permanent and progressive. The cul-de-sac incision and conservative treatment afford no relief.

Hydrosalpinx.-As most of these cases follow abortion or labor, there may be elicited a history of perhaps mild infection at that time. There are not repeated attacks of peritonitis arising from the tube, but, of course, an affected endometrium may give rise to them. Still, as a rule, the course of a case of hydrosalpinx is more free from attacks of peritonitis than are pus cases. There is no fever and no continuous pain. Over-distention of adherent bowels produces pain in the tubal locality. Women may have large dropsical tubes and suffer but little. They are very commonly felt when examination is made, because of other conditions, as retroversion. The masses are not very sensitive, are not firmly attached by lymph, and communicate the sensation of very fluid. contents. Upon opening the cul-de-sac they are readily found and easily freed (Fig. 22). Presenting at the vaginal incision they appear translucent and opalescent, or perfectly clear. Their sacs are transparent and exceedingly thin. They are easily ruptured by handling, and can be confounded with subperitoneal cysts only. Of course they are attached at the cornua, and may exist as single large cysts or as sacculated bunches of separate cysts occupying the tube cavity (Fig. 23).

sors.

Treatment. They are to be treated by opening the cul-de-sac, freeing the sacs, and incising them with scisAs the clear sterile fluid escapes, it is caught by gauze. The affected tube should be slit open for an inch. It is not necessary to do more. The tube oozes but little after incision and is returned into the pelvis. Preferably the incision should extend from the fimbriated end along the top of the tube. After the operation is finished the cul-de-sac is plugged with gauze which extends just within its cut edges. The first dressing is made in about eight days. No fever follows the operation. These cysts do not call for removal. (See conservative cul-desac operation.)

Pyosalpinx.—This is a purulent cyst of retention (Fig.

a hydrosalpinx projecting into the vagina through a cul-de

sac incision.

24). The tube is more dilated near its fimbriated end, and at the cornu of the uterus it is quite small and hard, and its lumen obliterated (Fig. 25). Very often the pus tube is associated with an ovary of normal appearance, but in most cases the ovary also is involved in the mass of inflammatory products, sometimes producing a tubo-ovarian

abscess. There are commonly many adhesions between the tube and adjacent organs. Some of the adhesions exist as old bands, but recent lymph is generally always found.

Symptoms. These are essentially those of acute gonorrheal or septic salpingitis in some cases, and in others there are no subjective symptoms other than a sense of moderate discomfort. Beyond a history of an infection,

with possibly the presence of some evidence of gonorrhea, there are no symptoms different from those found

FIG. 24.-An old pyosalpinx. a, The thickened tubal wall; b, the occluded fimbriated end; c, the tube split open, showing the "pyogenic membrane " (Winckel).

in other suppurative processes in the pelvis. Purulent endometritis commonly coexists.