CHAPTER XXI.

Fig. 134.—Fibroid polyp producing partial inversion of the uterus.

Treatment of the Fibroid Polyp.—When the fibroid tumor is polypoid, and projects into the uterine cavity, or the cervix, or beyond the external os, none of the operations that have just been described are required. The tumor should then be attacked by way of the vagina. If the fibroid polyp projects from the external os, the pedicle may very easily be divided with curved scissors. If the tumor is still within the cavity of the uterus, it will be necessary to dilate the cervix, or to enlarge the canal by lateral incisions, so that the pedicle may bereached. It should always be remembered that the polyp may, by traction, produce partial or complete inversion of the uterus (Fig. 134), and in dividing the pedicle, therefore, the operator should cut close to the tumor, leaving, if necessary, a portion of the surface of the tumor. In case the polyp is so large that the vagina is filled to such an extent that the pedicle is not accessible, it is advisable to remove the tumor piecemeal, grasping portions with a tenaculum and cutting away with scissors until the pedicle is reached. The fibroid polyp is not vascular, and hemorrhage is not alarming. The pedicle usually contains no large vessel. It retracts after the tumor has been cut away, and spontaneous hemostasis is secured. It was formerly the custom to ligate the pedicle or to remove the polyp with the écraseur, but these methods are unnecessary. If any hemorrhage should follow the operation, the cavity of the uterus should be packed with sterile gauze.

Adenomyomais a rare form of myoma of the uterus, which contains epithelial canals of the glandular type. Unlike the common fibromyoma, this tumor has no connective-tissue capsule and its structure cannot be well differentiated from the tissue of the surrounding uterine wall.

Adenomyomata are of two varieties: in one variety the epithelial canals seem to be derived from the utricular glands; in the other from the embryonal remains of the Wolffian body.

In the first variety the tumor is situated in the posterior, anterior, or lateral uterine wall, and has the usual characteristics of a fibromyoma, except for the presence of glandular structures and the absence of a capsule.

Adenomyomata, which are derived from the Wolffian body, develop in the posterior portion of a uterine horn, or less often in the tube, and when small, in the peripheral layers of the muscular wall. The tumor may afterward become interstitial or submucous.

These tumors are of various degrees of hardness. They may be dense in consistence, in case the muscular tissue is in excess of the glandular, or they may be soft cystic tumors containing numerous distinct macroscopic cavities. Telangiectatic adenomyomata also occur.

Thetreatmentof adenomyoma of the uterus is hysterectomy.

If there exists in the genital tract any obstruction that prevents the escape of menstrual blood, the uterus will become distended and the condition ofhematometrawill be present. If the retained fluid consists chiefly of the mucous secretion of the utricular glands, the condition is described ashydrometra; or if suppuration has taken place, so that the uterus becomes distended with pus, the condition is calledpyometra.

Fig. 135.—Hematometra.

The uterine walls may be very much attenuated by the distention, or the muscular coat may hypertrophy as the accumulation progresses.

The cause of these conditions may be congenital or acquired atresia of any part of the genital tract. The symptoms usually appear after puberty. The menstrual period is accompanied by intense bearing-down pain in the region of the uterus. There is no appearance of menstrual blood. A round tumor may be felt in the hypogastrium. Examination will reveal the obstruction in the cervical canal. Sometimes the chief accumulation and distention occur in the cervix; in other cases the body of the uterus is chiefly affected.

Distention of the Fallopian tubes, with the formation of hematosalpinx, hydrosalpinx, or pyosalpinx, often accompanies old cases of hematometra.

Thetreatmentconsists in relieving the obstruction and in maintaining the patulous condition of the genital tract. If the cervix is the seat of the obstruction, it should be punctured with a trocar and thoroughly dilated. It may be necessary to practise repeated dilatation in order to keep the canal open.

The accompanying disease of the Fallopian tubes may persist after drainage of the uterus, and salpingo-oöphorectomy or hysterectomy may be ultimately required.

Tuberculosis of the uterus is not a very rare disease. In this respect it differs from tuberculosis of the cervix, which, as has already been said, is a most unusual site for the appearance of tuberculosis. Even in advanced cases of tuberculosis of the body of the uterus it is very rare that the condition extends below the internal os.

Tuberculosis of the uterus is often found post-mortem in women who have died of phthisis or other form of tubercular disease. It has also been recognized during life, and operation has been performed for its relief.

Tuberculosis of the uterus seems most frequently to be secondary to a tubercular lesion in some other part of the body. It often begins in the Fallopian tubes, and extends thence to the endometrium; or it may be primary in the endometrium, caused by infection through the genital tract.

The disease first attacks the endometrium, and in the late stages extends to the muscular coat.

Tuberculosis of the endometrium may occur in three forms—miliary tuberculosis, chronic diffuse tuberculosis (caseous endometritis), and chronic fibroid tuberculosis.

Miliary tuberculosisof the uterus may be part of a general miliary tuberculosis. Typical miliary tubercles are found scattered throughout the endometrium, usually situated immediately beneath the epithelium (Fig. 136).

Chronic diffuse tuberculosisis the most frequent form. The uterine cavity is filled with cheesy material. The mucous membrane is the seat of irregularly shaped ulcers and tubercles in various stages of development. When the disease has extended to the muscular coat of theuterus, the whole organ becomes considerably enlarged. Degeneration and softening of the uterine wall may be so extensive as to cause rupture. The internal os may become closed, and a pyometra may be produced.

Fig. 136.—Miliary tuberculosis of the endometrium and glandular endometritis (Beyea).

Fig. 137.—Advanced fibroid tuberculosis of the endometrium (Beyea).

Chronic fibroid tuberculosisof the endometrium seems to be the rarest form of the disease. A microscopic section of this form of tuberculosis is shown inFig. 137. The endometrial tissue was almost entirely destroyed,and was replaced by a mass of typical miliary tubercles. There were no traces of glandular tissue. The tubercles were separated from each other by a very extensive small round-cell infiltration and a small amount of remaining stroma tissue. To the naked eye the endometrium did not appear to be diseased.

Tuberculosis of the uterus may occur at any period of life. It is most often found between the twentieth and fortieth years.

Thesymptomsof tuberculosis of the uterus are not at all characteristic. In the early stages they resemble those of non-tubercular endometritis. There is sometimes a very profuse leucorrhea, which may contain the characteristic cheesy material. The body of the uterus may be considerably hypertrophied. If the condition follows tuberculosis elsewhere, or if any form of genital tuberculosis exists in the husband, the physician would be led to suspect tuberculosis of the uterus.

Thediagnosiscan be made only by thorough curetting of the uterine cavity and the microscopic examination of the tissue removed. The tubercle bacillus has not often been found, but the other microscopic appearances are frequently characteristic. In the case from which the section shown inFig. 137was taken the diagnosis of tuberculosis of the endometrium was made by such curetting and examination.

Thetreatmentof tuberculosis of the uterus is hysterectomy. The operation is indicated in every case except those in which there is present in some other part of the body an incurable tubercular lesion.

In inversion of the uterus this organ is turned partly or completely inside out. The condition usually results from childbirth or from the growth of an interstitial or polypoid tumor.

There seem to be two factors that result in the production of inversion: a degeneration or atrophy of part of the uterine wall, and traction, as from the drag of a uterine polyp or of the umbilical cord. These causes may act together or independently.

If a portion of the uterine wall has lost its strength or tonicity, it may be depressed toward the uterine cavity. The depression is increased by the traction of a tumor or of the umbilical cord. The inversion having been started in this way, may be rapidly increased by uterine contractions. Emmet says that inversion usually takes place between the birth of the child and the delivery of the placenta. A consideration of the subject of acute inversion following labor belongs to obstetrics. It is very important that reduction should be accomplished immediately. The delay of a few hours greatly increases the difficulty of replacement. Emmet says: “The uterus is generally well contracted in twelve hours, and with many cases it would be then quite as difficult to effect a reduction as if a year had elapsed.”

If the placenta is still attached to the inverted uterus, it should be removed before reduction is attempted. Inversion of the uterus when seen by the gynecologist is usually of the chronic form. It has existed for a few weeks or for several years.

Various degrees of inversion are met with. Rarelyinversion of one horn of the uterus is seen. In the case of fibroid polyp there may be a slight depression of part of the uterine wall, resulting from local atrophy and traction. In other cases inversion of the fundus as far as the internal os exists. The most usual condition is one of complete inversion, in which the body of the uterus protrudes from the external os into the vagina (Fig. 138). The cervix may or may not be inverted. Sometimes the inversion is complicated by vaginal prolapse—or, rather, by inversion of the vagina—so that the whole genital tract becomes turned inside out and protrudes from the vulva. The exposed endometrium becomes congested and bleeds easily. Ulceration or gangrene may result.

Fig. 138.—Complete inversion of the uterus.

If the inversion is extensive, the Fallopian tubes and the ovaries are drawn in the cup formed on the upper aspect of the uterus. Intestines or omentum may also lie in this cup. In cases of long standing the rim of the cup formed by the muscular cervix becomes very much contracted, and adhesions may take place between the peritoneal surfaces. These complications offer great, sometimes insurmountable, difficulty to reduction in old cases.

Inversion of the uterus is not a common disease. It is very rarely seen at the present day.

By far the most frequent form is that which follows labor; it is much less often caused by fibroid polyp. It seems especially likely to occur in sarcoma of the uterus.

Fig. 139.—Inversion of the uterus (Jeançons):a, mons veneris;c,c, nymphæ;d, clitoris;e, external meatus;g, anterior lip of cervix;h,h, the internal surface of the uterus.

The symptoms of chronic inversion are hemorrhage, discharge, backache, bearing-down pains in the pelvis, vesical disturbance, very pronounced anemia, and general physical weakness. Menstruation is very much increased in amount, and intermenstrual bleeding may occur after standing or on any physical effort.

Inversion of the uterus very rarely exists without causing serious symptoms. The majority of unrelieved cases end fatally from anemia, septicemia, or peritonitis. Afew cases of spontaneous reduction and cure have been recorded.

Thediagnosisof recent inversion is very easy. The body of the uterus usually projects into the vagina, and the placenta may be found attached to it. The abdominal hand fails to feel the rounded body of the uterus in the normal position, but in its place is a cup-shaped hollow.

Chronic inversion if uncomplicated by other lesion—e. g.a uterine tumor—may also be readily recognized by careful examination. There are, however, a number of cases on record in which the inverted fundus uteri was amputated in mistake for a fibroid polyp.

The diagnosis may be made by inspection, bimanual examination, and the uterine sound.

In complete inversion, inspection shows a round tumor filling the vagina or protruding from the vulva. The tumor is covered with mucous membrane, perhaps ulcerated in places, and sometimes partly covered with stratified squamous epithelium, which has, as a result of irritation, replaced the normal epithelium of the endometrium. It is of a deeper red color than a pedunculated fibroid. The tumor bleeds easily. In the only case of inversion seen by the writer the orifices of the Fallopian tubes could be determined.

Digital examination reveals the rounded shape of the tumor and its soft character—softer than a fibroid polyp. The tumor may be so soft that it becomes flattened against the posterior vaginal wall.

The tumor is found to be free on all sides except at its upper extremity, where there is a pedunculated attachment around which may be felt the more or less attenuated cervix.

If the cervical canal be not obliterated by adhesion to the neck of the tumor, the finger may be passed upward, and will determine that the mucous membrane is reflected symmetrically all around on to the neck of the tumor.

Unless the woman be fat, the abdominal hand will determine that the uterine body is not in its normal position.In its place may be felt the cup-shaped portion of the inverted uterus.

If the woman be fat, the rim of the cup may be felt by palpation through the rectum, the uterus being drawn down, if necessary, by a tape passed around the upper portion of the tumor.

The sound passed around the neck of the tumor will show the diminished depth of the uterine cavity and the symmetrical reflection of the cervix on to the neck of the tumor.

If the inversion be partial, the fundus lying still above the internal os, the difficulty of diagnosis becomes much greater. Examination under anesthesia may be necessary, when the cup-shaped depression on the top of the uterus may be detected, and dilatation of the cervix will enable the examiner to palpate the intra-uterine tumor.

The differential diagnosis between inversion and uterine polyp is made by determining, in the latter condition, that the body of the uterus lies in its normal relationship to the cervix, and that the upper surface is not cupped.

The sound usually passes to unequal distances around the neck of a fibroid polyp, unless it be situated symmetrically in the centre of the fundus. The depth of the uterus in the case of uterine polyp is usually greater than two and a half inches, as a result of the hypertrophy that accompanies polypi.

It is said that if the sound passes to a less depth than two and a half inches in the case of uterine polyp, accompanying partial inversion of the uterus should be suspected.

Treatment.—As I have already said, an inverted uterus should be reduced immediately after the accident occurs. If this is not done, the difficulties of reduction become very great. Until about fifty years ago, reduction in chronic cases was considered to be impossible. A considerable variety of methods of reduction have been recommended. Some operators advocate reduction by the hands alone; others advise the assistance of instruments;and others, again, the employment of continuous elastic pressure.

The woman should be kept in bed for a few days before the operation. Saline laxatives should be administered. The parts should be prepared by vaginal injections of hot water in large quantity, administered three times a day. A large Barnes bag or colpeurynter filled with air or water should be placed in the vagina for two or three days before the operation, in order to distend the genital tract sufficiently to admit the hand. In some cases the pressure of such a bag, applied for from one to eleven days, has itself effected reduction. At the time of operation an anesthetic should be administered and the woman should be placed in the lithotomy position. The bladder should be emptied.

Fig. 140.—White’s repositor for inversion of the uterus.

The hand should be greased before introduction into the vagina. Emmet describes the method of reduction as follows: “My hand was passed into the vagina, and, with the fingers and thumb encircling the portion of the body close to the seat of inversion, the fundus was allowed to rest in the palm of the hand. This portion of the body was firmly grasped, pushed upward, and the fingers were then immediately separated to their utmost; at the same time the other hand was employed over the abdomen in the attempt to roll out the parts forming the ring, by sliding the abdominal parietes over its edge. This manœuver was repeated and continued. At length, as the diameter of the uterine cervix and os was increased by lateral dilatation with the outspread fingers, the long diameter of the body of the uterus became shortened, and the degree of inversion proportionally lessened.After the body had advanced well within the cervix, steady upward pressure upon the fundus was applied by the tips of all the fingers brought together.”

The reduction may be aided by the use of White’s repositor (Fig. 140). This instrument consists of an india-rubber cup set on a curved iron staff which has at its other end a stout spiral spring. The cup is placed against the inverted fundus, and the spring against the body of the operator, who is thus enabled to maintain continuous pressure during the manipulations of his fingers.

Fig. 141.—Emmet’s method of retaining partially reduced inversion.

Reduction of chronic inversion by manual methods is a long and exhausting process, requiring sometimes three or four hours for its accomplishment. It is advisable to have several assistants for mutual relief. It may be necessary to desist, and to repeat the operation when the condition of the patient permits it. In case the reduction can be but partially accomplished, or when, from any cause, the attempt at reduction has to be temporarily abandoned, the result of the work done may be preserved by a method of Emmet’s of temporarily closing the cervix by suture (Fig. 141). This procedure not only prevents the complete inversion from returning, but the traction produced by stretching the cervix over the fundus itself favors reduction.

Reduction by Continuous Elastic Pressure.—This method is employed after the manual method has failed, or it may be used primarily. As has been said, the gradual pressure of a colpeurynter has in several instances accomplished reduction.

The most efficient instrument for maintaining continuous pressure consists of a wooden cup set on a stem that extends out of the vagina. Pressure is made by firm elastic bands attached to the stem; these bands pass, two in front and two behind, to a broad abdominal bandage. The elastic pressure is maintained for from one to three weeks.

The parts must be carefully watched for sloughing. The rim of the cup of the repositor should be covered with lint saturated with carbolized oil. The instrument should be removed and reapplied every day.

The direction of pressure may be regulated by the tension of the elastic bands.

Splitting the posterior lip of the cervix is sometimes a useful procedure in cases that have resisted other treatment. The cervix is split in the median line posteriorly; the body and fundus are replaced by taxis, and the incision is then closed by suture.

If inversion accompany a uterine polyp, the tumor should be removed; and if the inversion is not spontaneously corrected, it must be reduced.

If, after careful trial of conservative methods, reduction of an inverted uterus is found to be impossible, the physician may be compelled to amputate the inverted portion or perform hysterectomy.

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 byFigs. 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 onto 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 casesthere 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 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 foundcovered 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 attackof 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 thechronic 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 ofmucous 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, theinterstitialform 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 othercases, 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 apyosalpinx; when distended with a watery fluid, ahydrosalpinx; and when distended with blood, ahematosalpinx.

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 abdominalostium 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.

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