A Text-book of Diseases of Women

by Charles B. Penrose

In some cases the question arises as to whether both tubes should be removed when only one is grossly diseased. In the early stages of chronic pyosalpinx it often happens that but one tube is found diseased, while the other is apparently perfectly healthy or is only slightly adherent. Experience has shown that in a great many cases of tubal disease in which only one tube was removed, the second tube has become similarly affected, often within a short time, and a second operation has been required. This disaster is not likely to occur if the endometrial disease is eradicated by thorough curetting at the time of the first operation. But in some forms of salpingitis, as the gonorrheal, the infection is so deeply seated in the distal ends of the utricular glands that the most vigorous curetting fails to remove it, and the second tube will become infected from the original focus in the uterus.

So common is such occurrence that many women, profiting by the experience of their friends, request the operator to remove both tubes, even though he finds but one diseased. The advice already given in regard to conservative operation applies here also. It is safest in all forms of pyosalpinx to remove both appendages. In the less serious forms of salpingitis—hydrosalpinx and adherent tubes without cystic distention—there is less danger of recurrence, and the unilateral operation may be more safely performed. The importance of thorough treatment of the endometritis at the same time is emphasized by these considerations.

In many cases in which double salpingo-oöphorectomy is performed it is often advisable to remove the uterus at the same time. The uterus may be amputated at any convenient point of the cervix, or it may be completely removed at the vaginal junction. This operation ensures more certain and speedy relief from suffering, and is attended by but little, if any, greater mortality than the simple salpingo-oöphorectomy. The uterus without the tubes and ovaries is a useless structure. The operation is advisable if the uterus is retroverted and adherent, when the uterus is large and subinvoluted, when the disease of the endometrium is severe and is likely to persist—in any case, in fact, in which the physician fears that the uterus may be a subsequent source of trouble.

SUPPURATION OF THE PELVIC CELLULAR TISSUE.

Pus in the female pelvis, to which condition the vague term of pelvic abscess has been applied, is usually the result of salpingitis producing a pyosalpinx, of ovarian abscess, or of suppuration of an ovarian cyst, very often a dermoid. The disease may also occur from infection of a broad-ligament hematoma or from a pelvic hematocele caused by a ruptured tubal pregnancy.

Following these conditions the cellular tissue of the pelvis may become affected, so that the purulent accumulation may make its way between the layers of the broad ligament or in some other part of the pelvis.

Before the days of modern abdominal surgery these accumulations of pus were evacuated through the vagina, the rectum, or the abdominal wall, according to the direction in which the abscess seemed to point or in which it seemed to be most accessible. The sinuses thus formed often persisted for years or during the remaining life of the woman. There were many theories in regard to the origin of the suppuration, it being impossible to determine its true nature without opening the abdomen. Now we know that the great majority of such pelvic abscesses originated in septic infection of the Fallopian tubes, and that infection of the pelvic cellular tissue was secondary.

There are, however, rare cases in which the suppuration occurs primarily in the cellular tissue of the pelvis, without any involvement whatever of the tubes or ovaries. Such an accumulation of pus is usually found in the cellular tissue of the broad ligaments; it sometimes occurs in the utero-vesical tissue, and rarely in the tissue back of the cervical neck.

The cause of such suppuration is usually infection, by way of the lymphatics, from the uterus, or by the passage of septic organisms directly through the uterine wall. The condition is most frequently the result of puerperal sepsis. I have on one occasion seen it occur in connection with extensive venereal ulceration of the external genitals. It seems probable that a pelvic lymphatic gland, becoming infected, may break down and suppurate, forming the starting-point of the abscess.

The symptoms of this form of pelvic abscess are those characteristic of any other kind of suppuration in the pelvis.