may be distorted or pulled out of their usual position by inflammatory adhesions, and may thus be bent at sharp angles or bound down in various malpositions.

STENOSIS.

Congenital stenosis of the tubes, or complete closure of the lumen, may affect the entire length of the tube or a limited portion, principally near the middle. Acquired stenosis may result from pre-existing disease of the tube itself, or from adhesions secondary to localized peritonitis. The most frequent situation in these instances is the abdominal or fimbriated end. A narrowing of the lumen of the tube may be occasioned by angulation or by dislocations.

DILATATION.

Dilatation on the proximal side of obstructions or stenosis is frequent. The dilatation is more marked when inflammatory conditions of the mucous membrane are present. The abdominal end of the tube may enlarge so as to form a cyst of considerable size, filled with serous or seromucous liquid, when the middle portion is stenotic. When the lower end is obstructed the entire tube becomes dilated, and it frequently shows a tortuous and irregularly pouched condition, due to its attachments to the broad ligament. In such instances the mucous membrane is pushed inward at the bends, and projects prominently into the lumen of the tube. Secondary changes of the epithelial lining are not unusual in consequence of the irritation of the retained secretions. The normal epithelium may be wholly lost, and the lining may consist of squamous epithelial cells. Purely inflammatory dilatations will be referred to below.

CIRCULATORY DISTURBANCES.

Active hyperemia of the mucous membrane may be a part of acute inflammations of the tubes, and is very frequently found at the fimbriated extremity in association with peritonitis. The mucous membrane is swollen and bright red in color. There may be excess of mucous secretion.

Passive hyperemia occurs in conditions in which the general venous circulation in the abdomen is impeded.

Hemorrhages into the tubes may occur physiologically during the menstrual period, and sometimes considerable amounts of blood are found under these circumstances. Small hemorrhages into mucous membranes may occur in association with inflammations of the tubes and in the course of some of the infectious diseases. Hematoma of the tube, or the collection of blood in the tube, results from stenosis of the lower end with accumulation

of the menstrual discharges in the proximal portions. The blood may remain in a more or less natural condition for a long time, or may undergo secondary changes. Sometimes it discharges through the abdominal end of the tube into the peritoneal cavity, and leads to retro-uterine hematocele.

INFLAMMATIONS.

Inflammation of the tubes, or salpingitis, may be acute or

chronic.

Acute salpingitis presents itself in several forms, such as an acute catarrhal and a suppurative form. In most cases the inflam

FIG. 323.-Acute septic salpingitis: section about the middle of the tube (Beyea)

mation results from the entrance of irritants from the uterus, and the tubal disease is secondary, therefore, to endometritis or to other

disease of the uterus. Among the micro-organisms discovered, streptococci, staphylococci, the gonococcus, the Diplococcus pneumoniæ, and the Bacillus coli communis may be mentioned. The infective organisms may extend directly along the mucous membrane, or more rarely may reach the tubes through the lymphatics. In rare instances salpingitis may be secondary to local peritonitis. Pathologic Anatomy. In acute catarrhal salpingitis the mucous membrane is swollen, hyperemic, infiltrated with round cells, and covered with more or less abundant mucous secretion, which may distend the tube considerably. In the later stages the secretion is

apt to become mucopurulent. Interstitial inflammation, with thickening of all of the layers of the tube-wall, is frequently a secondary result. In acute suppurative salpingitis the walls of the tube are infiltrated with round cells (Fig. 323), the mucous surface may discharge abundant pus, and the tubes may become distended with this exudate if the abdominal and uterine ends are closed by the inflammatory process. This result, however, is less frequent than in the case of chronic salpingitis. The mucous membrane in these cases is intensely inflamed and often slightly ulcerated upon the surface. Sometimes the distention is so great that the tubes are converted into pus-sacs the size of an egg or a small lemon. In case of acute suppurative or necrotic salpingitis secondary to puerperal sepsis the mucous membrane may be covered with a necrotic membrane; the term diphtheritic salpingitis has sometimes been applied to such a condition.

The exudates within the tube may remain for a long time without change, or may undergo gradual inspissation, and sometimes

even calcification occurs. When ulcers of the mucous membranes have formed, rupture of the tube and consecutive peritonitis may occur, especially during straining efforts, as in labor. Acute local or general peritonitis more frequently results from discharge of infective matter from the abdominal end of the tube.

Microscopically, in all forms of salpingitis extensive round-cell infiltration is observed in all of the layers of the tubes.

Chronic salpingitis, as a rule, results from the continuation of an acute form. The wall of the tube becomes thickened and the muscular layer is often hyperplastic. Proliferative changes in the mucous membrane are not unusual, and may lead to actual polypoid outgrowths. Occasionally small follicular formations are seen in the mucosa; but ulcerations of the mucous membrane are infrequent. When the inflammation extends to the serous coat inflammatory adhesions are frequently formed (Fig. 324), and may bind the tube firmly to adjacent parts and occasion great conges

tion or distortion. Very often the abdominal end of the tube becomes occluded by inflammatory adhesions, or by inversion and agglutination of the fimbria. At the same time the swelling of the mucosa obstructs the uterine end, and in consequence the tube becomes a closed pouch which fills with pus (pyosalpinx), seropurulent liquid (hydrosalpinx) (Fig. 325), or hemorrhagic fluid (hematosalpinx). Intercurrent acute salpingitis frequently takes place in cases of chronic tubal disease.

INFECTIOUS DISEASES.

Tuberculosis of the tubes may be either primary or secondary, and is probably much more frequent than has been supposed. Secondary tuberculosis may occur in the miliary form in association with tuberculosis of the peritoneum or with general tubercu

losis. In other cases secondary tuberculosis leads to caseous and fibrous changes in the walls of the tubes. The latter become greatly thickened, and microscopically there is found a diffuse cellular infiltration with scattered giant cells and here and there definite tubercles. The fibrous changes progress more slowly, and may eventually become the conspicuous feature. Primary tuberculous salpingitis is similar in its appearance to the form just described. The infection may occur through entrance of the organisms at the uterine end of the tube, and certain observations would indicate that pre-existing gonorrheal salpingitis predisposes to secondary tuberculous infection. There are usually considerable adhesions of the tubes to the neighboring organs, and particularly to the ovary, and secondary miliary tuberculosis of the peritoneum

FIG. 326.--Tuberculosis of the Fallopian tubes. The disease has extended to the peritoneum, which is covered with tubercles (Penrose).

is frequently observed (Fig. 326). The lumen of the tube is filled with purulent liquid, and sometimes certain portions, particularly the abdominal end, may be greatly distended, forming cysts containing puriform liquid.

Syphilis has been observed in the form of gummata, and also. in the form of diffuse sclerosis, in cases of congenital origin.

TUMORS.

Fibromata and fibromyomata are met with in the external walls of the tubes as nodular masses. They frequently undergo secondary calcification. Lipoma occurs in the external coat lying between the layers of the broad ligament.

Papillomatous elevations of the mucous membrane are quite frequent, and in some cases a transformation of papilloma to carcinoma takes place. Probably most instances of primary