Hematosalpinx is the name of a cyst formed by the tube and filled with blood. There are two forms: in one the blood is not coagulated, but kept fluid by admixture with alkaline secretion from the inside of the tube; in the other is found a laminated fibrinous clot due to successive hemorrhages. In the former the wall need not undergo much change, and the blood may be reabsorbed; in the latter the wall is much thickened. The effused blood may be inspissated to a syrupy mass or changed to pus, and the wall may ulcerate and finally rupture, an accident which is much more common with hematosalpinx than with hydrosalpinx, and has to be guarded against in operating for atresia of the genital canal (p. 327).

Etiology.-Exanthematous and infectious diseases, phosphorus-poiSpecimen from my operation on Mrs. A. N- in St. Mark's Hospital, on April 30, 1892. In this case a unilateral hydrosalpinx formed a tumor filling the pelvis and reaching to the level of the umbilicus.

soning, extensive burns, and diseases of the heart, lungs, and kidneys, may cause ecchymosis or slight hemorrhage into the tubes.

In pyosalpinx hemorrhage may take place from the wall, and blood mix with the pus.

When there is an occlusion of the genital canal, the menstrual blood which normally is secreted in the tubes (p. 118) is retained and forms hematosalpinx combined with hematocolpos and hematometra, although the communication between the tube and the uterus may be interrupted (p. 326).

Hematosalpinx may also be due to a uterine fibroid or an inflamed ovary, causing salpingitis by extension of the inflammation of the endometrium or the ovary and closing the tube, or it may be a reflex effect of an extra-uterine pregnancy in the other tube.

Treatment.-Small tumors need no treatment. In that form which contains fluid blood, laparotomy or colpotomy may be performed, the tube cleaned out, made perviable, and allowed to remain (p. 533). If the cystic tube has developed down between the layers of the broad ligament, which may be supposed when it is low down and immovable, an incision may be made in the vaginal vault and the cyst drained. Large tumors filled with clots or blood mixed with pus should be removed by laparotomy. The same procedure becomes necessary after the operation for atresia of the genital canal, if it has not preceded it (p. 327).

CHAPTER III.

DISPLACEMENTS.

THE tube may be found in a crural or inguinal hernia, and is then generally accompanied by the ovary.

In the higher degrees of inversion of the uterus the tubes are always drawn into the sac formed by the inverted uterus (p. 462).

CHAPTER IV.

NEOPLASMS.

THE neoplasms of the tubes are not of much practical interest, as they often cannot be diagnosticated, are so small that they do no harm, or appear together with affections of greater importance in the neighboring organs.

A. Cysts.-Real cysts, which are something entirely different from cystic salpingitis (p. 541), may be found in all three layers composing the wall of the tube. They range in size from a millet-seed to a walnut, and contain a citrine, serous fluid. They are seen very frequently

in laparotomies and autopsies. One of them situated at the abdominal end of the tube is so common that it is described in works on normal anatomy under the name of the hydatid of Morgagni (p. 30). Some of these cysts are doubtless remnants of the Wolffian body (p. 20), and others are the result of extravasations of blood.'

The fluid contained in them is so bland that, even if through a rupture in the wall it should find its way into the peritoneum, it could hardly do any harm.

B. Fibroma.-Myomatous and fibrous tumors like those of the uterus (p. 468) are formed in the muscular coat, but do not, as a rule, acquire surgical dimensions. In one case, however, the growth had reached the size of a fetal head at term.

C. Lipoma. Fatty tumors of the size of a bean to that of a walnut have been found at the lower side.

D. Papilloma, a real neoplasm, must not be confounded with the growth of the mucous membrane due to simple hyperplasia and hypertrophy accompanying salpingitis (p. 525). Papillomatous tumors may close, dilate, and even rupture the tube, in which latter case a papillomatous infection would be likely to take place in the peritoneum. They are commonly small, but may reach the size of an

orange.

E. Cancer, either carcinoma or sarcoma, may occur primarily in the tubes, but is nearly always secondary to cancer of the uterus or the ovary.

The disease makes its appearance about the time of the menopause, and develops slowly. It gives rise to a sanious discharge from the vagina, which, in connection with the presence of a tumor and the absence of signs of uterine or vaginal cancer, may lead to a diagnosis. As a rule, it is not recognized before an autopsy is made.

If it can be diagnosticated in life, the tube and ovary should be removed by laparotomy.

F. Tuberculosis.-The Fallopian tube is more apt than any other part of the genital apparatus to be the seat of tuberculosis. In fact the tubes are affected in nearly all cases of tuberculosis of the genital tract, and genital tuberculosis is much more common than was formerly surmised.

It may be primary in this locality, and is then probably due to infection through the semen of a tuberculous man. Much more frequently, however, it is secondary, following tubercular peritonitis or being the effect of infection through the blood in persons suffering from phthisis. As a rule, both tubes are affected.

The wall is swollen, its epithelium is thrown off, the ostia are generally closed, the caliber is enlarged, and the tube is filled with a

1 This was so in a case of chronic oöphoritis and salpingitis operated on by me and examined miscroscopically by Charles Heitzmann.

caseous mass. The microscope reveals the characteristic formation of tubercles in the wall-nuclei centering around giant cells-and the presence of Koch's bacillus in the tissue and in the secretion. Often the peritoneum in the vicinity is studded with miliary tubercles. In advanced cases the whole mucous membrane is destroyed. The tubes are in general out of place, often drawn down along the edges of the uterus, and bound to neighboring parts by adhesions. They may form tumors as large as a goose-egg, the shape of which is that of a sausage, a club, or most frequently a string of 3 to 5 beads, the single knobs of which are round or oval and hard, while in pyosalpinx they are soft. Another point of difference between the two is that in pyosalpinx the part of the tube situated near the uterus is nearly always free, while in tuberculosis the disease affects this part and even the intramural portion as well.

Sometimes tubes, ovaries, and uterus are all matted together by exudation into one large mass.

The disease is very rarely acute; in general it has a chronic course. The symptoms are like those of salpingitis.

The diagnosis is often obscure; but occasionally it may be made by reference to hereditary predisposition; by finding signs of tuberculosis in other parts, especially the lungs; by finding caseous masses and bacilli in the vaginal secretion; and by the peculiarities of the tumor just mentioned.

Treatment.-As a prophylaxis connection with a man affected with tuberculosis should be avoided. The hygienic and medical treatment is the same as for tuberculosis in general. If the general condition of the patient is not too bad, salpingo-oophorectomy may perhaps effect a cure; but on account of the adhesions the operation is often difficult and sometimes impossible. If the uterus participates in the degeneration, this may be removed together with the tubes and ovaries. But as it is uncertain if all affected tissue has been removed, and as the operation itself by rupture of the tube and entrance of its contents into the peritoneal cavity may spread the infection, the treatment, upon the whole, is unsatisfactory. The presence of tubercular peritonitis or a mild degree of phthisis is no contraindication for the operation.1

1 An exhaustive monograph by J. W. Williams on "Tuberculosis of the Female Generative Organs" is published in Johns Hopkins Hospital Report in Pathology, ii., Baltimore, 1892, pp. 85-144.

PART VI.

DISEASES OF THE OVARIES.

CHAPTER I.

MALFORMATIONS.

Excessive Growth.-The ovaries of new-born children may have twice the normal size, which may either be due to a uniform hyperplasia of all the constituent parts, or, more frequently, to fetal inflammation, resulting in a preponderance of connective tissue and a partial or total disappearance of the Graafian follicles.

Supernumerary Ovaries.-Small globular, pedunculated bodies of the same structure as the normal ovaries, and varying in size from that of a pea to that of a hazelnut, are found in 5 per cent. of all bodies of women. These small ovaries are situated near the peritoneal border of the normal ovaries.

An ovary may be more or less completely divided into two parts by fissures. In a unique case there were even found three large ovaries, each bound to the uterus with a separate ligament.

The possibility of supernumerary ovaries must be kept in mind in order to explain the persistence of menstruation after the extirpation of both ovaries (pp. 119 and 539), the presence of two normal ovaries besides an ovarian cyst, and the occurrence of pregnancy after double ovariotomy - phenomena which have actually been observed.1

Absence or Rudimentary Development.-Both ovaries may be absent, a condition which usually is combined with absence of the uterus. One ovary may be absent in cases of uterus unicornis.

More common than the total absence is a rudimentary development of the ovary. Such rudimentary ovaries may or may not contain Graafian follicles. In the latter case they consist only of connective tissue and smooth muscle-fibers.

As a rule, the rudimentary condition is found in connection with an arrest of development of the uterus, but it may also be found when

For details see my article on "Malformations of the Female Genitals,” in Amer. System of Gynecology, edited by Mann, vol. i. p. 236.