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period of months. But I have seen a tube on several occasions, which was the size of a small banana, gradually diminish, shrivel, and entirely disappear, so far as its detection by my finger was concerned, after several months of iodine and glycerin applications, hot douches, and warm sitz baths. My partner, Dr. Wells, can substantiate my statement in this respect in regard to a lady whom he treated for me during my absence in Europe two years ago, and who, after about six months of this treatment, entirely recovered. Occasionally the tube obstinately refuses to diminish in size, fluctuation persists in it, and we are forced to believe that it contains fluid of some kind. This may be pus, and in that case aspiration per vaginam will reveal the true nature of the case, and it should be treated according to the rules laid down above. If the fluid turns out to be serum, its complete removal by aspiration in my experience usually results in a shrinking of the hydrosalpinx and a complete obliteration of the tube, with restoration to health, even though the tube may remain attached to Douglas' pouch.

The chronic stage is the one in which the case usually comes into the hands of the specialist. The treatment above outlined has either failed in the hands of the general practitioner, or else the true nature of the case has not been recognized, or the patient herself has neglected to seek advice until the acute and subacute stages had passed; or, indeed, there never was any acute or subacute stage, but gradual recurrences of so-called "pelvic congestion," evidenced by more or less severe pain, often following a chronic endometritis, have gradually resulted in an inflammatory hyperplasia of the tubal walls and agglutination of the fimbriated extremity, and an adhesion of ovary and tube to the neighboring peritoneum.

Now, I can fairly say that of the many hundred cases of this affection which I have seen in the chronic stage, but a very small proportion, as I have already stated, has seemed to me to warrant the removal of the diseased appendages. On the other hand, in looking over my records at the Mount Sinai Hospital for the last eighteen months I find forty-seven cases of chronic salpingo-oöphoritis recorded, all of which were treated by the iodine and glycerin, hot douche, and warm sitz-bath methods, and of whom thirty-eight were discharged

improved, four cured, and five unimproved; the average duration of the treatment being three weeks. Of the unimproved I should say one remained in the hospital only two days, another three days, a third six days, a fourth seven days, and a fifth fourteen days-evidently too short a time in any case to expect any benefit from treatment. I have in my mind ten cases occurring in my private practice during the last seven or eight years, in whom the removal of the enor mously swollen tubes would certainly have been justified, if I had not felt that it was my duty to endeavor to do all I could to obviate the necessity for the operation. One, a lady from Buffalo, consulted me eight years ago for as violent a salpingitis of both sides as I ever saw. She had an acute endometritis, her ovaries and tubes were bound down, her uterus absolutely immovable, the right appendages enlarged to the size of an orange, and I felt obliged to tell her that it would be impossible for me to cure her except by removing the appendages. She refused the operation, but insisted upon being treated, no matter how severe the treatment was, so long as it benefited her and enabled her to live without being operated upon, in comparative comfort. Her menstrual periods were profuse, the pain at times so severe as to require morphine, and had been so for years. I never knew a woman more persistent in her endeavors to regain health without the aid of the knife. Blisters, iodine, glycerin, hot sitz baths, hot douches, persistent local use of galvanism for months, finally succeeded in improving this case so materially that now the lady has been in very fair health for at least five years and has seldom been compelled to consult me or any other physician for her pelvic organs.

Six of the cases were seen by me during the last two years. I saw the patients in the subacute stage at first, in consultation, later they came to my office: the tube was still as large as when I had seen the patients in bed; it was apparently immovable, was painful, but there was no more febrile reaction. In from three to six months I had succeeded, by means of the palliative treatment just mentio ed, in reducing the tube so that it was practically no longer detectable per vaginam, and, so far as any symptoms were concerned, the patients were entirely well. The cases in which

I have succeeded in benefiting patients with adherent, more or less enlarged appendages by this treatment are so numerous that, while I do not pretend to have absolutely cured any of them, I certainly have felt that they have escaped in my hands the necessity for, and the dangers of, a laparatomy. They may not have conceived, they may never conceive; but certainly, if I had removed their appendages, the possibility of conception would have been out of the question. In one case which was sent to me by my partner, Dr. Wells, I found both tubes enlarged to the size of a small sausage and adherent, as well as the uterus. The woman was sterile, and I predicted a continuance of that condition. In spite of that, and, strange to say, before the year was out, the woman conceived and aborted. The tubes were no longer to be felt as distinct swellings, and Dr. Wells tells me that she has aborted twice since. If I ever saw a case which justified, in my opinion, the removal of the appendages, this was one, and still, even though she aborted, the capability for conception remained.

Much has been written and said about the use of massage to procure the detachment of the adherent appendages. I confess that I doubt very strongly whether any treatment of this kind will avail. From my experience with the liberation of adherent appendages through an abdominal incision, I do not see how anything short of the finger introduced in that manner can succeed in peeling loose the adherent organs. Local galvanism undoubtedly exerts an exceedingly beneficial influence, if persisted in and not used strong enough to give pain, in relieving local pain, which is one of the constant symptoms of inflamed and adherent ovaries and tubes. Quite recently active dilatation of the uterus, the use of the curette, and drainage of the uterine cavity, with the avowed intention of also draining the canal of the tube, has been recommended by Polk, Strong of Boston, Pryor, Krug, and others. While I can readily understand the utility of dilating a uterus which contains septic material from which a direct infection has spread to the canal of the tube, I really cannot see what good it is going to do to subject the patient to the risks necessarily following such dilatation and curetting, when she has nothing but a chronic endometritis, and when the accumulation of

pus in the tube is either entirely sealed off from the uterine cavity or when there is really no distinct purulent accumulation in the tube. That a connection between the uterine cavity and the Fallopian tube may be secured, on rare occasions, by means of dilatation of the uterine canal and a fortunate patulous condition of the uterine opening of the tube, cannot be denied. The late Dr. H. Lenox Hodge, of Philadelphia, de-monstrated many years ago the possibility of the fetus in a tubal pregnancy being forced into and escaping through the uterine canal. Dr. Emmet corroborates this experience, and I myself have seen a similar case. We frequently hear of cases where periodical discharges of so-called purulent material take place from the uterus, being preceded by pain in the ovarian regions. The assumption has been made, with fair justification, that these purulent accumulations came from a pyo-salpinx which filled and discharged and refilled and discharged again, but I am not at all sure that Bland Sutton is not correct when he says, in his recent work on the "Surgical Diseases of the Tubes and Ovaries," that there is no trustworthy evidence that a pyo-salpinx or a hydro-salpinx discharges into the uterus. I, for my part, have never seen a case where an accompanying endometritis would not sufficiently explain the occurrence of the discharge. A case recently seen by me corroborates this statement. The patient had precisely the history of periodical purulent discharges preceded by pain in the ovarian regions which I have just mentioned.. The diagnosis of pyo-salpinx had been made by Dr. Bache Emmet, who had seen her before me. He subsequently operated upon her in his service at the Woman's Hospital, and informed me that there was absolutely no trace of pus or suppuration in the tubes. When I recall the numerous cases of salpingitis upon which I have operated in which the walls of the tube were enormously hypertrophied and the tube

1 The danger of dilatation and curetting under these conditions was shown me by a case seen last year, where a lady, who had formerly had an undoubted pyo-salpinx which gradually disappeared, required this treatment for retention of portions of the ovum after incomplete abortion. She developed an acute pyo-salpinx on the same side, which I opened and drained per vaginam, with fortunately complete recovery.

2 Reported by Dr. Cornelius Williams, who called me in consultation,. N. Y. Med. Journal, 1878.

divided into separate sacs, each containing a small quantity of muco-pus, with perhaps a little true pus in the ampulla at the infundibulum, I can readily understand how utterly futile. would be the attempt to produce a drainage of such a tube through the uterine canal, no matter how widely dilated or how patulous the uterine orifice of the tube. I confess, therefore, that I am not as yet a convert to this treatment of salpingitis, although I am willing to admit that it is in the highest degree plausible and may be the one method of the future by which we can reach and treat by local applications these obstinate conditions of the Fallopian tube.

I am sorry to say that, so far as actual cure is concerned, the palliative treatment referred to in the above lines is by no means as satisfactory as I could wish it to be. But I still feel that if by these remarks I can induce those of my colleagues, particularly the younger generation, who have not yet grown to believe that they know everything and that they are infallible, to be more conservative with the knife and to try to preserve to a woman her distinctive organs as long as possible, I shall feel amply repaid and able to endure with equanimity the criticism which undoubtedly I shall receive from some of the gentlemen referred to, with whom I do not agree.

Operative Conservative Methods of Treatment.-It might be as well to call these methods preservative instead of conservative, because they are intended, while surgical, still to preserve or restore the integrity of the diseased tube. All these methods imply the performance of an abdominal section. Hadra, formerly of Austin, now of Galveston, Texas, seems to have been among the first to recommend the detachment with the fingers of the adherent tubes, which, if found healthy, he left otherwise intact (1885). Polk (1887) went even further than this, for after detaching the adherent tube he expressed the mucus from it so as to restore its calibre, and attached the uterus to the anterior abdominal wall in order to prevent the readhesion of the tube. Martin (1888) removed the fimbriated extremity of the tube and restored its lumen. Howitz, Championnière, Terrillon, practised a similar method with excellent results. In a paper written by me on "A. Year's Work in Laparatomy," published in January, 1888, I

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