DISEASES OF THE FALLOPIAN TUBES (Continued).
TUBERCULOSIS.
Tuberculosis attacks the Fallopian tubes much more frequently than any other part of the genital apparatus. The disease may be associated with tuberculosis of the peritoneum or with tuberculosis of the ovaries and the uterus. As has already been said, tuberculosis of the uterus often originates in the tubes and extends thence to the endometrium.
The tubercular Fallopian tube varies much in appearance according to the nature and stage of the disease. The strictly tubercular lesions may be masked by those of ordinary inflammation. There may be peritoneal adhesions, often very dense and widespread, between the tube and adjacent organs, and the ostium abdominale may be closed, as in non-tubercular salpingitis.
In some cases these simple inflammatory adhesions probably existed before the tubercular infection took place, the tuberculosis occurring in an old diseased tube. In other cases it is probable that the inflammatory adhesions and products occurred as a result of the tuberculosis, which attacked a tube previously healthy. In the latter case such adhesions may be viewed as a conservative process.
The tubercular tube is often very much enlarged from infiltration of its walls and dilatation of its lumen. It may be filled with typical caseous material, and when this is removed the mucous membrane will be found the seat of deep, jagged, ulcerated areas.
If the abdominal ostium is not entirely closed, the cheesy material may project into the abdominal cavity. If the disease has extended to the peritoneal coat, the covering of the tube will be found studded with typical tubercles ([Fig. 152]). Such tuberculosis of the peritoneum may be confined to that covering the tube, or it may extend to the uterus and throughout the abdominal cavity.
In peritoneal tuberculosis that has originated in the tube the lesions are found to be most widespread in the pelvic peritoneum.
Fig. 152.—Tuberculosis of the Fallopian tubes. The disease has extended to the peritoneum, which is covered with tubercles.
In some cases the ostium becomes closed, and the tubes are found distended with pus, forming tubercular pyosalpinx. Such tubes sometimes attain enormous size, containing a quart or more of purulent material.
In less extreme cases than those just described the tubercular area may be limited to a portion of the tube, and gives rise to one or more nodular enlargements ([Fig. 153]). In other cases there is no gross change in the shape or size of the tube, and only a few miliary tubercles are found scattered throughout the mucous membrane.
In a very large number of the cases of tuberculosis of the Fallopian tubes, the lesions resemble in all respects those of ordinary salpingitis, and are not in any way recognizable by the naked eye as characteristic of tuberculosis. There are no cheesy contents; there are no tubercles upon the peritoneum; the mucous membrane shows no macroscopical changes that would lead to the suspicion of tuberculosis. In these cases the tubes are usually closed at the abdominal ostium; there may or may not be cystic distention; and the adhesions, which are usually very firm, distort the shape of the tube and bind it to the posterior aspect of the broad ligament, the uterus, or other pelvic structure. Until recent years such cases were supposed to be simple cases of salpingitis. Careful microscopic examination, however, has shown that this forms one variety of tubal tuberculosis, and that a certain proportion of such cases of salpingitis are tubercular. The term “unsuspected tuberculosis” has been applied by Williams to such cases.
Fig. 153.—Tuberculosis of the Fallopian tubes: A, tubercular nodules.
Cases of tuberculosis of the Fallopian tubes may be divided into three classes: Miliary tuberculosis; chronic diffuse tuberculosis (cheesy tubes); and chronic fibroid tuberculosis.
Miliary tuberculosis of the tubes may be a part of a general miliary tuberculosis, or it may occur primarily in the tube. Microscopic examination shows giant epithelioid cell-tubercles scattered throughout the mucous membrane.
Miliary tuberculosis is the first stage of tuberculosis of the tubes. The process may progress no farther, or it may become converted into one of the other varieties.
In chronic diffuse tuberculosis the mucous membrane is infiltrated with epithelioid cells, miliary tubercles, and areas of caseation. The tube may be filled with cheesy material or with pus, and in time the mucous membrane becomes completely destroyed. In this form of tuberculosis the gross appearances are usually characteristic, and are those which have already been described.
In chronic fibroid tuberculosis there is a great increase of connective tissue between the tubercles. The lumen of the tube is distorted, and a few miliary tubercles are found scattered through the mucous membrane. This form of the disease is very slow and chronic, and represents a usual method of spontaneous cure.
Since the discovery of so-called unsuspected tuberculosis of the Fallopian tubes the disease has been found to be much more frequent than was formerly supposed.
Williams found tuberculosis of the tubes in one out of every twelve operations for the removal of tubes and ovaries that were the seat of past or present inflammatory disease.
Dr. Beyea and I have found tuberculosis of the tubes present in 18 per cent. of the cases that were subjected to the operation of salpingo-oöphorectomy for inflammatory disease of the tubes.
It may be said, therefore, that tuberculosis is present in from 8 to 18 per cent. of all cases of inflammatory disease of the uterine appendages. It is impossible, however, to say whether or not tuberculosis is the cause of the disease in all cases, or whether tuberculosis has been grafted upon a previous non-tubercular affection. Other organisms, along with the tubercle bacillus, are frequently found in the Fallopian tube.
Tuberculosis of the Fallopian tubes may be primary or secondary.
In primary tuberculosis the tubes are the primary seat of the disease, being affected before other structures of the body.
In secondary tuberculosis the tubes are affected from a tubercular focus in some other part of the body.
Tuberculosis of the tubes is usually secondary.
Infection takes place in a variety of ways. Infection through the blood is the most usual way.
Infection may take place from a tubercular ulcer of the intestine or bladder becoming adherent to the tube. The tube may become involved by extension of tuberculosis of the peritoneum to it. In many cases the reverse order happens: the tube is first involved by the tuberculosis, and the disease extends thence to the peritoneum. In other cases it is the peritoneum that is primarily affected. It seems probable that tubercle bacilli, having gained entrance to the peritoneum from a tuberculous mesenteric gland or from an intestinal ulceration, fall to the pelvis and are drawn into the Fallopian tubes, there producing tuberculous lesions without first affecting the peritoneum.
It seems probable that in a good many cases of tuberculosis of the tubes the infection takes place from without by way of the genital tract. Dirty instruments, syringes, or the examining finger may cause it in this way. Infection may also occur from clothing or bed-sheets soiled by sputum or other tubercular discharge. Coitus with men affected with genito-urinary tuberculosis or any other form of tuberculosis may be an occasional cause. It has been shown that tubercle bacilli may be present in the testes and prostate glands of consumptives without any evidence of genito-urinary tuberculosis being present.
Tubal tuberculosis may occur by way of the genital tract from infection from the discharges from some other tubercular focus in the woman, as in the lungs, bladder, or intestinal tract.
The symptoms of tuberculosis of the Fallopian tubes are not at all characteristic. Most cases of tubal tuberculosis have been discovered at the autopsy or have been unexpectedly found at operation.
The symptoms resemble those of non-tubercular salpingitis. There is the same ovarian pain and dysmenorrhea. Bimanual examination reveals the enlarged or nodular and distorted condition of the tube. The adhesions are often very firm and dense, and the tubal tumor is often of stony hardness.
The diagnosis of uncomplicated tubal tuberculosis is difficult, and in many cases impossible. If the peritoneal covering of the tube is involved, the small tubercles may sometimes be felt by vaginal or rectal palpation. Or, if the condition has extended to the posterior aspect of the uterus, the tubercles may be felt here, by dragging the cervix down with a tenaculum and palpating the posterior uterine surface with a finger in the vagina or the rectum. The association of salpingitis with pulmonary tuberculosis would lead the physician to suspect that the salpingitis might be tubercular. If the woman has tuberculosis of the peritoneum, and the tubes are found enlarged, it is most probable that they are tubercular. A knowledge of a genito-urinary lesion of tubercular nature in the husband should lead us to fear tubal tuberculosis in the wife.
Prognosis.—Tubal tuberculosis is a dangerous disease. There are several methods of termination. It very often leads to tuberculosis of the peritoneum. For this reason peritoneal tuberculosis is more common in women than in men.
A tubercular abscess may be formed in the pelvis, and the woman may die as the result of prolonged discharge and suppuration, as in the case of non-tubercular pyosalpinx. General tubercular infection may arise from the tubercular focus in the tubes.
Tuberculosis of the tubes may, and probably often does, undergo spontaneous cure. The fibroid changes that have been described lead to this end. In some cases calcification occurs, as in tuberculosis elsewhere, and the disease is cured in this way. [Fig. 154] represents an old tubercular pyosalpinx that was filled with calcified plates.
Even though these conservative changes take place and all danger from the tuberculosis has disappeared, the woman will continue to suffer pain and dysmenorrhea from the tubal and ovarian adhesions.
Treatment.—The treatment of tubal tuberculosis is celiotomy, with removal of the tubes and ovaries. If the uterus is involved, it should also be removed. Removal of the tubes, however, is the important feature of the operation. I have seen perfect and permanent recovery occur after removing the tubes, even though the disease had extended into the uterine cornua. As the disease very rarely extends below the internal os, the uterus may be amputated at any convenient point of the cervix.
Fig. 154.—A tubercular pyosalpinx. To the left are three calcified plates that were found in the tube.
Tuberculosis of the peritoneum is an indication for, rather than a contraindication to, the operation. The most extensive cases of peritoneal tuberculosis have been cured by opening and draining the abdomen. If the tubes are rendered inaccessible from the involvement of surrounding structures, the operator must content himself with opening and draining the abdomen.
Adenoma of the Fallopian tube is a rare disease; but a few cases have been described in medical records. The presence of primary adenoma in the Fallopian tube is strong proof of the glandular character of the mucous membrane—an anatomical point which, as has already been said, has been denied by some writers. In adenoma the tube becomes distended with the typical adenomatous mass, which may protrude from the abdominal ostium.
In some of the reported cases there has been found a considerable quantity of free fluid in the peritoneum, though the peritoneum itself was not diseased. It seems probable that this secretion originated in the tube and escaped at the ostium.
Myoma.—Notwithstanding the frequency of myomatous tumors of the uterus, the condition is exceedingly rare in the Fallopian tubes. The tumors originate in the muscular coat, and are usually so small as to create no disturbance.
Cancer.—Primary cancer of the Fallopian tubes is an extremely rare disease. A very few isolated cases have been reported.
Cancer of the tubes secondary to cancer of the body of the uterus occurs more frequently.
Sarcoma of the tube is a very rare disease.
Actinomycosis of the Fallopian tubes has been described.
Syphilitic gummata occasionally attack the Fallopian tube in women who are the victims of constitutional syphilis.
The diagnosis of these unusual lesions of the Fallopian tubes is impossible with our present knowledge. The conditions have usually been found post-mortem or have been unexpectedly discovered at operation. The subjective symptoms throw no light upon the subject of differential diagnosis. Examination reveals merely a tubal tumor.
As the rule is to operate in all cases of tubal tumor, the proper treatment will probably be applied, notwithstanding the uncertainty or mistake of diagnosis.