emptying of the hematometra. I do not know of any such cases having been reported, yet that they are possible is attested by the lumen of the tube and uterus often being found dilated. In cases of retro-uterine hematocele, the uterus may exude a discharge, lasting for months, and an examination will show the source to be the hematocele. The symptoms of hematosalpinx are very similar to those of hydrosalpinx, differing only in that the exacerbations of the affection from recurring menstruations are more regular. As it usually occurs in connection with hematometra, its symptoms are insignificant compared with these caused by the latter, and are usually isolated only after the hematometra has been evacuated. Hematosalpinx ruptures more frequently than hydrosalpinx, on account of the more rapid accumulation of the contents of the sac. It can be diagnosticated with certainty only when associated with hematocolpos and hematometra. Percussion should be employed to ascertain the border-line of dulness, for repeated or too forcible palpation may cause rupture. An irregular, lateral tumor is probably hematosalpinx. A distended uterine horn is nearer the median line, and is more or less crescent-shaped. Treatment.*-When possible operative measures are to be avoided. Evacuation by abdominal puncture is, in many respects, dangerous; this must also be said as to puncture through the vagina, for the tumor is usually fixed above the true pelvis. Laparotomy would be indicated when recovery did not ensue after the operative cure of hematometra if rupture seemed imminent. Laparo-salpingotomy might not be too late, even though perforation had already occurred. * Vide Hematocolpos, p. 114, and Hematometra, p. 471. CHAPTER III. NEOPLASMS OF THE FALLOPIAN TUBES. THE structure of the uterine and tubal walls being similar, all tumors which affect the uterus may be found in the tubes, affections of the uterine glands being excepted. Neoplasms of the tubes are much rarer and smaller than those of the uterus. Again, they are usually secondary, primary affections of this kind being extremely rare. It is a remarkable fact that the fimbria are least often affected in many cases, which is the converse of what would be expected. a. Tubal cysts are found in the peritoneum, in the muscular layers, and in the mucous membrane. They are most common in the first, and appear as small vesicles the size of a poppy seed and larger. The hydatid of Morgagni has been described (see p. 493). The small peritoneal cysts contain a clear serum or a thick colloid fluid, and occasionally form a pedicle. Rokitansky found they had a delicate capsule of fibrillated connective tissue. The cysts of the muscular tissue are seldom larger than those of the peritoneum, and probably result from slight extravasations of blood. In the mucous membrane we find numbers of small vesicles, occurring generally in the ampulla and less frequently in the isthmus; I have found them in about 4 per cent. of my autopsies, the largest being the size of a hazel nut. They may be under the mucous membrane, in size as large as a walnut (Kiwisch). In general, these formations have but little significance, since they always remain small. They may rupture and cause a varying amount of perimetritis, as may happen in Morgagni's hydatids. b. Fibromata or myomata of the tube seldom attain a large size; there are generally several, and they vary in size; I have seen them as large as a pea, Rokitanksy as large as a bean, and Simpson reports one the size of a child's head. Their construction corresponds to that of uterine myomata, in the presence of smooth muscular fibres and connective tissue, though the latter appears to preponderate. The majority are subserous, and may thus form a pedicle, but some may also be intra-parietal. Henning has reported cases of papillary tumor of the tubal mucous membrane.* c. Rokitansky observed a lipoma the size of a walnut on the lower border of the tube in a woman aged 47 years. Lipomata have no practical significance because of their small size. d. In 73 cases of uterine cancer, Kiwisch found cancer of the tube 18 times. Secondary involvement is therefore infrequent, and this is probably due to the fact that the lower portion of the Rechte Tube mit Krebsknoten, right tube with cancer nodules; Tubenende, end of tube; Carcinoma ovarii dextri, cancer of the right ovary. uterus is commonly affected. The tubes rarely become affected in cancer of Douglas's cul-de-sac.. I found isolated cancerous nodules in the tubes in a case of medullary cancer of the uterine fundus and ovarian carcinoma (fig. 83). Scanzoni reports a case of primary cancer of the tube, but the author believes it to have really been secondary. A carcinomatous tube may rupture, causing fatal peritonitis, as in Dittrich's case. Such affections are usually discovered post-mortem. As they are commonly secondary and associated with coexisting disease of other organs, no especial treatment will be required. CHAPTER IV. INFLAMMATIONS AND TUBERCULOSIS OF THE TUBES. a. CATARRH and purulent inflammation of the tubes may be acute or chronic, and, as a rule, appears simultaneously on both sides. The mucous membrane of the fimbria is reddened and swollen, and presents a sago-like appearance. The secretion, which is abnormally abundant, is at first clear, neutral or acid and contains hyaline and mucus, but gradually becomes purulent. The wall of the tube is thickened and convoluted; the extremity chiefly affected becomes adherent, perisalpingitis and adhesions to adjacent organs ensue, and the accumulated secretion finally causes pyosalpinx. Constrictions form at various points, and these cause sacculated pyosalpinx, pyosalpinx saccata. The mucous membrane is thick, and contains polypoid villi; the epithelium is swollen, sometimes flattened, and its ciliæ often absent. Continued pressure causes atrophy of the mucous and muscular tissues, and perforation of the wall from ulceration may follow, as shown in cases of puerperal salpingitis by Ed. Martin and Förster. When there is no atresia of the fimbriated extremity, the pus may be discharged into the abdominal cavity; in either case, pelviperitonitis would result from the evacuation. Etiology.-Tubal catarrh occurs most frequently about the age of puberty and during the child-bearing period. It is seldom primary, but usually secondary to analogous affections of the uterus. Its most frequent cause is gonorrhoeal and puerperal infection, though it may occur with myoma, carcinoma, displacements, ovarian disease and exanthematous and infectious diseases, such as cholera and typhoid fever. The menstrual colic of prostitutes is largely due to salpingitis, and the same complaint in young married women may be attributed to sexual excess during wedding tours and to imprudence during menstruation-dancing, riding, etc. In parturient women it may be either primary or secondary. In isolated cases, an example of which recently came under my notice, the fimbriae may be swollen, oedematous and of a cherry-red color, while the inflammation does not extend to the canal proper, and the lumen is neither dilated nor does it contain any abnormal substance. The symptoms of tubal catarrh are menstrual colic and the symptoms of pelviperitonitis, and these can be described together, when speaking of the latter affection. The terminations may be in recovery, caseation of the pus, perforation into the rectum (Andral), or the abdominal cavity (Förster, Ed. Martin, Burnier, Cerné and Janeway), or in fatal hemorrhage (Chase). Sterility always follows when the case ends in recovery. The prognosis is very uncertain. Treatment.-If there is atresia or closure of the outer extremity while the uterine ostium remains permeable, irrigation might be attempted to wash out the retained fluids. Exploration of the tube by the sound has received some attention in this affection, as well as in dropsy of the tube. In one case only* was it possible, as proved by post-mortem examination, to easily reach the cavity of the tube; in this patient the presence of an ovarian tumor had enlarged the cavity of the uterus, which allowed of ready access to the tube. The exceptional cases of Veit, Duncan, Hildebrandt and C. von Braun, in which it was claimed that the tube had been thus explored in the living subject, have not been proved by an autopsy. Furthermore, it has been shown that the wall of the uterus, just after delivery or during an extrauteriue pregnancy, may easily be penetrated by the sound as no febrile symptoms follow, and this could very likely have been mistaken for sounding the tube. The probability of perforating the tube and of fatal peritonitis following renders it a dangerous operation. When a fluctuating tumor is found, the contents of which appear to be purulent, judging by the fever, hypersensitiveness and redness of the skin, au exploratory punc ture is indicated, to be followed by a free incision and evacuation through the abdominal walls, vagina or rectum; the cure will be hastened by thorough disinfection of the cavity. Hegar† performed the first laparotomy for pyosalpinx. When this disease attacks both tubes, laparo-salpingotomy was performed by Lawson * Bischoff's case, Bandl, 1. c., p. 25. |