A Text-book of Diseases of Women

by Charles B. Penrose

DISEASES OF THE FALLOPIAN TUBES.

The review of a few facts about the anatomy of the Fallopian tubes will assist in the study of the diseases that affect these structures.

The average length of the normal Fallopian tube is 4 inches (10 centimeters). The tubes are often of unequal length, the difference sometimes being equal to 1 centimeter. The length of the Fallopian tube is subject to considerable variation, and in some forms of ovarian disease the length of the tube may be very much increased.

The uterine end of the tube varies in thickness from 2 to 4 millimeters. The outer end varies from 7 to 10 millimeters in thickness.

The narrow uterine end of the tube is called the isthmus. The outer end, of trumpet-shape, is called the ampulla. The canal of the tube is small. At the uterine end, or ostium internum, it will barely admit a bristle. Beyond the middle of the tube the canal gradually widens to the outer opening—the ostium abdominale.

The ostium abdominale is surrounded by peculiar luxuriant folds of mucous membrane called fimbriæ. The fimbriæ are formed by the outward bulging of the exuberant mucous membrane.

The Fallopian tube consists of three coats, the peritoneal, the muscular, and the mucous.

The peritoneal coat, which invests the tube for two-thirds of its circumference, is formed by the free border of the broad ligament, between the folds of which the Fallopian tube lies. Loose connective tissue attaches the peritoneal to the middle or muscular coat.

The muscular coat consists of unstriped muscular fiber which is continuous with that of the uterus. The muscular fibers are arranged in two layers, an outer longitudinal and an inner circular layer.

The inner or mucous coat, which is continuous with the mucous membrane of the uterus, is covered with columnar ciliated epithelium.

Fig. 142.—Section of the normal Fallopian tube near the uterine cornu (Beyea).

In the outer portion of the tube the mucous membrane is thrown into longitudinal folds or plicæ. These folds increase in thickness and in number as the ostium abdominale is approached. The difference in the degree of plication at the two ends of the tube is shown by [Figs. 142], [143]. The folds of mucous membrane project beyond the ostium to form the fimbriæ. Like the rest of the mucous membrane, the fimbriæ are covered by columnar ciliated epithelium.

The peritoneal covering does not, as a rule, extend on to the fimbriæ. It terminates by a sharp line which marks also the termination of the circular muscular fibers of the middle coat of the tube. The fimbriæ are subject to great variation in number and in distribution. Sometimes the Fallopian tube has one or two accessory ostia in the vicinity of the usual opening. These accessory ostia are situated on the upper aspect of the tube and are surrounded by more or less luxuriant fimbriæ. Occasionally a small pedunculated tuft of fimbriæ is found on the outer portion of the tube ([Fig. 144], B). In some cases there is an accessory tubal end supplied with an ostium ([Fig. 144], A).

Fig. 143.—Section of the normal Fallopian tube near the abdominal ostium (Beyea).

Fig. 144.—Fallopian tube and ovary: A, accessory tubal end with an ostium; B, pedunculated tuft of fimbriæ.

Fig. 145.—Fallopian tube, ovary, and parovarium: a, hydatid of Morgagni; b, cyst of Kobelt’s tube; c, Gärtner’s duct.

Very often a small pedunculated cyst, about the size of a pea, is found attached to the fimbriæ or to the outer aspect of the tube.

These cysts are called hydatids, or cysts of Morgagni. They are said to occur in about 8 per cent. of adults and in 20 per cent. of fetuses. They are not pathological.

The cyst wall is composed of three coats: an external peritoneal coat; a middle muscular coat, arranged in two layers; and an inner mucous coat covered with columnar ciliated epithelium. The cyst contains a clear watery fluid.

No distinct glands, such as are found in the cervix and the body of the uterus, have been observed in the Fallopian tubes. The mucous crypts formed by the folds of the mucous membrane are probably glandular in character and secrete an albuminous fluid.

INFLAMMATION OF THE FALLOPIAN TUBES, OR SALPINGITIS.

Inflammation is the disease that most usually affects the Fallopian tubes. The condition is, as a rule, secondary to endometritis, the mucous membrane of the tubes becoming inflamed by direct extension from the mucous membrane of the uterus.

The causes of salpingitis are as numerous as those of endometritis. The most common causes of salpingitis are sepsis and gonorrhea.

Any form of inflammation of the endometrium may extend to the Fallopian tubes, but the septic and the gonorrheal forms of endometritis are especially virulent, and it is the rule in these diseases that the tubes are affected.

The various forms of glandular and interstitial endometritis that have already been described, and which are due to subinvolution, laceration of the cervix, uterine displacements, fibroid tumors, etc., may exist for a long time without producing any perceptible disease of the tubes. In sepsis and gonorrhea, however, the tubes become very quickly affected after the uterine cavity has been invaded, and for this reason these forms of endometritis excite the greatest apprehension.

Like inflammation of other structures, salpingitis may be either acute or chronic.

Fig. 146.—Acute septic salpingitis: section about the middle of the tube (Beyea).

Acute Salpingitis.—In the first stages of acute salpingitis the disease is confined to the mucous membrane of the tube. It very quickly extends thence, however, to the muscular and peritoneal coats, which become infiltrated with embryonic cells characteristic of the early stages of inflammation ([Fig. 146]).

If the tube is laid open, the mucous membrane is found covered with a muco-purulent secretion. The whole tube is soft, succulent, and friable. The friability is such that the tube may readily be ruptured by bending. The fimbriæ are swollen and congested. A drop of pus is often seen exuding from the ostium abdominale.

In acute salpingitis the tube may become very quickly (in a week or ten days) enlarged to the size of the index finger or the thumb.

The condition that has been described is that found in the severe cases of acute salpingitis, the result of gonorrhea or of sepsis after labor. Opportunity is afforded to examine such cases when the woman has been subjected to celiotomy, or at the post-mortem when the woman has died of acute peritonitis or sepsis.

It is probable that a good many cases of acute salpingitis undergo resolution, and that the tube is restored to its normal condition.

It is also probable that milder forms of acute salpingitis occur—cases in which the disease is limited to the mucous membrane and is merely catarrhal in character, there being no pus, but a hypersecretion of mucus from the tube-lining. Such cases, however, recover or pass into a chronic form of simple catarrhal salpingitis; and the diagnosis made by a study of the subjective and objective symptoms cannot be confirmed by operation or autopsy.

Resolution with perfect restoration of the Fallopian tube to its normal condition is, of course, always to be hoped for. In some cases a few fine peritoneal adhesions between the tube and neighboring structures—such as the ovary, the uterus, the anterior or the posterior surfaces of the broad ligament, or a loop of intestine—may result before resolution takes place, and persist after all other traces of inflammation have disappeared. In other cases cure may result, after a greater or less degree of permanent damage has been done to the abdominal ostium of the tube, by the shrinking and distortion or crumpling of the fimbriæ. Such indications of an old, cured attack of salpingitis are not infrequently seen during celiotomy for other conditions.

When resolution and cure do not occur, a speedy fatal result may take place by direct extension of the infection from the tube to the general peritoneum, with the production of general peritonitis. Between this extreme and the mild forms of very localized peritonitis, marked by a few harmless adhesions, all degrees may exist. Sometimes a local accumulation of pus occurs in the pelvis, walled off from the general peritoneum by rapidly formed adhesions. In other cases a tubal abscess is quickly formed by inflammatory closure of the abdominal ostium and distention of the tube with pus; or the cellular tissue of the broad ligament may become infected, and the abscess may originate there. And, finally, if the woman escape these dangers, one or other of the various forms of chronic salpingitis may result, and render her a lifelong invalid.

Chronic Salpingitis.—Salpingitis is usually seen in the chronic form. An acute primary salpingitis must not be confounded with an acute attack of inflammation or with an acute exacerbation in an old chronic case. It is rare that acute gonorrheal salpingitis is seen. The disease is usually subacute or chronic from the beginning, as are many of the other manifestations of gonorrhea in woman, like gonorrheal cervicitis and endometritis. The most frequent form of acute salpingitis met with is the septic variety, which occurs as a result of septic infection after a criminal abortion, a miscarriage, or a labor. It is usually complicated by severe septic endometritis, peritonitis, or general sepsis.

The lesions found in chronic salpingitis are numerous. The simplest form of the disease is the chronic catarrhal salpingitis, in which the pathological changes are confined to the mucous membrane of the tube. The muscular and peritoneal coats are not affected. The ostium abdominale remains open and is of the normal shape. The mucous membrane is congested. The folds of mucous membrane, or the plicæ, are hypertrophied from gradual infiltration of inflammatory products. The tube may become somewhat enlarged and more tortuous than normal. If the inflammatory condition extends to the middle or muscular coat of the tube, the interstitial form of salpingitis is produced. The wall of the tube becomes thicker and harder. The microscope shows an increased amount of connective tissue in the tube-wall.

As chronic salpingitis progresses the ciliæ of the lining cells disappear.

If the disease extends through the peritoneal coat, inflammatory adhesions take place between the tube and neighboring structures. The tube is often found adherent to the posterior aspect of the uterus, the broad ligament, or the ovary.

The most usual seat of adhesions is about the abdominal ostium. Adhesions here are caused by leakage or escape of septic material into the peritoneal cavity. The leakage is slow, and the gradually formed adhesions in time close the ostium by gluing it to adjacent structures, so that further escape of tubal contents by this opening is stopped.

If, in such a case, the tube is freed from its adhesions, the fimbriæ will be found in the normal position with the ostium abdominale open.

The usual method of closure of the distal end of the Fallopian tube is by another process. It takes place as follows: When the inflammation reaches the muscular coat of the tube, this coat becomes lengthened and extends beyond the fimbriæ, which apparently retract and become invaginated in the tube. The opening of the tube, instead of being flaring with protruding, diverging fimbriæ, becomes rounded and narrow ([Fig. 147]). The fimbriæ become drawn farther into the tube until they appear to be directed inward instead of outward. The ostium becomes narrower, and more rounded, until the edges finally meet and unite by peritoneal adhesions.

Tubes representing all stages of this process of closure are often found in operating for inflammatory disease.

Closure of the abdominal ostium by any method is to be viewed as a conservative process. It prevents leakage, through this channel, of septic material, and consequently diminishes the danger of peritonitis.

Fig. 147.—Salpingitis with partial inversion of the fimbriæ.

When the abdominal ostium has become closed, the tubal contents and secretions may have a sufficient passage for escape by the isthmus into the uterus, and no further changes take place beyond slow infiltration and degeneration of the tube-walls. The tube may become much hypertrophied, not from distention of the lumen, but as the result of simple inflammatory infiltration of the mucous and muscular coats, and may attain the size of the thumb. The walls may become much degenerated, soft, and friable, so that the tube may easily be cut through by a ligature or may be broken by bending.

The whole tube may become much elongated and very tortuous, reaching a length of six or eight inches. The isthmus of the tube, or the portion in immediate relation to the uterus, is usually least affected. The whole tube may become much hypertrophied, and yet the isthmus will remain approximately of its normal size. In other cases, however, the disease extends throughout the whole length of the tube into the uterine horn, and the degeneration of the tube may be such that it may readily be broken off at its junction with the uterus.

If, after the ostium abdominale has been closed, anything occurs to obstruct the escape of the tubal contents into the uterus, cystic distention of the tube will take place. Such obstruction may be produced by swelling of the mucous membrane in the narrow isthmus; by cicatricial contraction; or by a sharp flexure in any part of the tortuous tube. Sometimes there are two or more distended portions of the same tube.

When the tube is distended with pus, the condition is called a pyosalpinx; when distended with a watery fluid, a hydrosalpinx; and when distended with blood, a hematosalpinx.

Tubal cysts of this kind may attain large size, in some cases equal to that of the fetal head.

The shape of the tube becomes much altered. The greatest distention is at the distal portion, so that the tube assumes a pear-shape. The lower portion of the tube is restrained by the mesosalpinx and the tubo-ovarian ligament, so that as the tube increases in length the upper portion appears to outgrow the lower, and a retort-shaped tumor results, or the tube may become tortuous and folded upon itself.

As the tube enlarges the layers of the mesosalpinx may become separated, and the tube burrows between them until it is brought into immediate contact with the ovary, and the retort-shaped tumor appears with the ovary lying in the concave portion.

In some cases the ovary and the tube become adherent by peritoneal adhesions, and the mesosalpinx, which is wrinkled and folded between them, may be restored by separation of the adhesions.

In other cases the mesosalpinx itself becomes much thickened by inflammatory infiltration, and keeps the tube and ovary separated.

In chronic salpingitis the inflammatory process usually in time extends to the ovary, and some of the forms of chronic ovaritis are produced.

The capsule of the ovary becomes thickened, and rupture of the ripe ovarian follicles is prevented. Small cysts throughout the ovary are formed in this way. Two or more cysts may become converted into one cavity by absorption of the intervening walls, so that cystic spaces of larger size, equal to that of a duck-egg, may result. Such cysts may become infected by pyogenic organisms from the tube, and an ovarian abscess is produced.

Fig. 148.—Tubo-ovarian abscess.

Tubo-ovarian Abscess.—If the tube is brought into immediate contact with the ovary, either by agglutination of the fimbriated end to the surface of the ovary, or by adhesion of the side of the tube to the ovary, or by burrowing between the layers of the broad ligament, the tissue intervening between the cavity of the tube and the cyst of the ovary may be absorbed or perforated, and the two cavities will be thrown into one, forming a tubo-ovarian abscess or a tubo-ovarian cyst ([Fig. 148]). The opening between the tubal and ovarian portions of the cyst does not usually correspond to the abdominal ostium of the tube, but may be an adventitious opening in the side of the tube ([Fig. 148]).

Pyosalpinx.—When the Fallopian tube is distended with pus or with other fluid, its walls gradually become thinned. In this respect the Fallopian tube differs from the body of the uterus, in which a hypertrophy of the muscular coat usually takes place, under the influence of distention from the presence of retained fluid within it.

This gradual thinning of the tube-wall predisposes to rupture or leakage and the escape of the contents into the abdominal cavity. A pyosalpinx often becomes adherent to the rectum, the small intestine, or the bladder. The wall of the intestine or the bladder becomes perforated, and the pus is discharged in this way. It seems probable that in some unusual cases the obstruction in the lumen of the tube is temporarily overcome, and that evacuation takes place through the uterus, followed by refilling of the tube. This, however, is a very unusual occurrence, and is not frequent, as is assumed by some writers. The evidence of such discharge is based only on clinical observation. There is no good pathological evidence of such an occurrence. It is probable that in most of the reported cases the purulent or watery discharge which escaped in a sudden gush was derived from, and had been retained in, the body of the uterus.

The pus of pyosalpinx varies greatly in character. In the early stages of the disease it is actively septic and contains a variety of micro-organisms.

These organisms are the gonococcus, streptococcus, staphylococcus, the bacillus coli communis, the tubercle bacillus, and the pneumococcus.

In the later stages, however, these organisms become inert, die, and disappear, so that in the majority of cases of chronic pyosalpinx the pus is found to be bacteriologically sterile. Observation on this subject made by a number of investigators shows that out of 133 cases of acute and chronic suppuration of the uterine appendages in which the pus was examined bacteriologically, no organisms whatever were found in 82 cases; in other words, the pus was sterile in about 61 per cent. of the cases. The pyosalpinx in time, therefore, becomes inert so far as any active inflammatory action is concerned, and resembles a chronic abscess in other parts of the body. Active inflammatory action may, however, be excited at any time, as in other chronic abscess, by a new infection, septic organisms entering the abscess by way of the uterine cavity, an adherent loop of intestine, or the bladder. The woman will then have an attack of acute septic inflammation in the old pyosalpinx, and will be exposed to the various dangers that were imminent during the primary acute stages of the disease.

Fig. 149.—Hydrosalpinx, showing complete inversion of the fimbriæ.

It seems probable that if the woman survive the dangers to which she is exposed from a pyosalpinx, the tumor may in time become converted into a hydrosalpinx. The solid constituents of the fluid become absorbed or deposited upon the cyst-walls, and a clear watery fluid remains. In hydrosalpinx the recesses of the tube are often found to contain cheesy material and cholesterin—remnants of the old purulent accumulation. The tubo-ovarian cyst is formed in this way from a former tubo-ovarian abscess.

Hydrosalpinx.—The fluid in a hydrosalpinx may be colorless, slightly yellow, or brownish or chocolate colored from the presence of blood. As the accumulation increases, the walls of the cyst atrophy and become very thin. The epithelium and the mucous membrane atrophy and in time disappear, until nothing but a thin-walled transparent cyst remains ([Fig. 149]). The cyst-wall in hydrosalpinx is always thinner and more transparent than that in pyosalpinx. On the inner wall of the cyst delicate ridges corresponding to the plicæ or folds of mucous membrane may be traced. There may often be discovered, at the distal end of the retort-shaped tumor, a slight depression that marks the position of the abdominal ostium, while upon the inner aspect of this depression may be found the remains of the invaginated fimbriæ. The size of the tube in hydrosalpinx varies from that of the little finger to a tumor as large as the fetal head. Large hydrosalpinx tumors are very unusual, because the fluid probably leaks slowly through the thin cyst-wall, and because the secreting surface of the cyst becomes destroyed by pressure. The fluid from a hydrosalpinx is sterile, unirritating to the peritoneum, and is readily absorbed. The cyst may rupture spontaneously or as the result of some slight accident; the fluid will be absorbed by the peritoneum, and only the shrivelled, atrophied sac will remain. In old cases of this kind the Fallopian tube is represented by an impervious cord. Such specimens have often been found in old prostitutes who have survived the dangers of their calling.

Hematosalpinx.—True hematosalpinx, a closed Fallopian tube distended with blood, is a rare condition. Tubal pregnancy is the usual cause of an accumulation of blood in the Fallopian tube, but the term hematosalpinx should not be applied to this condition. True hematosalpinx occurs when, from any cause, hemorrhage takes place into a tube that had previously been closed by inflammatory action. Such an accident may be caused by traumatism or by torsion of the pedicle of a tubal cyst. Slight hemorrhages of this kind occur in pyosalpinx and in hydrosalpinx, and cause the brownish discoloration that is sometimes seen in the contents of these tumors.

The various forms of inflammatory disease of the tubes that have been described under names which designate the gross appearance of the disease are all really but different manifestations of the same primary condition. Gonorrheal or septic infection may produce any of the forms of tubal disease that have been mentioned. Interstitial salpingitis without closure of the ostium, pyosalpinx, hydrosalpinx, hematosalpinx, tubo-ovarian abscess, etc. are not distinct diseases, but are different manifestations of the same disease, representing different stages of progress or different methods of development. Several of these different forms are often found in the same woman. On one side there may be a hydrosalpinx, on the other a pyosalpinx, both caused by a primary chronic gonorrhea; the distal end of one tube may be distended by a clear watery fluid, forming a hydrosalpinx, while the isthmus may be distended with pus, forming a pyosalpinx; a hematosalpinx may be formed on one side, while a tubo-ovarian abscess exists on the other; and so through a great variety of combinations.

Pyosalpinx with active septic contents represents the early stages of tubal disease, or it represents a chronic condition in which reinfection has occurred. Pyosalpinx with sterile pus is like a chronic abscess anywhere else, and represents a chronic form of salpingitis that had been active and purulent in the beginning. Hydrosalpinx represents the disease less violent and septic in the beginning, and slow in progress; or it represents the last stages of an old pyosalpinx; while, finally, hematosalpinx represents a condition of salpingitis in which some accident has befallen the cystic tube and caused hemorrhage into its cavity.

The description given shows the progress, the dangers, and the terminations of salpingitis.

The disease is caused by extension of inflammation from the endometrium. The usual causes of this inflammation are gonorrhea, or infection after a criminal abortion, a labor, or a miscarriage. The gonorrheal salpingitis is usually slow or insidious from the beginning. The symptoms of the disease are often not troublesome until many months after the primary gonorrheal infection. The closure of the tube is slow, and it is sometimes not until the tube becomes distended with pus that the woman experiences much suffering and is placed in imminent danger. There are cases, however, of acute gonorrheal salpingitis in which the disease is virulent and active from the beginning. Infection may traverse the tube, reach the peritoneum through the open ostium, and produce general peritonitis within a few days of the primary attack of gonorrhea. In such cases it is probable that the infection is a mixed one, other organisms accompanying the gonococcus. In other cases the abdominal ostium becomes quickly closed and a gonorrheal tubal abscess is rapidly formed.

The septic variety of salpingitis, as has already been said, is more frequently acute from the beginning. Within ten days or two weeks after a criminal abortion, or after a miscarriage or labor, a large tubal abscess may be formed; or the septic organisms may pass through the tube before the ostium has been closed, and produce within a few days a general fatal peritonitis.

On the other hand, septic salpingitis is often slow, a mild attack of puerperal sepsis being the beginning of years of invalidism, of gradually increasing suffering, until gross tubal disease is produced.

The slowest forms of salpingitis are those that result from chronic endometritis, such as accompanies subinvolution, laceration of the cervix, retro-displacements, or uterine fibroid. Simple catarrhal salpingitis is often found in these diseases; or the abdominal ostium may be closed, and a small hydrosalpinx will be present; or the isthmus may be sufficiently open for drainage, and no tubal distention result. Hydrosalpinx is very often found with uterine fibroids.

Cancer of the cervix or the body of the uterus is a frequent cause of salpingitis, of hydrosalpinx, and of pyosalpinx. The endometrial inflammation secondary to the cancer extends into the tubes.

The progress of salpingitis is beset with danger.

Fig. 150.—Chronic salpingitis with general adhesions of tubes, ovaries, and uterus (Bandl).

At any time a pyosalpinx may rupture and a rapid fatal peritonitis result. Unusual effort, vaginal examination, or slight operations upon the cervix or body of the uterus may cause this accident. Not infrequently, such rupture has been produced by even gentle bimanual examination. I have seen a fatal peritonitis occur from rupture of a pyosalpinx during the replacement of a prolapsed uterus.

For this reason the operator should always determine by careful examination the presence or absence of tubal disease in every case before performing any of the minor gynecological operations or manipulations, such as trachelorrhaphy or the replacement of a retroverted uterus. Purulent disease of the tubes is a contraindication to all such procedures, unless an immediate subsequent celiotomy is to be performed. Great care must be exercised in any of the less dangerous forms of salpingitis. In any case of salpingitis, however mild, an acute attack may be excited by reinfection or by rough manipulation.

Fig. 151.—Chronic salpingitis: both Fallopian tubes are closed and adherent.

Rupture into the peritoneum is not the only danger to which the woman is exposed in salpingitis. The gradually formed adhesions in the pelvis impede the motion of the pelvic intestines and may cause intestinal obstruction. Obstruction of the ureters has occurred from pelvic inflammation. The Fallopian tube may discharge its contents through the bladder and produce violent cystitis, or it may discharge through the rectum or intestine, or adhere to the side of the vagina and discharge through this channel; or it may be evacuated through the abdominal parietes. Such fistulous openings rarely, if ever, close spontaneously and permanently. Temporary closure may occur, but the tube will refill and discharge as before.

Fistulæ of this kind persist for many years, becoming seats of tuberculosis or exhausting the woman by the continuous suppuration.

If the patient escape these dangers, the disease may become quiescent. Some of the less dangerous forms of salpingitis are produced, until finally, when the woman has reached middle life, a hydrosalpinx remains, or an adherent, atrophied, cord-like remnant of the tube. Though then freed from the various dangers that had threatened her life, she is not restored to health, but remains a suffering invalid.

Salpingitis may be unilateral or bilateral. It is more likely to be unilateral in the acute cases than in the chronic, for, as the primary focus of the disease exists in the body of the uterus, it will extend in time to the second tube in case only one had at first been involved. If the endometrial disease is cured before the second tube has been attacked, the salpingitis may remain unilateral. Double salpingitis is especially likely to occur in those diseases of the endometrium that are difficult or impossible to eradicate—diseases like chronic gonorrhea, where the infection lurks in the distal ends of the utricular glands and defies our methods of treatment. Operators have repeatedly removed a unilateral pyosalpinx, leaving the second tube apparently perfectly healthy, and yet, after the lapse of a few months, a second operation has been necessary for the relief of a similar pyosalpinx on the other side.

Symptoms of Acute and Chronic Salpingitis.—The symptoms of acute salpingitis are usually obscured by the accompanying symptoms of endometritis, ovarian congestion and inflammation, and localized peritonitis. The woman complains of pelvic pain and tenderness, which are most severe in one or both ovarian regions. There are elevation of temperature and rapid pulse. The knees are often drawn up as in peritonitis.

Bimanual examination reveals marked tenderness upon pressure in the vaginal fornices. There is an indistinct sense of fulness in the region of the tubes. If the pelvic peritoneum and cellular tissue are involved, the whole vaginal vault will feel full and resistant. The tissues lying to the sides and behind the uterus are thickened and resistant. If the woman is thin and there is not much surrounding inflammation, it is sometimes possible to palpate the enlarged tender tube between the vaginal finger and the abdominal hand. Usually, however, the tenderness is too great to permit this. The tube, from its increase in weight, may fall below its normal level, and may be felt lying behind the uterus in Douglas’s pouch.

Usually, in cases of acute salpingitis, the examiner is obliged to content himself with the determination of an indistinct fulness and marked tenderness in the region of the Fallopian tubes.

Before the true pathology of salpingitis was known these cases were described as pelvic peritonitis or pelvic cellulitis. It was supposed that the inflammation involved the peritoneum of the pelvis or the cellular tissue of the broad ligaments. It is true that this is often the case, and that inflammation of these structures accompanies the salpingitis, but it is the tubal inflammation which is the primary disease.

The most pronounced symptom of chronic salpingitis is pain. The pain is referred to one or to both ovarian regions as the disease is unilateral or bilateral. It is due not only to the salpingitis, but to the accompanying ovaritis. The pain is continuous. It is relieved by the recumbent posture, and is increased whenever the woman is upon her feet or is performing any work. The pain is increased by a jolt or sudden movement, by defecation, often by urination and by coitus. The pain during coitus, from direct pressure, is often so great that marital relations are abolished. I have seen a woman with salpingitis who was obliged to take a dose of morphine before every act of defecation. The pain from the jolting of a carriage often renders riding impossible.

The pain is dull and aching in character or sharp and lancinating. It may extend down the anterior aspect of the thighs.

The pain is very much worse at each menstrual period. All the genital structures become congested and swollen at this time, and such phenomena, occurring in the adherent inflamed tubes and ovaries, often cause unbearable pain. The dysmenorrhea in salpingitis is usually very characteristic. It begins several days—sometimes a week—before the bleeding appears. It starts in one or both ovarian regions, and radiates thence throughout the pelvis and down the thighs. It will be remembered that the dysmenorrhea of anteflexion begins only a few hours before the bleeding—that the pain is usually situated in the center of the lower abdomen, in the region of the uterus, is expulsive in character, and is relieved when the bleeding has become well established.

The dysmenorrhea of salpingitis usually lasts throughout the whole of the period.

The pain of salpingitis persists throughout the whole course of the disease. It is common to all forms of salpingitis, and seems to bear no relation to the gross character of the lesions of the tubes. The pain and the dysmenorrhea are often as marked in a case of salpingitis without cystic distention as in a case of large pyosalpinx.

The pain persists after the dangerous stages of the disease have been passed. Relief begins only with the cessation of menstruation, when general atrophy takes place in the genital organs.

The pain of salpingitis is often obvious from the expression and the posture of the woman. She walks with the body slightly flexed forward; she sits down gently upon a chair; she protects herself, by support with the hand, from the jolting of a carriage or a car.

The woman frequently suffers with marked exacerbations of the pain, which occur independently of the menstrual periods, and are caused by leakage from the tube and the resulting local peritonitis. The woman often describes such attacks as attacks of “inflammation of the bowels.” They occur usually during the early stages of the disease. Each attack, if survived, results in a more perfect closure of the ostium abdominale, and diminishes the risk of subsequent attacks. At these times all the symptoms of local peritonitis are present: elevated temperature, rapid pulse, local or general distention, and tenderness. In any case of pyosalpinx or of old chronic salpingitis close questioning of the patient will elicit a history of this kind.

Acute attacks of pain, fever, and other disturbance also occur in cases of chronic salpingitis from acute reinfection of the diseased tube. The disease may have been quiescent for a long time, and yet active reinfection may take place by way of the uterine cavity or by the passage of the colon bacillus through an adherent intestinal wall; or infection may occur through an adherent bladder.

Salpingitis is usually accompanied by menorrhagia. It is impossible to determine how much of this is to be attributed to the tubal disease. There is always an accompanying endometritis which is sufficient to account for it.

Sterility is the rule in cases of salpingitis. The disease of the mucous membrane and the destruction of the ciliæ render the passage of the ovum into the uterus difficult. For this reason tubal pregnancy may occur in salpingitis, impregnation and attachment of the ovum taking place within the tube. Inflammation of the ovary, which prevents the rupture of the ripened ovarian follicles, is another cause of the sterility. When the abdominal ostia are closed absolute sterility is present.

In chronic salpingitis the condition of the Fallopian tubes is revealed by bimanual examination. The tube usually falls below its normal level, and may be felt by the vaginal finger lying beside the uterus, or behind it, in Douglas’s pouch. By careful palpation the connection of the tubal tumor with the uterus may be traced. Bimanual examination is most satisfactory in the quiescent stages of the disease. During an exacerbation or during one of the acute attacks of inflammation the tenderness prohibits thorough palpation, and the surrounding inflammatory infiltration masks the condition of the tube. The tube may be felt as a hard cord, or as a cystic tumor with the ovary lying in its concavity, or as a tortuous, sausage-shaped mass.

In old chronic cases the tube and ovary may be felt as a hard, knot-like mass adherent to the side of the uterus or coiled about the cornu ([Fig. 151]).

In nearly every case the isthmus is rendered hard and cord-like by inflammatory infiltration. This indurated condition of the isthmus is a feature of tubal disease that is usually readily determined, and it is of decided diagnostic value. The connection, by such a cord, of the mass felt in the pelvis with the uterine cornu is the most valuable proof that the tumor is tubal in character.

Diagnosis.—The diagnosis of chronic disease of the Fallopian tubes must be made from a study of the history, the symptoms, and by physical examination.

The history is always of value. Careful questioning will usually show that the ovarian pain dates from a criminal abortion, from an attack of fever after a miscarriage or labor, or from a suspicious coitus. Women who have been infected with chronic gonorrhea by their husbands attribute the origin of the disease to their marriage. The woman will often say that for some days after marriage she suffered with irritation and burning of the external genitals, with dysuria, perhaps with a slight vaginal discharge, and that after this, very gradually, the ovarian pain developed. She may have had one child or a miscarriage, but with this exception is usually sterile.

The history of attacks of local peritonitis, confining the women to bed for several days or weeks, can also usually be obtained.

The character and the situation of the pain and the character of the dysmenorrhea usually point strongly to salpingitis. The physical examination is not by any means always satisfactory. The small flaccid tubal tumors are often difficult to palpate, especially in fat women, and the gross forms of the disease may be obscured by surrounding adhesions and inflammation. The examination, however, when taken in connection with the history and the symptoms, will usually enable one to make the diagnosis. Inflammatory tumors in the female pelvis are very generally tubal in origin.

It is difficult to estimate the mortality of salpingitis. It is certainly a frequent cause of death—not only immediately, by some of the acute accidents that may occur, but as a result of gradual exhaustion from prolonged suppuration. Acute salpingitis, and the purulent forms of the disease, should always be viewed with anxiety. As appendicitis is the usual cause of peritonitis in man, so is salpingitis the usual cause of this disease in the woman. In every case of peritonitis in a woman, therefore, careful examination of the pelvic organs should be made.

Salpingitis is an exceedingly common disease. It occurs in all classes of society, but most frequently in the lower walks of life. Salpingitis is the rule in prostitutes, and in them is caused by gonorrhea or by septic infection at criminal abortion.

Treatment.—The treatment of acute salpingitis in its early stage should be expectant: absolute rest in the recumbent position, vaginal douches of a gallon of hot sterile water (100°-110° F.) two or three times a day, small doses of saline purgatives (Rochelle salts, ʒss-ʒj every one or two hours) until mild purgation is produced, should be prescribed, and should be continued as required. Relief of pain is afforded by hot fomentations over the lower abdomen. It is best to administer no opium, as it is very important to watch these cases closely, and the symptoms that demand operation might be masked by the administration of an anodyne. Examinations should be made with great care and gentleness, and no oftener than is necessary to determine the progress of the disease. If the patient is progressing satisfactorily, repeated examinations are contraindicated.

A chill followed by a rapid high elevation of temperature (105°-106° F.) is often caused by even gentle manipulation of the upper organs of generation in cases of acute inflammation.

The case must be watched carefully and continuously. In the gonorrheal and septic forms of the disease there is great danger of extension to the peritoneum, or of the formation of a tubal or other form of pelvic abscess that will imperil the life of the woman.

As a general rule, it may be said that, unless there are well-marked symptoms of extensive pelvic peritonitis, or unless a distinct tumor can be felt in the pelvis, operation is not indicated. As resolution undoubtedly takes place even after severe acute attacks of salpingitis, it is right to treat the woman with this end in view rather than to resort to an immediate mutilating operation.

If, under the expectant plan of treatment, the patient does not improve; if the area of pelvic tenderness increases; if the local tympany (which may at first be present only on one or both sides of the pelvis, and which indicates merely local peritoneal irritation or inflammation) extends upward; if the temperature and pulse-rate increase; if constipation appears; if, in fact, indications of extension of the peritonitis are present,—celiotomy should be immediately performed. The diseased tube or tubes should be removed, and, if necessary, the abdomen should be drained.

Fatal peritonitis sometimes results within three or four days after the onset of acute salpingitis. As soon, therefore, as the physician realizes the imminence of this complication in any case, he should not delay in removing the source of infection.

The other acute termination of salpingitis, the formation of an abscess in the pelvis, likewise demands operative interference. This condition is readily recognized. The woman has one or more chills. The temperature becomes more elevated and the pulse more rapid. The pelvic tenderness and pain may become more distinctly localized to one or both ovarian regions. Defecation and urination increase the pain. Bimanual examination reveals an exceedingly tender mass, either indurated or perhaps soft and fluctuating, lying to either side of, or behind the uterus. The character, upon palpation, of the mass depends upon the nature and extent of the peritoneal adhesions that surround it. The diagnosis of a pelvic abscess resulting from acute salpingitis is usually easy.

There is some difference of opinion among operators in regard to the best treatment for this condition. Some advise evacuation of the abscess by way of the vagina; others advise celiotomy, with removal of the abscess and the Fallopian tube that caused it, followed, if necessary, by abdominal or vaginal drainage. I prefer the latter method of treatment, for reasons that will appear under the consideration of the technique of operation.

Treatment of Chronic Salpingitis.—Cases of simple chronic catarrhal salpingitis undoubtedly recover after the cure of the endometrial disease of which the salpingitis forms a part. The tube may be restored perfectly to its normal condition; or there may remain an atrophic condition of the mucous membrane; or the fimbriæ may be left somewhat distorted, crumpled, or slightly drawn within the tube; or there may be a few fine peritoneal adhesions, like cobwebs, between the distal end of the tube, the broad ligament, and the ovary. Such slight lesions may cause no trouble beyond interfering a little with the fecundity of the woman.

When, however, the adhesions are more extensive, treatment for their relief may be demanded, even though all inflammatory action has disappeared from the body of the uterus and the tubes. Treatment in such cases is demanded, not to cure the salpingitis or on account of any danger that threatens the woman’s life, but to relieve the pain caused by the results of the inflammation.

It may be necessary to perform celiotomy in order to free or break up adhesions that bind down the ovary in an abnormal position, or to liberate an adherent intestine, or to replace a uterus that has been displaced by the traction of adhesions.

The degree of suffering experienced by the woman is the guide in advising such operative interference.

Pelvic massage has been used for the relief of pelvic adhesions of this kind, the uterus, tubes, and ovaries being manipulated between the fingers in the vagina and a hand upon the abdomen. The results of this treatment have not been encouraging.

In discussing the treatment of chronic salpingitis the cases may be divided into two classes: those in which palliative treatment may be followed, and those in which operation is demanded.

There are a great number of cases of chronic salpingitis in which there is no gross disease of the tubes, and in which operation upon the tubes is not immediately indicated. It is proper in such cases to try milder palliative treatment first.

Salpingitis is always preceded, and usually accompanied, by inflammation of the endometrium, and in every chronic case attention should first be directed to the cure of the endometritis.

If there is no tubal and ovarian displacement—that is, if the ovary is not prolapsed; if the uterus has not been retroverted; if there are no extensive tubal adhesions; and if there is no gross disease of the tube, such as pyosalpinx, hydrosalpinx, hematosalpinx, a thorough curetting of the uterus, or, if necessary, a trachelorrhaphy or an amputation of the cervix, will often relieve the woman of her suffering, and it may not be necessary to operate for the damaged tubes.

In all such cases, however, the operator must be very careful to exclude active or purulent tubal disease. If he overlooks a pyosalpinx, the curettage or the trachelorrhaphy may be followed by an active peritoneal inflammation that will destroy the woman.

If there is ovarian or uterine displacement, we cannot expect relief until these conditions have been treated, and such treatment usually requires celiotomy.

The pain and dysmenorrhea of chronic tubal disease may be relieved by rest in the recumbent position during the menstrual period; by the administration of saline laxatives (the pain is always increased by constipation); by vaginal douches of large quantities of hot water (one gallon at 110° F.) administered two or three times a day in the recumbent posture; and by applications of Churchill’s tincture of iodine to the vaginal vault, and the use of the glycerin tampon. The directions for this treatment have been given under the preparatory treatment of laceration of the cervix.

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.

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.

The purulent accumulation may be detected by bimanual examination. It usually bulges into the vagina at the lateral fornices or before or behind the cervix. The abscess-mass is in close relationship with the uterus. In this respect it differs from a simple tubal or an ovarian abscess, in which cases a distinct separation of the tubal or ovarian tumor from the uterus may be determined, at any rate, before the pelvic cellular tissue has become involved.

If the abscess bulge in the anterior vaginal fornix, it is very probably of neither tubal nor ovarian origin, as tubal and ovarian abscesses lie to the side of, or behind, the uterus.

The sense of fluctuation is often difficult or impossible to determine. The infiltration of the surrounding structures gives to the mass a dense hard feeling that obscures fluctuation. To the experienced finger, however, this indurated condition of the tissues is characteristic of pelvic suppuration, as is the sense of fluctuation elsewhere.

The treatment of pelvic suppuration of this nature is evacuation by way of the vagina. The incision should be made into the most prominent part of the mass. When made into the lateral fornices, the operator should remember the position of the ureters and the uterine arteries. The ureters lie a little over half an inch from the cervix. In every case it is safest to make the incision close to the cervix and to work carefully into the abscess-cavity. The pus should be evacuated, and a double drainage-tube should be introduced for subsequent washing.

In most cases, however, the physician cannot determine with any certainty that the abscess is simply confined to the pelvic cellular tissue and did not originate in the Fallopian tube. If there is any doubt of this kind, celiotomy should be performed and the true nature of the condition determined. If a pyosalpinx or an ovarian abscess is present, as is usually the case, the condition may be dealt with as has already been advised. If the uterine adnexa are healthy, the abdomen may be closed and a subsequent vaginal incision may be made.

Indiscriminate evacuation of collections of pus in the pelvis by way of the vagina has resulted in a great deal of harm. The abscess, being usually of tubal origin, often persists indefinitely. Intestine, ureters, bladder, and blood-vessels have often been injured; and when subsequent celiotomy is performed the operation is attended with great danger from the presence of the fistulous opening.

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