Reprinted from Annals of Gynaecology and Podiatry, February, 1891. Pyosalpinx in Relation to Ster- ility in Women. BY Dr. C. P. Noble. PHILADELPHIA UNIVERSITY OF PENNSYLVANIA PRESS 1F91 Reprinted from Annals of Gynecology and Pediatry, February, 1891. Pyosalpinx in Relation to Ster- ility in Women. BY Dr. C. P. Noble. The relation of inflammatory disease of the uterine appendages to sterility in women, as cause and effect, is becoming more gener- ally appreciated. That it is one of the most important causes of sterility none will deny. Fortunately, also, the explanation of the ster- ility from this cause is easily given. It is due to a closure of the fimbriated opening of the tube by plastic exudate, or to stricture in the lumen of the tube, which prevents the meet- ing of the ovum and spermatozoa. If the dis- eased condition exists in both uterine appen- dages, and both tulles are occluded, the woman is sterile. Most observers will be willing to admit that she is permanently ster- ile, and that the uterine appendages are no- 2 longer useful organs. The difficulty in arriv- ing at this conclusion lies in the difficulty of diagnosticating the exact condition of the uterine appendages by the ordinary means of diagnosis at our command. In nulliparous sterile women-sterile from inflammatory dis- ease of the uterine appendages-the desire for children is frequently the reason for con- sulting the physician. Under such circum- stances, positive knowledge concerning the possibilities of conception in such cases will be of much value. It has been stated that pyosalpinx is always a bilateral disease, or at least that when pyosalpinx exists upon one side, salpingitis, with strictures of the lumen of the tube, will be found on the other side. That this is usually true I believe, but it is not invariably so. In support of this statement I shall re- port two cases, and exhibit the specimens re- moved by abdominal section, and also make reference to other cases coming under my notice. The point which I shall establish thus is of very practical interest, from several points of view. It shows, ist, that pyosal- pinx is not necessarily a bar to conception ; and 2d, that pyosalpinx discovered after a 3 given labor may have existed prior to the pregnancy, and not be of recent origin. This second fact is of special interest because of its bearing upon the causation of certain cases of so-called puerperal fever. A pyo- salpinx existing during pregnancy may be ruptured during labor and set up purulent peritonitis-a variety of what has been styled autogenetic puerperal fever. These considerations suggest the query, Is it desirable that pregnancy should occur when serious inflammatory disease (such as pyosal- pinx and abscess of the ovary or hydrosal- pinx, of course, limited to one side) of the Fallopian tube or ovary exists ? In view of the possibilities of rupture of the sac during labor, with resulting peritonitis, even the most ardent advocate of fecundity in women will be obliged to answer, No. What, then, is the physician's duty when consulted by a sterile woman, anxious for children, who has pyosalpinx or other serious inflammatory disease of the uterine appen- dages ? To advise the removal of the dis- eased organs which are functionally use- less, a detriment to health and a menace to life. But if the disease be unilateral, what 4 is to be done ? If the diseased uterine ap- pendage be removed and the healthy one be left, life may be saved, health be restored, pregnancy result, and all go well. Unfortu- nately, however, experience has shown that when the healthy ovary and tube upon one side have been left, inflammation is likely to su- pervene and subsequent operation for their removal be required. This is said to be true, especially in cases of gonorrhoeal salpingitis. In view of all the facts, it seems to me that it is wise to explain to the woman the anatomy and physiology of the parts, the danger to health and life of salpingitis in its various forms, the impossibility of concep- tion taking place through an occluded tube, and the danger arising from pregnancy and labor should one tube be healthy and the other be diseased, and to recommend opera- tion for the removal of the diseased organs. If a healthy tube and ovary be left after op- eration, I think the woman can be told that pregnancy will be more likely to take place than if she possess a diseased ovary and tube as well. The possibility of the later occurrence of salpingitis having been ex- plained to her, the woman should be permit- 5 ted to choose whether she will run this risk, in the hope that thereby she may be able to bear children. That this is possible one of the cases to be reported will show. When seriously diseased uterine appen- dages are removed, such as cases of pyosal- pinx, hydrosalpinx and haematosalpinx, the question of sterility or fecundity has no bear- ing on the case, as pregnancy with such or- gans is so remote a possibility as to be be- yond computation. The removal of the uterine appendages renders a woman sterile only when healthy organs are removed. The first case which I shall report demon- strates the possibility of having a patulous tube on one side and a pyosalpinx on the other. The left Fallopian tube of this woman contained a pint of pus. The history indicates the occurrence of two, if not three, pregnancies during the course of the salpin- gitis. Mrs. X., aged 36 years, has had two chil- dren, aged 16 and 18 years, and one miscar- riage at the second month, six months after the birth of the first child. She was always well until her marriage at the age of 20. At the first period after her marriage she had 6 "acute ovaritis." In this connection it is interesting to know that her husband had had gonorrhoea, followed by gleet, for eigh- teen months, but had been pronounced well some months before marriage. Sixteen months after marriage a girl baby was born spontaneously. Childbed fever of mild type followed, which kept her in bed four weeks. She has never been well since. Three months after labor an attack of salpingitis put her in bed for six weeks. Three months later she miscarried at the second month. Within seven years she had six severe attacks of pelvic inflammation, each one confining her to bed from four to six weeks. When the first baby was 5 years old an abscess dis- charged per vaginam, after which she was better for a time and conceived again. Dur- ing the past seven years, after the birth of the second daughter, she has had three at- tacks of pelvic inflammation. Menorrhagia, metrorrhagia, dysmenorrhoea, etc., have been almost constant. She has been in bed or ly- ing around two-thirds of the time for sixteen years. I saw her first in May, 1889, diagnosticated pyosalpinx and advised operation. She was 7 greatly prostrated and emaciated, being un- able to walk. She was operated on at the Kensington Hospital for Women, June 19th, 1889, and a huge pyosalpinx containing a pint of pus was removed. The ovary and tube removed from the right side were thickened by chronic congestion, but the tube was pat- ulous. A slow convalescence followed, due in part to an inflammation about the left pedicle. Mrs. X. is now relatively well, hav- ing gained many pounds in flesh. The second case also illustrates the occur- rence of pyosalpinx without the involvement of the other uterine appendage. A huge acute pyosalpinx and abscess of the ovary existed on the right side, and the left ovary and tube were perfectly healthy. The healthy appendage was not removed, and the woman is now, one year after the operation, eight months pregnant. Mrs. Y., aged 23, has always been well until she aborted at the third month, Nov., 1889. The physician in attendance stated that the ovum was putrescent; emptied the uterus manually, but used no measures for the disinfection of the birth canal. She had no further medical attendance. Symptoms 8 of pelvic inflammation slowly developed, and seven weeks later, when I saw her, she was profoundly prostrated, suffering with fever, sweats and anorexia. Examination showed a fluctuating mass connected with the right horn of the uterus, which filled nearly the whole pelvic cavity. This patient was oper- ated upon in extremis January 2d, 1890. The pulse at the time was 150; the tempera- ture 1050 F., the skin leaky, and the face anxious. There was no indication of spread- ing peritonitis ; the condition was plainly one of septic intoxication. When the exploring finger was introduced into the pelvis and the mass touched, pus gushed forth and a large part of an ovarian abscess sac floated up. An immense tube, of a calibre in places of an inch, and six inches in length, was now tied off. In view of the condition of the pa- tient, it was considered unwise to prolong the operation to enucleate the remaining por- tion of the right ovary. Thorough irrigation followed, and the drainage tube was placed behind the right broad ligament. As the left tube and ovary were healthy they were not disturbed. The woman gradually but steadily improved, and is now in good health and is eight months pregnant. 9 A case illustrating the possibility of preg- nancy during the existence of a pyosalpinx came under my care in the Spring of 1889. I was called to see a woman who gave a his- tory of pelvic inflammatory attacks, extend- ing over some years ; also a history' of prob- able pregnancy of three or four months. Some weeks before, she had visited a physi- cian, representing that she had " caught cold on her monthlies," and received local treat- ment. From the woman's statement, I be- lieve that the sound was introduced and an intra-uterine application made. From that time she began to bleed and to have pelvic pain, fever and vomiting. On examination I found the pelvis filled with a mass, the cervix pushed forward and upward against the pubes, great pelvic congestion and universal tenderness. Afterward, under ether, I satis- fied myself that the cervix and pelvic tumor were continuous, and diagnosed pregnancy in a retroflexed and adherent uterus, compli- cated by tubal inflammation on the right side. In the hope that the woman would abort, or that pregnancy continuing the adhesions would stretch and the uterus rise into the belly, a temporizing policy was adopted. 10 Later, I made up my mind to induce an abortion, but was dissuaded by a medical friend. Thus two months went by and the abdomen began to enlarge, the pelvic condi- tions remaining the same. Careful examina- tion failed to reveal fcetal heart-beats or the rhythmic contractions of the pregnant ute- rus. The absence of the foetal heart sounds could be explained on the supposition that the foetus was dead. In that case, however, it was difficult to understand the continued growth of the mass. The absence of the in- termittent uterine contractions made me hes- itate concerning the diagnosis, which I came to regard as very doubtful. The case passed into other hands, and later the abdomen was opened upon the supposition that the mass was an ovarian tumor. The uterus was tapped, and a living seven months' foetus was extracted. Everything was found matted together, and the patient becoming collapsed the uterine incision was closed and nothing further attempted. She died some hours later. At the post-mortem, a tumor of the anterior wall of the uterus was found ; also a pyosalpinx on the right side. The pelvic and abdominal viscera were universally ad- 11 herent. This case has many points of inter- est. The foetal heart was not heard because the foetus was packed in the pelvis and be- hind the tumor of the uterus. (The vagina- scope might have cleared up the diagnosis). The intermittent contractions of the uterus could not be felt because the fundus of the uterus was in the pelvis, and because the tumor of the uterus was anterior. From the standpoint of diagnosis the case was certainly obscure, and I consider the error in diagnosis no reflection upon the surgeon who operated. The case is reported as a pregnancy occur- ring in the course of a pyosalpinx. Still another case came under my notice during the year. A colored woman living in West Chester was confined, and immediately developed an acute purulent peritonitis and shortly died. At the autopsy a ruptured pyo- salpinx was found. The case was communi- cated to me by the physician in charge, and undoubtedly the pyosalpinx antedated the pregnancy. The details of the case have escaped my memory. The object of this paper is to demonstrate from the data furnished : i. That serious inflammatory disease of 12 the uterine appendages, including pyosal- pinx, may be unilateral, and that pregnancy may occur during the course of the disease. 2. That when pregnancy follows the use of palliative treatment in any case of salpingi- tis, it does not follow that the treatment, whether electrical or medicinal, has rendered the tube patulous, because the ovum may have descended a healthy tube on the oppo- site side. 3. That pregnancy adds greatly to the dangers attending pyosalpinx, or other serious inflammation of the uterine append- ages, and hence is to be avoided during the existence of such disease. Finally, I submit for discussion the method discussed in the paper of dealing with cases of unilateral inflammatory disease of the uterine appendages, especially in women de- sirous of bearing children.