A Text-book of Diseases of Women

by Charles B. Penrose

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.