CHAPTER II.

SALPINGITIS.

SALPINGITIS is the inflammation of the Fallopian tubes.

Different Forms.-It may be acute catarrhal or acute purulent, both of which are seated in the mucous membrane, and are, therefore, called endosalpingitis; or it may be chronic interstitial, which is also called pachysalpingitis, mural. salpingitis, or parenchymatous salpingitis, and is located in the muscular coat. Salpingitis may be cystic, and according to the character of the fluid contained in the dilated tube it is called pyosalpinx, which is filled with pus, hydrosalpinx, which contains a watery fluid, and hematosalpinx, the contents of which are bloody.

Perisalpingitis is the inflammation of the peritoneal covering of the tube, a condition which only occurs as part of a more extended pelvic peritonitis.

Profluent salpingitis is only a variety characterized by the discharge of a watery fluid, pus, or blood from the tube through the uterus and vagina. When the fluid is watery the disease is also called hydrops tubæ profluens or intermittent hydrocele of the ovary (Bland Sutton. See Tubo-ovarian Cysts in the pathology of the Ovaries.)

Under the name of Salpingitis isthmica nodosa has been described a form of chronic salpingitis in which nodules can be felt at the corners of the uterus. In their interior is found the tubal canal, hyperplasia and hypertrophy of the muscular elements of the wall, and sometimes cysts.

Pyosalpinx saccata is a variety of pyosalpinx in which the lumen of the tube is partitioned off into a series of pus-filled sacs, which partitions may subsequently become absorbed, so as to form one cavity.

Taking the etiology as base for a classification, salpingitis may be divided into infectious and non-infectious. The non-infectious is always catarrhal; the infectious is nearly always purulent, but may in the beginning or toward the end of the disease be catarrhal.

Pathological Anatomy.-One or both tubes may be diseased. The infectious form is usually bilateral. The tube is swollen to a thickness varying from that of a little finger to that of a thumb. In catarrhal salpingitis the affection is chiefly limited to the mucous membrane. The folds are edematous and hyperemic or slightly infiltrated with small round cells.

The epithelial cells are swollen, show slight increase in size of their nuclei, and vacuoles form in their protoplasm. Side-branches grow out from the folds, and these, as well as the original folds, may grow together, forming closed cavities. The muscular coat does not

participate much in the inflammatory process. The secretion is increased, and contains mucus, albuminoids, and thrown-off epithelial cells.

In purulent salpingitis the process is more destructive. The tubes are swollen, often distorted, adherent to neighboring organs, and sometimes divided by internal partitions or external bands into a series of compartments, which give them a beaded appearance. The epithelial cells lose their cilia. The epithelium is thrown off over large areas, and the underlying tissue is crowded with small round cells, which are thrown off as pus-corpuscles. The mucous membrane is the primary seat, but by extension the inflammation invades the muscular coat, and the connective tissue between the muscle-bundles becomes infiltrated with pus-corpuscles. The fimbria become agglutinated to one another or to the ovary. In the beginning the ostium uterinum may remain open, constituting a profluent purulent salpingitis. If purulent salpingitis is cured, it leads to a temporary or permanent hypertrophy of the wall by formation of new connective tissue. The vegetations springing from the folds grow together, forming a whole layer of new formation lining the original tube.

Interstitial salpingitis is a chronic disease which has its seat in the muscular coat. It may follow either catarrhal or purulent salpingitis. The extension from the mucous membrane to the muscular layer takes place through the connective tissue. In the first stage the connective tissue between the muscle-bundles is edematous. Next, a large number of inflammatory corpuscles (small round cells) form in it, and even the smooth muscle-fibers themselves break down and are transformed into such cells. Later, the interstitial inflammation may lead to the formation of new connective tissue. It is doubtful if muscular tissue is also formed. In this way the wall is thickened, and the process may end in a permanent hypertrophy (Fig. 278). On the other hand, interstitial salpingitis may lead to atrophy of the tube. Here the wall is thin, the caliber small, and the epithelium partially lost. The muscle-tissue is to some extent replaced by connective tissue.

The different forms of salpingitis, especially the purulent, are often accompanied by pelvic peritonitis, due to an extension of the inflammation through the wall of the tube to its peritoneal covering, or to the entrance of irritating fluid into the peritoneal cavity through the ostium abdominale. In most cases the ovary becomes implicated in the inflammation. It is full of small cysts or may form an abscess. An exudation is formed in Douglas's pouch or around the tube and ovary, which are then matted together into one globular mass. Ad

1 H. J. Boldt has made a special study, illustrated by instructive drawings, of the microscopical changes characteristic of this form in Amer. Jour. Obst., Feb., 1888, vol. xxi. p. 122.

FIG. 278.

Hypertrophy of Fallopian Tube due to Interstitial Salpingitis. The tube is cut open, showing the lumen, a, in the middle of the thick hard wall, b.1

Salpingitis: a, tube finger-thick at lower end, narrowed in many places; b, cyst as large as a chestnut situated in the wall of the tube; c, ovary containing a recently ruptured Graafian follicle, the size of a large hazelnut; d, torn adhesions.2

1 Specimen from my salpingo-oophorectomy on Mrs. S., in St. Mark's Hospital, on July 24, 1890.

2 Specimen from my salpingo-oophorectomy on Mrs. L. S., in St. Mark's Hospital, on August 29, 1890.

hesions are formed to the intestines, the omentum, the bladder, the uterus, the broad ligament, or the wall of the pelvis.

The loss of epithelium and growth of new folds springing from those normally formed by the mucous membrane may lead to closure of the

1. Left Tube cut open, Catarrhal and Interstitial Salpingitis: a, closed fimbria; a b, a c, thickness of wall; d, central cavity.

2. Right Tube cut open, Pyosalpinx: a, closed fimbria; b, cavity filled with pus; c, c, c, smaller cavities communicating with central canal. 3. Small round body found loose in pelvic cavity, probably atrophic right ovary.1

ends of the tube or coalescence between the walls in one or more places in their course. As a rule, the abdominal opening is first closed by agglutination between the fimbria or between them and the ovary. Later, agglutination may also take place at the uterine end. If both ends are closed, the fluid accumulates, forming a cyst, filled with a serous, mucous, pultaceous, purulent, or bloody fluid. The wall is in most places thickened, but through distention or ulceration in the interior it has thin places liable to rupture. Most frequently this thinning is found in the upper and posterior part of the tube, so that the fluid, in case of rupture of the wall, flows into the peritoneal cavity. In rarer instances the rupture takes place downward between the folds of the broad ligament and produces pelvic cellulitis and abscess.

These tubal cysts are mostly club-shaped, with a thinner inner end and a thicker outer. Sometimes they are more pear-shaped or round, or form a string of alternating wide and narrow parts, like a string 1 Specimen from my salpingo-oophorectomy on Mrs. F. K., in St. Mark's Hospi tal, on May 19, 1894.

of sausages (Fig. 279). Different forms may be found simultaneously in the same individual. Thus I have seen pyosalpinx in one tube, the fluid being purulent with a few columnar cells, while the other tube showed marked interstitial and catarrhal salpingitis, the much distended canal being filled with a putty-like mass exclusively composed of ciliated columnar epithelial cells (Fig. 280).

Frequency.-Salpingitis is a very common disease.

Etiology. Salpingitis is hardly ever a primary disease. As a rule, it is secondary to inflammation of the uterus or the peritoneum. The inflammation may follow the mucous membrane or be propagated from the uterus through the lymphatics of the broad ligament.

The disease is nearly always limited to the period of genital activity. It is quite frequent in prostitutes, causing colica scortorum; and unfortunately, it appears often in newly-married pure women.

Malformations, such as atrophy, a spiral twist, and angles in the course of the tubes, predispose to their inflammation.

It

Salpingitis may be due to infectious and exanthematous diseases, such as cholera, typhoid fever, scarlet fever, and smallpox. may be brought on by flexion, myoma or carcinoma of the uterus, and perhaps stenosis of the os, with retention of mucus in the cavity, or by ovarian disease. It may be caused by exposure to cold, violent exercise immediately before menstruation, or too frequent coition. But in the large majority of cases salpingitis, and that in its worst form, the purulent salpingitis, is either gonorrheal or puerperal. If gonorrhea once invades the uterus, it has a great tendency to spread to the tubes. Puerperal salpingitis is found as part of the affections characteristic of puerperal infection or of incomplete abortions, in which the ovum or the spongy decidua is allowed to remain in the uterus.

Purulent salpingitis may also be due to gynecological treatment, not only operations, such as incision of the cervix; but the mere introduction of a sound or the administration of an intra-uterine douche may, in rare cases, lead to salpingitis or change a comparatively harmless catarrhal into a purulent inflammation.

Symptoms.-There is no pathognomonic symptom. Even a dangerous puerperal salpingitis, calling for removal of the pus-filled tubes, need not cause any other symptom than emaciation and recurrent fever. A symptom, however, that must awaken great suspicion is an intermittent outflow of mucous or purulent fluid from the genitals, but the same may sometimes be due to endometritis. The patient is, as a rule, sterile, or has had one child, so-called secondary sterility. The disease is, in most cases bilateral or, if only found on one side, the left is more likely to be affected, a peculiarity which may have its cause in the preponderance of cervical tears on this side (p. 396) or the absence of a valve in the left ovarian vein (p. 74).

Pain may be insignificant or excruciating. It is felt in one or both