Like inflammation of other structures, salpingitis may be either acute or chronic.

Acute Salpingitis.-In the first stages of acute salpingitis the disease is confined to the mucous membrane

(Beyea).

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. 145).

If the tube is laid open, the mucous membrane is found

covered 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 fimbria 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 fimbria. Such indications of an old, cured attack

of 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.

It

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. 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 the chronic 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 of

mucous 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, the interstitial form 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 cilia 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 fimbria 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 fimbria, 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. 146). The fimbria 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.

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

FIG. 146.-Salpingitis with partial inversion of the fimbria.

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 other