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Salpingitis and tubal patency
SALPINGITIS AND TUBAL PATENCY FREDERICK L. SCHWARTZ, M.D. SAN DIEGO, CALIFORNIA
T
HE question of tuba1 patency and the most desirabIe method of determining it are &II matters of discussion. The reIation of tuba1 patency to the presence or absence of abnorma1 change has been given much Iess thought. Opinion is very definiteIy divided as to the reIative merits of insufllation and hysterosalpingography. WhiIe there is genera1 accord that hysterosalpingography gives much more definite information, many gynecoIogists beIieve that it aIso carries more potentia1 hazards for the patient. PossibIe compIications of hysterosaIpingography, Iisted by Bernard0 Schaffer, are: Increase in endometriosis, increased tendency to ectopic pregnancy, toxic phenomena due to iodism, severe infection due to residua1 inff ammatory processes, fat emboIism, rupture of the tubes, and rupture of the uterus due to the presence of neopIasm. E. Leinziger Iists the dangers as: (I) ChemicaI toxic, (2) mechanica1, (3) embolic, and (4) inflammatory. In his opinion, hysterosaIpingography shouId be done onIy as a hospital procedure. Yukio Hukata concIudes that iodized oi1 stimuIates edema, and that when iodized oi1 escapes from the FaIIopian tubes it produces adhesions in nearby structures. ComparabIe iI effects have, on the other hand, been reported with gas insufllation. GreenhiII comments on a series of 600 Rubin tests performed by HeaIy, with three deaths in apparentIy norma women. AI1 examinations were performed under ether anesthesia, and the deaths were in a group in which nitrous oxide and oxygen were used for insufllation. He deduces that some of these cases must have been hysteroSaIpingographies. WhiIe insutllation is the procedure of his choice, it is his opinion that the injection of iodized oi1 is practicaIIy harmIess when properly performed.
Strong proponents of iodized oi1 are LeventhaI and SoIomon. They beIieve that when properly used, it carries a negIigibIe morbidity, and is superior to gas ins&lation both from a diagnostic and therapeutic standpoint. The number of pregnancies in their series is remarkabIe. Out of I 14 patients with one or both tubes patent, fiftyone conceived. In nineteen cases with no demonstration of patency, three conceived. In the discussion of this paper, Dr. Ronald Crom summarizes the views of many in the folIowing statement: “My conversion to JipiodoI was due to the fact that tubes found to be impervious to carbon dioxide, repeatedIy became patent to an oiI substance at pressure beJow that used for gas insufJlations. Second, more patients and many of those previousIy insuflIated became pregnant. Third, peritonea1 reactions to JipiodoI when minimum quantities, 5 to 7.5 cc. were introduced, were no more common than after gas. Fourth, one can Iearn more about the condition of the uterus, tubes and ovaries than is the case with gas insuffIations.” In my own work, whiIe gas insuffIation is frequently done, hysterosalpingography became the procedure of choice when in doubt. When the fiIms of an increasing number of cases were studied in conjunction with the patients’ histories and physica1 condition, it seemed possibIe to obtain more information than the mere matter of tuba1 ,patency. Little couId be Cound in the Iiterature, however, as to the significance and prognostic vaIue of the various fiIIing changes in the tubes. Many patients with patency on both sides give a history of repeated attacks of saIpingitis, whiIe others with compIete biIatera1 blocking present an entireIy negative history and are weI1. In the avaiIabIe Iiterature, the first attempt to correIate tuba1 patency, cIinicaI
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and microscopic findings was reported by Watkins and Menne. Using both surgica1 and autopsy materia1 from patients with
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of hysterosaIpingography. This method was used in a series of zoo hysterosaIpingographies. In order better to correIate radio-
FIG. I. Film not a part of this series but shown through the courtesy of an associate. Vascular filling and apparent perforation; no iII effects.
chronic saIpingitis, forty-nine tubes were injected with radio-opaque materia1 and studied by x-ray. Of these tubes they found 30 per cent closed and 22 per cent narrowed in the intramura1 position. In the isthmian portion, 40 per cent were cIosed and 32 per cent narrowed. The fimbriated end was cIosed in 38 per cent of the cases. OccIusion seemed to depend on whether or not the fimbriae were adherent to the ovary. An interesting and apparently vaIid expIanation of the fact that tubes may be bIocked at the cornu and the patient quite free from symptoms, is found in a paper by Falk, in which he recommends tubal resection for recurrent saIpingitis. It is his contention that tubes tend to hea and steriIize themseIves if not reinfected from beIow. Forty-three, 67 per cent, of the cases in which tuba1 resection was done were reported as cIinicaIIy cured, or asymptomatic. Sixteen cases, or 24 per cent, had sIight symptoms, and five cases, or 7 per cent, had definite complaints. In a previous communication, I have described a method of obtaining a graphic record of the amount of uterine mobiIity by a minor variation from the usua1 technic
graphic findings with actual tissue changes, it was decided to review this series. The past history, the physica findings, and, as far as possibIe, the end resuIts were listed together with the fiIIing defects noted. Thirty-five of the fiIms were rechecks, Ieaving 165 patients to be considered. AI1 of these fiIms were made as an offIce procedure, and in no case there was sufficient reaction to prevent the patient coming in for her twenty-four hour film, or from carrying on her reguIar occupation. AI1 injections were made through a soft tipped cannuIa and manometric contro1 was not used. Injections were made very sIowIy and gentIy and after 3 to 4 cc. a fiIm was exposed, developed and viewed before proceeding. Injection was discontinued, however, and a fiIm made, regardIess of the amount injected, if the patient compIained of severe pain. At first the series consisted soIeIy of steriIity studies, but more recentIy I have extended the indications to incIude patients with recurrent saIpingitis who desired children. There were severa reasons for this step. As my experience grew, I found in sterility studies that hysterosaIpingography
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in patients with a previous history of sail ?ingitis evoked nc> more reactions than in any other pat ien It, provided the con-
American Jo urnal of Surgery
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with oi1 pouring throug ;h the perfon ttion. In addition the vascuIar channels are fiIIed with oil. Inquiry devek )ped the fact that
FIG. 2. Case No. 155. Left-sided salpingitis; narrowing and stricture of tube; polyp near left cornu causing spotting; patient had an unsuccessfut curettage prior to her ieferral.
dition was quiescent. SecondIy, such a study in a group of patients who required saIpingectomy offered an opportunity to compare the radiographic with the surgica1 and pathoIogic picture. Also, in many border-Iine cases much time might be saved in deciding whether chiId-bearing was possibIe or probabIe, and whether conservative treatment shouId be continued or surgery advised. Apart from the present series but interesting in demonstrating compIications that may arise, and aIso that they are Iess serious than commonIy considered, is a fiIm (Fig. I) made in my offIce by an associate, a gynecoIogist of unquestioned abiIity and experience. Contrary to custom, for some reason, this fIIm was not carefuIIy studied unti1 after the patient had returned the foIIowing day for her twentyfour hour check. In the fundus there appears to be a perforation from the cannuIa
the patient experienced one sharp pain during the .procedure, but feIt quite we11 afterward and continued her occupation as a war worker on the foIIowing day without symptoms or complications of any kind. To faciIitate anaIysis the cases are tabulated in series; patency or bIocking at cornu, isthmus and fimbria is designated, together with information ‘as to the patient’s condition. Many of the patients Iisted as recurrent saIpingitis presented onIy minima1 symptoms which were reIieved by occasiona treatment. In a11 patients subjected to surgery, fmdings were confirmed by tissue examination and the patients were a11reIieved of their symptoms. In the present series of 165 patients, there were tweIve pregnancies, and eighteen on whom biIatera1 saIpingectomy was done. In a11 patients subjected to surgery, all tubes were studied by seria1 sections, by Dr. James D. Edgar, head of Department
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of PathoIogy, Mercy Hospital, San Diego, California. AI1 but four of these patients had some
From seria1 fiIms it partiaI obstruction. appeared that many of these tubes had been opened by pressure of the oi1. Of
FIG. 3. Case No. 136. Recurrent Matera Iow hanging - - tubes; both tubes patent; tion at extremities.
degree of tuba1 patency, but in no case at surgery was there found ‘any evidence of irritation from the iodized oi1. As previousIy mentioned, none of these patients presented any untoward reaction from the examination; however, no such examination was made unti1 the patient was temperature free and quiescent for several weeks and couId withstand a fairIy vigorous bimanua1 examination without reaction. It is quite probabIe that there wouId have been a Iarger number of pregnancies had it not been for the war. No doubt some famiIies are deferring pregnancies for the time being, and other famiIies are separated. There were twenty-nine women with both tubes compIeteIy patent and with entireIy negative history and findings. There was onIy one pregnancy in this group, but it may be added that disturbances of ovuIation were quite frequent in the same group. With both tubes patent but some history of saIpingitis, there were seventy-four patients. In this group tubes were Iisted as patent, provided they were permeabIe to oiI, even though there was evidence of
JULY, 1944
saIpingitis; Iarge beading and diIa-
these women, nine became pregnant and seven were subjected to surgery. The number of pregnancies is greatest in this group and most pregnancies foIIowed shortIy after hysterosaIpingography. Very possibIy mechanica opening may have been a factor. AI1 of the pregnancies reported were normal uterine and no cases of ectopic gestation were encountered. In five patients one tube was found to be patent with the other bIocked at the cornu. None of these patients couId recaI1 any definite attacks of peIvic disease aIthough a11 admitted occasiona peIvic pain during chiIdhood and puberty. In this group no evidence of saIpingitis was found on peIvic examination and two became pregnant shortIy after study. There were twenty-one women with one tube patent and the other bIocked at the cornu who compIained of pain on the patent side. Most of these patients stated that their pain had previousIy been biIateral or even more severe on the opposite side. PhysicaI examination confirmed the diagnosis of saIpingitis on the patent side. In this group there were no pregnancies
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and seven of these women required surgica1 reIief. In four patients with one tube bIocked
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surgery for the reIief of her symptoms. The other ten were free from symptoms and significant cIinica1 findings at the time of
FIG. 4. Case No. 165. Recurrent biIatera1 salpingitis; surgery; both tubes partially patent; narrowing of tubes with displacement of uterus.
at the cornu there were biIatera1 symptoms and one patient with one tube bIocked at the cornu presented symptoms on the same side. In a11 of these women the symptoms were miId in nature and may have been maintained through the Iymphatics. One patient had one tube patent and the other bIocked at the isthmus. About a year prior to her steriIity study a Iarge right ovarian cyst was removed and a portion of the tube was removed with the cyst. She has not become pregnant and further study shows the majority of her cycIes to be anovuIatory. There were no history, symptoms or findings characteristic of salpingitis in this patient. Five women had one tube bIocked at the fimbriated extremity and one of these required radica1 surgery for reIief of her symptoms. In these cases there had obviousIy been at some time a suffIcientIy severe inffammatory process to cause the fimbriae to adhere to the ovary or other adjacent structures. An interesting group consists of eIeven women with both tubes bIocked at the cornu. One of these patients required
study. These ten were steriIity studies in which gas wouId not pass and here again further questioning deveIoped the presence of vague undiagnosed peIvic pain in their earIier years. It seems probabIe that in these patients a pre-existing saIpingitis had heaIed after occIusion at the cornu. Two patients presented biIatera1 isthmia bIocking. One of these had miId recurrent saIpingitis. In the other there had been a gonorrhea1 salpingitis foIlowed by a biIateraI hemisaIpingectomy. She is quite we11 at the present time. In eight patients one tube was bIocked at the cornu and the other at the fimbriated Five of these were we11 and extremity. without any significant physica findings at the time of study. Two of the three presenting symptoms required operation. Four patients had both tubes bIocked at the fimbriated extremities. Three of these were free from symptoms and had no definite history of saIpingitis. The other has had a biIatera1 saIpingectomy. Many of the patients with one tube bIocked at the cornu gave a history of previousIy having had symptoms on the
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bIocked side. It is significant to note that of eIeven women with biIatera1 cornua1 bIocking ten were weI1.
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One additiona finding of interest is the fact that a fair number of women find their symptoms reIieved by hysterosaIpingog-
FIG. 5. Case No. 131. Recurrent biIatera1 salpingitis; surgery; both tubes patent but eIongated with cIubbing and adhesions at extremities.
When the tubes are patent in the presence of definite saIpingitis the most characteristic radioIogic findings are elongation, redundancy and cIubbing of the extremity and areas of narrowing. UsuaIIy the uterus is dispIaced to one side, probabIy due to contraction of a previous inff ammation. The tube on that side may be narrowed or beaded near the uterus, the midportion looped or convoluted, and the fimbriated extremity Iow and often partiaIIy obstructed. The opposite tube is eIongated and usuaIIy narrowed and may show simiIar changes at the extremity. In spite of their permeabiIity pregnancy was rare in this type of tube. The fiIms seIected (Figs. 2, 3 and 4) from this series for presentation show these changes fairIy weI1. The not infrequent findings of tubal occIusion in young women that are symptom free and without history of infection suggest the possibiIity of a blood or Iymph-borne saIpingitis during chiIdhood or adoIescence. It may be that some of the vague, Iower abdomina1 pains in young girIs are an unrecognized saIpingitis.
raphy. There has been neither suff%ient time eIapsed nor a suff’cient number of cases to evaluate properly this finding. Whether this improvement is due to the possibIe hydrauIic opening of the tubes or to the IocaI effect of the oi1 is impossibIe to determine. In view of the varied treatments many of these patients have had, I cannot consider the effect entireIy psychic. SUMMARY
In determining tuba1 patency, hysterosaIpingography, when properIy done, even in the presence of saIpingitis, carries no more risk than any other diagnostic procedure. WhiIe it carries more possibIe complications, the morbidity is negIigibIe, and it is superior to gas insufllation from both diagnostic and therapeutic standpoints. In the presence of saIpingitis of sufficient duration and severity to warrant surgery, but in which preservation of chiId-bearing function is desired, this procedure is of vaIue in deciding between continued loca1 treatment and surgery.
Schwartz-SaIpingitis
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BiIateFaI saIDineitis No salpingkis; previous right oophorectomy Negative history and findings Negative history and findings
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salpingitis;
gery BiIateraI saIpingitis; we11 now Right salpingitis Negative history and findings Negative history and findings BiIateraI saIpingitis BiIateraI salpingitis Negative history and findings BiIateraI salpingitis Bilateral saloineitis BiIateraI sal’pingitis BiIateraI salpingitis; pregnancy Negative history and findings Previous saIpingitis; we11 IIOW
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A series of 163 patients was reviewed. Radiographic findings were compared with the surgica1 and pathoIogic picture. There were tweIve pregnancies and eighteen on whom bilatera1 saIpingectomy was done. In a11 those coming to surgery, defmite tissue changes were found, and al1 pa-
New SERIESVOL.LXV. No.
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Schwartz-SaIpingitis
tients were free from symptoms after surgery. SaIpingitis may be present even though a tube is permeable. Such tubes present certain characteristic radioIogic features, such as elongation, cIubbing and redundancy at the extremity, and areas of stenosis and diIation. Pregnancy is rare in this type of tube in spite of its permeabiIity. OccIusion at the cornu prevents reinfection from beIow and as a genera1 ruIe resuJts in seIf-steriIization and healing of the tubes. There were twenty-nine women with both tubes compIeteIy patent, with entireIy negative history and findings. Disturbances of ovulation were quite frequent, with onIy one pregnancy in the group. Seventy-four patients had both tubes patent but some history of saIpingitis. In this group tubes were Iisted as patent, provided they were permeabIe to oi1, even though there was evidence of partia1 obstruction. From seria1 fiIms it appeared that many of these tubes had been opened by pressure of the oi1. Of these, nine patients became pregnant and seven were sub jetted to surgery. Of five patients with one tube patent and the other bIocked at the cornu, with negative history and findings, two became pregnant. Twenty-one women had one tube bIocked at the cornu, with symptoms on the patent side. There were no pregnancies and seven of these required surgery. With one tube bIocked at the cornu, four cases had biIatera1 symptoms, and one case presented symptoms on the same side. One patient had one tube patent, and the other bIocked at the isthmus, foIIowing remova of a Iarge ovarian cyst. Five women had one tube bIocked at the fimbriated extremity, and one of these required surgery. Of eIeven cases with both tubes bIocked at the cornu, ten were we11 and the other we11 after operation. Two patients had both tubes bIocked at
American Journal of Surgery
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the isthmus. One had previousry a biIatera1 hemisaIpingectomy and is weI1; the other had miId recurrent saIpingitis. Eight women had one tube bIocked at the cornu and the other bJocked at the fimbriated extremity. Five were free from symptoms, and two of the three with symptoms required operation. Four patients had both tubes bIocked at the fimbriated extremities; three are weIJ and the other has had a biJatera1 saIpingectomy. The not infrequent radioIogic findings of tuba1 damage in young women with compIeteIy negative histories and tuba1 fmdings suggests the possibiIity that the vague Jower abdominal pains often compIained of during chiIdhood and adoIescence may be the resuIt of an unrecognized bIood or Iymph-borne saIpingitis. In a number of cases with a record of previous varied treatments, symptoms have been relieved by hysterosaIpingography. Tuba1 patency can be and often is coincidenta with salpingitis, aIthough the majority of such tubes are not compIeteIy patent. CornuaI 0ccIusion usuaIIy resuIts in seIf-sterilization and seIf-heaIing. REFERENCES CROM, RONALD S. Discussion of: Leventhal, M. L. and SoIomon, E. M. Am. J. Obsc. CY Gynec., 41: 628664, 1941. FALK, H. C. Tuba1 resection as treatment for recurrent saIpingitis; preliminary report. Am. J. Surg., 33: 509-5 12, 1936. GREENHILL, J. P. Yearbook of Obstetrics & Gynecology. P. 340, 194 I. HUKATA, Y. Experimental study on hysterosalpingography. Jap. J. Obst. &+Gynec., 24: 24-32, 1941. LEINZINGER, E. Gefahren und Schliden durch Kontrastfiilbmg der Gebiirmutter und ihre Verhiitung. Miincben. med. Wcbscbr., 87: 1023-1026, 1940. LEVENTHAL, M. L. and SOLOMON, E. M. Therapeutic value of tuba1 patency tests in sterility and infertiIity. Am. J. Obst. CYGynec., 41: 628-664, 1941. SCHAFFER, B. Accidentes de Ia histerosaIpingografia. La inyeccion venosa accidentat. Bol. Sot. de obst. y ginec. de Buenos Aires, 20: 517-530, 1941. SCHWARTZ, F. L. Uterine p&apse, an x-ray study. Am. J. Surg., 53: I I I-I 16, 1941. WATKINS, R. E. and MENNE, F. R. OccIusions of lumen of FaIIopian tube. J. A. M. A., 95; 16471653, wo.
T
HE question of tuba1 patency and the most desirabIe method of determining it are &II matters of discussion. The reIation of tuba1 patency to the presence or absence of abnorma1 change has been given much Iess thought. Opinion is very definiteIy divided as to the reIative merits of insufllation and hysterosalpingography. WhiIe there is genera1 accord that hysterosalpingography gives much more definite information, many gynecoIogists beIieve that it aIso carries more potentia1 hazards for the patient. PossibIe compIications of hysterosaIpingography, Iisted by Bernard0 Schaffer, are: Increase in endometriosis, increased tendency to ectopic pregnancy, toxic phenomena due to iodism, severe infection due to residua1 inff ammatory processes, fat emboIism, rupture of the tubes, and rupture of the uterus due to the presence of neopIasm. E. Leinziger Iists the dangers as: (I) ChemicaI toxic, (2) mechanica1, (3) embolic, and (4) inflammatory. In his opinion, hysterosaIpingography shouId be done onIy as a hospital procedure. Yukio Hukata concIudes that iodized oi1 stimuIates edema, and that when iodized oi1 escapes from the FaIIopian tubes it produces adhesions in nearby structures. ComparabIe iI effects have, on the other hand, been reported with gas insufllation. GreenhiII comments on a series of 600 Rubin tests performed by HeaIy, with three deaths in apparentIy norma women. AI1 examinations were performed under ether anesthesia, and the deaths were in a group in which nitrous oxide and oxygen were used for insufllation. He deduces that some of these cases must have been hysteroSaIpingographies. WhiIe insutllation is the procedure of his choice, it is his opinion that the injection of iodized oi1 is practicaIIy harmIess when properly performed.
Strong proponents of iodized oi1 are LeventhaI and SoIomon. They beIieve that when properly used, it carries a negIigibIe morbidity, and is superior to gas ins&lation both from a diagnostic and therapeutic standpoint. The number of pregnancies in their series is remarkabIe. Out of I 14 patients with one or both tubes patent, fiftyone conceived. In nineteen cases with no demonstration of patency, three conceived. In the discussion of this paper, Dr. Ronald Crom summarizes the views of many in the folIowing statement: “My conversion to JipiodoI was due to the fact that tubes found to be impervious to carbon dioxide, repeatedIy became patent to an oiI substance at pressure beJow that used for gas insufJlations. Second, more patients and many of those previousIy insuflIated became pregnant. Third, peritonea1 reactions to JipiodoI when minimum quantities, 5 to 7.5 cc. were introduced, were no more common than after gas. Fourth, one can Iearn more about the condition of the uterus, tubes and ovaries than is the case with gas insuffIations.” In my own work, whiIe gas insuffIation is frequently done, hysterosalpingography became the procedure of choice when in doubt. When the fiIms of an increasing number of cases were studied in conjunction with the patients’ histories and physica1 condition, it seemed possibIe to obtain more information than the mere matter of tuba1 ,patency. Little couId be Cound in the Iiterature, however, as to the significance and prognostic vaIue of the various fiIIing changes in the tubes. Many patients with patency on both sides give a history of repeated attacks of saIpingitis, whiIe others with compIete biIatera1 blocking present an entireIy negative history and are weI1. In the avaiIabIe Iiterature, the first attempt to correIate tuba1 patency, cIinicaI
66
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and microscopic findings was reported by Watkins and Menne. Using both surgica1 and autopsy materia1 from patients with
JULY,1944
of hysterosaIpingography. This method was used in a series of zoo hysterosaIpingographies. In order better to correIate radio-
FIG. I. Film not a part of this series but shown through the courtesy of an associate. Vascular filling and apparent perforation; no iII effects.
chronic saIpingitis, forty-nine tubes were injected with radio-opaque materia1 and studied by x-ray. Of these tubes they found 30 per cent closed and 22 per cent narrowed in the intramura1 position. In the isthmian portion, 40 per cent were cIosed and 32 per cent narrowed. The fimbriated end was cIosed in 38 per cent of the cases. OccIusion seemed to depend on whether or not the fimbriae were adherent to the ovary. An interesting and apparently vaIid expIanation of the fact that tubes may be bIocked at the cornu and the patient quite free from symptoms, is found in a paper by Falk, in which he recommends tubal resection for recurrent saIpingitis. It is his contention that tubes tend to hea and steriIize themseIves if not reinfected from beIow. Forty-three, 67 per cent, of the cases in which tuba1 resection was done were reported as cIinicaIIy cured, or asymptomatic. Sixteen cases, or 24 per cent, had sIight symptoms, and five cases, or 7 per cent, had definite complaints. In a previous communication, I have described a method of obtaining a graphic record of the amount of uterine mobiIity by a minor variation from the usua1 technic
graphic findings with actual tissue changes, it was decided to review this series. The past history, the physica findings, and, as far as possibIe, the end resuIts were listed together with the fiIIing defects noted. Thirty-five of the fiIms were rechecks, Ieaving 165 patients to be considered. AI1 of these fiIms were made as an offIce procedure, and in no case there was sufficient reaction to prevent the patient coming in for her twenty-four hour film, or from carrying on her reguIar occupation. AI1 injections were made through a soft tipped cannuIa and manometric contro1 was not used. Injections were made very sIowIy and gentIy and after 3 to 4 cc. a fiIm was exposed, developed and viewed before proceeding. Injection was discontinued, however, and a fiIm made, regardIess of the amount injected, if the patient compIained of severe pain. At first the series consisted soIeIy of steriIity studies, but more recentIy I have extended the indications to incIude patients with recurrent saIpingitis who desired children. There were severa reasons for this step. As my experience grew, I found in sterility studies that hysterosaIpingography
NEW’ SERIES VOL.LXV, Nc,.
I
Schwartz-SaIpingitis
in patients with a previous history of sail ?ingitis evoked nc> more reactions than in any other pat ien It, provided the con-
American Jo urnal of Surgery
47
with oi1 pouring throug ;h the perfon ttion. In addition the vascuIar channels are fiIIed with oil. Inquiry devek )ped the fact that
FIG. 2. Case No. 155. Left-sided salpingitis; narrowing and stricture of tube; polyp near left cornu causing spotting; patient had an unsuccessfut curettage prior to her ieferral.
dition was quiescent. SecondIy, such a study in a group of patients who required saIpingectomy offered an opportunity to compare the radiographic with the surgica1 and pathoIogic picture. Also, in many border-Iine cases much time might be saved in deciding whether chiId-bearing was possibIe or probabIe, and whether conservative treatment shouId be continued or surgery advised. Apart from the present series but interesting in demonstrating compIications that may arise, and aIso that they are Iess serious than commonIy considered, is a fiIm (Fig. I) made in my offIce by an associate, a gynecoIogist of unquestioned abiIity and experience. Contrary to custom, for some reason, this fIIm was not carefuIIy studied unti1 after the patient had returned the foIIowing day for her twentyfour hour check. In the fundus there appears to be a perforation from the cannuIa
the patient experienced one sharp pain during the .procedure, but feIt quite we11 afterward and continued her occupation as a war worker on the foIIowing day without symptoms or complications of any kind. To faciIitate anaIysis the cases are tabulated in series; patency or bIocking at cornu, isthmus and fimbria is designated, together with information ‘as to the patient’s condition. Many of the patients Iisted as recurrent saIpingitis presented onIy minima1 symptoms which were reIieved by occasiona treatment. In a11 patients subjected to surgery, fmdings were confirmed by tissue examination and the patients were a11reIieved of their symptoms. In the present series of 165 patients, there were tweIve pregnancies, and eighteen on whom biIatera1 saIpingectomy was done. In a11 patients subjected to surgery, all tubes were studied by seria1 sections, by Dr. James D. Edgar, head of Department
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Schwartz-SaIpingitis
of PathoIogy, Mercy Hospital, San Diego, California. AI1 but four of these patients had some
From seria1 fiIms it partiaI obstruction. appeared that many of these tubes had been opened by pressure of the oi1. Of
FIG. 3. Case No. 136. Recurrent Matera Iow hanging - - tubes; both tubes patent; tion at extremities.
degree of tuba1 patency, but in no case at surgery was there found ‘any evidence of irritation from the iodized oi1. As previousIy mentioned, none of these patients presented any untoward reaction from the examination; however, no such examination was made unti1 the patient was temperature free and quiescent for several weeks and couId withstand a fairIy vigorous bimanua1 examination without reaction. It is quite probabIe that there wouId have been a Iarger number of pregnancies had it not been for the war. No doubt some famiIies are deferring pregnancies for the time being, and other famiIies are separated. There were twenty-nine women with both tubes compIeteIy patent and with entireIy negative history and findings. There was onIy one pregnancy in this group, but it may be added that disturbances of ovuIation were quite frequent in the same group. With both tubes patent but some history of saIpingitis, there were seventy-four patients. In this group tubes were Iisted as patent, provided they were permeabIe to oiI, even though there was evidence of
JULY, 1944
saIpingitis; Iarge beading and diIa-
these women, nine became pregnant and seven were subjected to surgery. The number of pregnancies is greatest in this group and most pregnancies foIIowed shortIy after hysterosaIpingography. Very possibIy mechanica opening may have been a factor. AI1 of the pregnancies reported were normal uterine and no cases of ectopic gestation were encountered. In five patients one tube was found to be patent with the other bIocked at the cornu. None of these patients couId recaI1 any definite attacks of peIvic disease aIthough a11 admitted occasiona peIvic pain during chiIdhood and puberty. In this group no evidence of saIpingitis was found on peIvic examination and two became pregnant shortIy after study. There were twenty-one women with one tube patent and the other bIocked at the cornu who compIained of pain on the patent side. Most of these patients stated that their pain had previousIy been biIateral or even more severe on the opposite side. PhysicaI examination confirmed the diagnosis of saIpingitis on the patent side. In this group there were no pregnancies
NEW SERIESVOL.LXV, No. I
Schwartz-SaIpingitis
and seven of these women required surgica1 reIief. In four patients with one tube bIocked
Amencan Journal of Surgery
69
surgery for the reIief of her symptoms. The other ten were free from symptoms and significant cIinica1 findings at the time of
FIG. 4. Case No. 165. Recurrent biIatera1 salpingitis; surgery; both tubes partially patent; narrowing of tubes with displacement of uterus.
at the cornu there were biIatera1 symptoms and one patient with one tube bIocked at the cornu presented symptoms on the same side. In a11 of these women the symptoms were miId in nature and may have been maintained through the Iymphatics. One patient had one tube patent and the other bIocked at the isthmus. About a year prior to her steriIity study a Iarge right ovarian cyst was removed and a portion of the tube was removed with the cyst. She has not become pregnant and further study shows the majority of her cycIes to be anovuIatory. There were no history, symptoms or findings characteristic of salpingitis in this patient. Five women had one tube bIocked at the fimbriated extremity and one of these required radica1 surgery for reIief of her symptoms. In these cases there had obviousIy been at some time a suffIcientIy severe inffammatory process to cause the fimbriae to adhere to the ovary or other adjacent structures. An interesting group consists of eIeven women with both tubes bIocked at the cornu. One of these patients required
study. These ten were steriIity studies in which gas wouId not pass and here again further questioning deveIoped the presence of vague undiagnosed peIvic pain in their earIier years. It seems probabIe that in these patients a pre-existing saIpingitis had heaIed after occIusion at the cornu. Two patients presented biIatera1 isthmia bIocking. One of these had miId recurrent saIpingitis. In the other there had been a gonorrhea1 salpingitis foIlowed by a biIateraI hemisaIpingectomy. She is quite we11 at the present time. In eight patients one tube was bIocked at the cornu and the other at the fimbriated Five of these were we11 and extremity. without any significant physica findings at the time of study. Two of the three presenting symptoms required operation. Four patients had both tubes bIocked at the fimbriated extremities. Three of these were free from symptoms and had no definite history of saIpingitis. The other has had a biIatera1 saIpingectomy. Many of the patients with one tube bIocked at the cornu gave a history of previousIy having had symptoms on the
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Schwartz-SaIpingitis
bIocked side. It is significant to note that of eIeven women with biIatera1 cornua1 bIocking ten were weI1.
JULY. 1944
One additiona finding of interest is the fact that a fair number of women find their symptoms reIieved by hysterosaIpingog-
FIG. 5. Case No. 131. Recurrent biIatera1 salpingitis; surgery; both tubes patent but eIongated with cIubbing and adhesions at extremities.
When the tubes are patent in the presence of definite saIpingitis the most characteristic radioIogic findings are elongation, redundancy and cIubbing of the extremity and areas of narrowing. UsuaIIy the uterus is dispIaced to one side, probabIy due to contraction of a previous inff ammation. The tube on that side may be narrowed or beaded near the uterus, the midportion looped or convoluted, and the fimbriated extremity Iow and often partiaIIy obstructed. The opposite tube is eIongated and usuaIIy narrowed and may show simiIar changes at the extremity. In spite of their permeabiIity pregnancy was rare in this type of tube. The fiIms seIected (Figs. 2, 3 and 4) from this series for presentation show these changes fairIy weI1. The not infrequent findings of tubal occIusion in young women that are symptom free and without history of infection suggest the possibiIity of a blood or Iymph-borne saIpingitis during chiIdhood or adoIescence. It may be that some of the vague, Iower abdomina1 pains in young girIs are an unrecognized saIpingitis.
raphy. There has been neither suff%ient time eIapsed nor a suff’cient number of cases to evaluate properly this finding. Whether this improvement is due to the possibIe hydrauIic opening of the tubes or to the IocaI effect of the oi1 is impossibIe to determine. In view of the varied treatments many of these patients have had, I cannot consider the effect entireIy psychic. SUMMARY
In determining tuba1 patency, hysterosaIpingography, when properIy done, even in the presence of saIpingitis, carries no more risk than any other diagnostic procedure. WhiIe it carries more possibIe complications, the morbidity is negIigibIe, and it is superior to gas insufllation from both diagnostic and therapeutic standpoints. In the presence of saIpingitis of sufficient duration and severity to warrant surgery, but in which preservation of chiId-bearing function is desired, this procedure is of vaIue in deciding between continued loca1 treatment and surgery.
Schwartz-SaIpingitis
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BiIateFaI saIDineitis No salpingkis; previous right oophorectomy Negative history and findings Negative history and findings
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W. W. s. w. M. W.
BiIateraI salpingitis BiIateraI saloinaitis WeII; previous tuba1 pIastic BiIateraI saIpingitis; pregnancy Left salpingitis Bilateral salpingitis Right salpingitis WeII; previous right hemisaIpingectomy Right saIpingitis BiIateraI saIpingitis Left salpingitis Negative history and findings Previous salpingitis; we11 now Right saIpingitis; surgery BiIateraI saIpingitis Negative history and findings Right saIpingitis; surgery BiIateraI salpingitis We11 now; previous saIpingitis SaIpingitis; pregnancy Salpingitis; surgery
A series of 163 patients was reviewed. Radiographic findings were compared with the surgica1 and pathoIogic picture. There were tweIve pregnancies and eighteen on whom bilatera1 saIpingectomy was done. In a11 those coming to surgery, defmite tissue changes were found, and al1 pa-
New SERIESVOL.LXV. No.
I
Schwartz-SaIpingitis
tients were free from symptoms after surgery. SaIpingitis may be present even though a tube is permeable. Such tubes present certain characteristic radioIogic features, such as elongation, cIubbing and redundancy at the extremity, and areas of stenosis and diIation. Pregnancy is rare in this type of tube in spite of its permeabiIity. OccIusion at the cornu prevents reinfection from beIow and as a genera1 ruIe resuJts in seIf-steriIization and healing of the tubes. There were twenty-nine women with both tubes compIeteIy patent, with entireIy negative history and findings. Disturbances of ovulation were quite frequent, with onIy one pregnancy in the group. Seventy-four patients had both tubes patent but some history of saIpingitis. In this group tubes were Iisted as patent, provided they were permeabIe to oi1, even though there was evidence of partia1 obstruction. From seria1 fiIms it appeared that many of these tubes had been opened by pressure of the oi1. Of these, nine patients became pregnant and seven were sub jetted to surgery. Of five patients with one tube patent and the other bIocked at the cornu, with negative history and findings, two became pregnant. Twenty-one women had one tube bIocked at the cornu, with symptoms on the patent side. There were no pregnancies and seven of these required surgery. With one tube bIocked at the cornu, four cases had biIatera1 symptoms, and one case presented symptoms on the same side. One patient had one tube patent, and the other bIocked at the isthmus, foIIowing remova of a Iarge ovarian cyst. Five women had one tube bIocked at the fimbriated extremity, and one of these required surgery. Of eIeven cases with both tubes bIocked at the cornu, ten were we11 and the other we11 after operation. Two patients had both tubes bIocked at
American Journal of Surgery
73
the isthmus. One had previousry a biIatera1 hemisaIpingectomy and is weI1; the other had miId recurrent saIpingitis. Eight women had one tube bIocked at the cornu and the other bJocked at the fimbriated extremity. Five were free from symptoms, and two of the three with symptoms required operation. Four patients had both tubes bIocked at the fimbriated extremities; three are weIJ and the other has had a biJatera1 saIpingectomy. The not infrequent radioIogic findings of tuba1 damage in young women with compIeteIy negative histories and tuba1 fmdings suggests the possibiIity that the vague Jower abdominal pains often compIained of during chiIdhood and adoIescence may be the resuIt of an unrecognized bIood or Iymph-borne saIpingitis. In a number of cases with a record of previous varied treatments, symptoms have been relieved by hysterosaIpingography. Tuba1 patency can be and often is coincidenta with salpingitis, aIthough the majority of such tubes are not compIeteIy patent. CornuaI 0ccIusion usuaIIy resuIts in seIf-sterilization and seIf-heaIing. REFERENCES CROM, RONALD S. Discussion of: Leventhal, M. L. and SoIomon, E. M. Am. J. Obsc. CY Gynec., 41: 628664, 1941. FALK, H. C. Tuba1 resection as treatment for recurrent saIpingitis; preliminary report. Am. J. Surg., 33: 509-5 12, 1936. GREENHILL, J. P. Yearbook of Obstetrics & Gynecology. P. 340, 194 I. HUKATA, Y. Experimental study on hysterosalpingography. Jap. J. Obst. &+Gynec., 24: 24-32, 1941. LEINZINGER, E. Gefahren und Schliden durch Kontrastfiilbmg der Gebiirmutter und ihre Verhiitung. Miincben. med. Wcbscbr., 87: 1023-1026, 1940. LEVENTHAL, M. L. and SOLOMON, E. M. Therapeutic value of tuba1 patency tests in sterility and infertiIity. Am. J. Obst. CYGynec., 41: 628-664, 1941. SCHAFFER, B. Accidentes de Ia histerosaIpingografia. La inyeccion venosa accidentat. Bol. Sot. de obst. y ginec. de Buenos Aires, 20: 517-530, 1941. SCHWARTZ, F. L. Uterine p&apse, an x-ray study. Am. J. Surg., 53: I I I-I 16, 1941. WATKINS, R. E. and MENNE, F. R. OccIusions of lumen of FaIIopian tube. J. A. M. A., 95; 16471653, wo.