suddenly, usu- ally in the night, and was immediately followed by a brown- ish, foul-smelling discharge. She had been treated for retro- version. On examination a mass the size of an egg was found in the pelvis behind and to the right side of the uterus. The mass was firmly adherent to the rectum and immovable. The ute- rus was moderately movable. The mass seemed to be tubo- ovarian, but it had an entirely different feel from the ordinary cases. It seemed to have infiltrated the surrounding tissues rather than to have been glued to them by adhesions. It was not tender. On June 22d the abdomen was opened by the ordinary median incision. The mass was found to be the right Fallo- pian tube. It was studded with tubercles, as were the uterus and left tube, though to a less degree. It was removed as close to the uterus as possible. There was considerable bleed- ing from the torn adhesions, so a glass drainage tube was left in the pelvis. The thickened tube was doubled on itself and filled with cheesy pus, forming a mass as large as a hen's egg. (See plate.) Dr. Whitney, the pathologist of the hospital, kindly fur- nished me with the following report: "The tube was very much thickened and the cavity di- lated, and adherent to its end was a hard, rounded body sup- posed to be the ovary. Section through the uterine end of the tube showed a marked thickening of the wall, and scat- tered through it were small accumulations of round cells; beneath the peritoneal surface there were minute round masses of small round cells with a tendency to cheesy degene- ration, and lying among them were scattered large multinu- cleated bodies (giant cells). The membrane lining the tube at this part was thickened, but otherwise not abnormal. . . . The portion attached to the ovary (?) showed an extreme thickening with cheesy masses in the interior and foci of round cells, cheesy degenerated, with occasional giant cells. No ovarian structure was found. . . . The process is a tu- bercular salpingitis and peritonitis probably involving the ovary." The patient made a good recovery. The drainage tube . FEBRUARY,1892. UTERINE END OF TUBE. TUBERCULAR S A LP I N G I T I S - ELLIO T. LIFE SIZE. EXTERNAL END OF TUBE . ELLIOT : TUBERCULAR SALPINGITIS. 5 was removed on the second day and the stitches on the tenth, when the wound was found to have healed by first intention. I have delayed publishing this case in order that sufficient time should have elapsed to suggest the possibility of a per- manent cure. It is now three and one-half years since the operation, and I have seen the patient occasionally during this time. She has not only remained well, but has steadily improved in her health. I will quote from a letter recently received from her: " I am happy to say that I am twice as well as I was last spring when I wrote you. My courses are regular and seldom painful. I have no pain on either side, and I am stronger than I ever was in my life. I play a heavy organ in our church twice on Sundays and two evenings dur- ing the week. I have done that these last six months. The church is two miles from here, and I often walk down instead of driving." Case IL-Miss R. entered the Massachusetts General Hos- pital on May 29th, 1S90. She had begun to have constant pain in the lower abdomen two months before entrance, and on April 10th Dr. Mead, of Everett, had attended her in an attack of pelvic peritonitis which lasted two weeks. The pain continued, especially in the right side. On May 20th the temperature rose to 102.5°, and an examination revealed a tender mass to the right of the uterus. On the 27th the temperature was 103.5°, with chillsand vomiting. The cata- menia had occurred regularly and normally. She was 20 years old and a native of Nova Scotia. No- thing could be learned from the family history. Her general appearance was fairly good. Examination by Dr. Homans showed the abdomen mode- rately distended and tympanitic, except in the right inguinal region, where percussion showed marked dulness as compared with the other side. There was exquisite tenderness over the area of dulness. With rest in bed the patient slowly improved. After one week there was much less pain, but the temperature remained at about 100°. In three weeks the condition was much the same. On June 20th I took charge of the hospital wards for Dr. Homans. I found a hard mass about as large as an orange in 6 ELLIOT : TUBERCULAR SALPINGITIS. the right lateral cul-de-sac, apparently in connection with the uterine appendages. The mass was firmly fixed. June 26th, the right ovary and tube were dug out of a dense mass of adhesions. The tissue between the tube and the pelvis had become so degenerated that the bone was actu- ally scraped with the finger nail. The tube was ruptured and considerable pus escaped into the abdominal cavity. It was thoroughly sponged out and a glass drainage tube placed in the hole from which the mass was torn. The tube was not thickened as in the first case, but con- sisted of a series of thin-walled sacs about the size of walnuts, which were filled with pus and cheesy material. Dr. Whit- ney, pathologist, reported that the process was undoubtedly tuberculous. The patient made a rather slow recovery. On June 28th the discharge from the drainage tube was noticed to have a fecal character. A fecal fistula was established, which was frequently washed out, and finally closed on July 10th. July 26th the temperature rose to 102° with headache. No local cause could be found for this disturbance, which subsided in a few days. The patient was discharged from the hospital in fairly good condition. On September 16th, having previously been feeling pretty well, she was taken with severe headache and vomiting. These symptoms continued with great severity, and finally the fecal fistula was forced open. The temperature varied •between 100° and 102°. September 26th she re-entered the hospital under Dr. Cabot. She was semi-unconscious and did not recognize familiar faces. There was marked general hyperesthesia, ptosis of the left lid, dilatation of the left pupil, and photo- phobia. The pulse was 80°. Vomiting, headache, and eye- ache continued. The diagnosis of tubercular meningitis was made. Her condition became steadily worse, and she died on October 1st. The autopsy showed tuberculosis of lungs, kidneys, spleen, and liver, also tubercular meningitis, pleuritis, and peritonitis. Besides the above cases I have had opportunities of seeing this disease in the later stages. Tuberculosis of the tube, irre- spective of a general infection, may spread by direct extension 7 ELLIOT : TUBERCULAR SALPINGITIS. or by rupture of cheesy degenerated spots in tubes tilled with pus. This last gives rise to a pelvic abscess, or more commonly to an abscess just above the pelvis. Such cases of circum- scribed tubercular peritonitis are usually chronic in character and have a thick wall. 1 have seen six cases of this variety. When opened and drained these cases usually improve very much at first, but the sinus is slow to heal and the case drags on much like an old hip disease. Two of the six cases referred to were apparently well when last seen ; one died ; one, after two years, still has an unhealed sinus; the other two have been lost sight of. Jf left unoperated on, these cases die of purulent perito- nitis or general tubercular infection. I saw such a case in consultation in 1888. The patient, a young lady, had noticed a tender tumor over the pelvis six months previous, and was dying of purulent tubercular peritonitis and tuberculosis of both lungs. When the tubercles spread over the peritoneal surface, clear ascitic fluid is usually formed and we have the ordinary tubercular peritonitis. In such cases, where the tubercles are found on the otherwise normal tubes as well as on the other organs, it is difficult to determine whether the disease has ex- tended from the tubes or from some other organ, notably the intestines. The general arguments in favor of its tubal ori- gin are that tubercular peritonitis is much more common in women than in men (Fehling1 found that out of forty-two cases collected only two were in men), while genito-urinary tuberculosis is even more common in men than in women ; also, the Fallopian tube is by far the most common seat of chronic tuberculosis in the female genitals.2 On the other hand, a great many cases of tubercular peritonitis have been cured by operation without removing the tube; I myself3 have reported such a case, which has now remained well four years. While this point remains unsettled, suspicion must 1 Centralblatt fur Gyniikologie, No. 45, 1887. * According to Winckel, Hennig found it in the ovaries six times ; right tube, fifteen times ; left tube, twelve times ; uterus, twelve times ; vagina, twice. Geil never saw it in the ovaries, but found it in the right tube forty- four times; left tube, forty-two times; uterus, thirty-five times; vagina, once. * Boston Medical and Surgical Journal, May 17th, 1888. 8 ELLIOT : TUBERCULAR SALPINGITIS. always rest on the tube. Hegar has suggested that the tube should be removed, in cases of tubercular peritonitis, if there is any indication that it was the primary seat. * Werth1 says that two forms of tubercular salpingitis should be distinguished. One form is a part of general tuberculosis, the other might be called chronic tubercular inflammation. In the first both muscular and serous coats undergo a cheesy degeneration, bacilli being found in the interior of the tube in great numbers. In the second the tube wall undergoes hyper- trophy and cell infiltration and contains only a few bacilli. The two cases here reported are examples of these two forms, the first representing the chronic variety, and the sec- ond the acute. The first of my cases has remained well for three and one-half years, which is longer than any recorded case, except perhaps one of Hegar.2 The second died in three months of general tuberculosis. Of course the chronic variety will give the best results ; in fact, it is useless to operate on a case already secondarily infect- ed, unless the process in other organs is quiescent. It is, how- ever, often impossible to determine if the disease is purely local. As to the diagnosis of tubercular salpingitis, the general phthisical appearance of the patient, together with chronic tubes not very tender but firmly fixed by infiltrating adhe- sions, are the main points. The bacillus should be looked for in the vaginal discharge in all suspected cases. Hegar lays stress on being able to find, by bimanual examination, wreath- like masses of firm nodules about the size of small nuts. Summary.-1. There is hope of curing a patient with tuber- cular salpingitis. 2. The operation should be done as early as possible. 3. If the tube has ruptured and an abscess has formed in the neighborhood, there is still a possibility of cure; in such cases, besides draining the abscess, a reasonable attempt should be made to remove the tube. 4. In operations for tubercular peritonitis the Fallopian tubes should always be examined, and removed if they contain pus or in any way suggest that they are the starting point of the disease. 1 Centralblatt fiir Gynftkologie, p. 499, 1389. a Id., p. 70, 1888.