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. As a 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 the menopause or when immediate certain relief is demanded from prolonged suffering.