CHAPTER XVIII THE DIAGNOSIS OF DISEASES OF THE FALLOPIAN TUBES (Part 1)

CHAPTER XVIII THE DIAGNOSIS OF DISEASES OF THE FALLOPIAN TUBES Anatomy and age changes, p. 324. Congenital Anomalies, p. 326: Absence of the tubes, p. 326. Accessory tubes and ostia, p. 326. Diverticula from the tube, p. 326. Hernia of the tube, p. 326. Displacement and elongation of the tube, p. 326. Cyst of Morgagni, p. 327. Salpingitis, p. 327: Acute, p. 327. Chronic, p. 329. Gonorrheal, p. 330. Tuberculous, p. 330. Actinomycotic, p. 332. Echinococcus infection, p. 332. Syphilitic, p. 332. Retention tumors (Sactosalpinx) , p. 332. Pyosalpinx, p. 332. Hydro- salpinx, p. 333. Hematosalpinx, p, 334. Diagnosis of Sactosalpinx, p. 335. Differential diagnosis of Appendicitis and Salpingitis, p. 336. New Growths, p. 337: Polypus, p. 337. Papilloma, p. 337. Embryoma, p. 338. Myoma and fibroma, p. 338. Fibromyxoma, p. 338. Carcinoma, p. 338. Sarcoma, p. 339. Chorioepithelioma, p. 339. ANATOMY AND AGE CHANGES The Fallopian tubes are developed from the portion of Miiller's ducts lying above the round ligaments, and as they come from the same structures as the uterus and vagina they are continuous with these organs and their canals, and are parts of one long tube, branching, when it reaches the uterine horns, into two tubes. (See Fig. 71, page 198.) Each tube occupies the free border of the broad ligament. It has an average length of four inches (10 centimeters) but may vary; sometimes one tube is longer than its fellow. The inner third of the tube is narrow and is from one-sixteenth to one-eighth inch (2 to 4 millimeters) in diameter; it is called the isthmus. The outer two-thirds is larger in diameter, three-eighths inch (7 to 8 millimeters), is called the ampulla, and ends in the infundibulum, or trumpet-shaped depression, in the center of which is the ostium abdominale surrounded by the fimbria, or fringes. These fringes are extensions of the reduplicated mucous membrane lining the tube and are of uneven length. Running from the abdominal 324 ANATOMY AND AGE CHANGES ostium to the ovary is the tvbo-omrian ligament, traversed by a furrow so that it appears to be a long fimbria. This represents the uppermost portion of Muller's duct that lias been opened out, instead of remaining as a closed tube. The tube is convoluted, the isthmus is directed outward and slightly upward; while tin- ampulla arches over and descends, so that the infundibulum is directed toward the ovary and the fimbriae are in contact with that gland. (See Fig. 116, p. 285.) The lumen of the tube varies from the diameter of a bristle at the isthmus to a quarter of an inch (some 5 millimeters) in the ampulla. It is lined with mucous membrane, and covered with columnar ciliated epithelium, which is reduplicated and thrown into longitudinal folds. These folds become thicker as they ;q>- proach the infundibulum and on the abdominal side of the ostium are continuous with the fimbria1. The tube is composed of un- striped muscle fiber, continuous with that of the uterus, and ar- ranged in an outer longitudinal layer and an inner circular layer. Outside" the longitudinal layer is loose connective tissue between it and the peritoneum, which covers two-thirds of the circumfer- ence of the tube and is terminated by a sharp edge at the ostium abclominale. The function of the tubes is to cany the ova to the uterus. 1' has been shown by Hofmeier and Mandl (J. Whit ridge Williams. "Gynecology and Abdominal Surgery," Kelly and Noble, Vol. 11 . p. 132) that there is a current of fluid from the peritoneum, or secretion from the tubal mucosa, promoted by the cilia of the tubal epithelial cells, from the abdominal ostium of the tube to the internal os of the uterus. It has been proved by experiments on animals and a few observations on human beings that a few hours after coitus spermatozoa can be found in the outer portions of the tubes and even on the ovaries, so that it would appear that the spermatozoa get into the tubes in spite of the currenl againsl them, and that the tube is the normal place of impregnation rather than the uterus. Under norma] conditions the fertilized ovum is pa along by the cilia to the uterus where it becomes embedded in the uterine mucosa. Under abnormal conditions il is arrested in 'I"' tube and a tubal pregnancy results. At the menopause the Fallopian tubes a1 rophy, becomii and narrower and the epithelial element- disapp ,'"' DISEASES OF THE FALLOPIAN TUBES old woman they arc nothing but slender cords, often having no lumen. (See Fig. 119, p. 289.) CONGENITAL ANOMALIES Absence.— Complete absence of both tubes is exceedingly rare and occurs only in connection with failure or rudimentary develop- ment of t he uterus. Absence of one tube is found in cases of failure of development of the corresponding uterine horn. Partial de- velopment of the tube is more comman than complete absence, the tube being represented by a narrow, impervious cord, or a portion of t he t ube only may be implicated, and the isthmus may be normal while the ampulla is undeveloped or atypical, or vice versa. The diagnosis can not be made without an abdominal operation. Accessory tubes have been described not infrequently. Probably many of them are not true cases of extra tubes but accessory ostia, a much more common condition. Three reporters at least have given instances of true double tubes, and Nagel (VehVs " Handbuch," Bd. I.) found a double Miillerian duct in a human embryo. Accessory ampullae communicate with the main lumen of the tube, usually entering near the attachment of the mesosalpinx. Each has its own infundibulum and fimbriae. As many as six accessory ostia have been reported; one or two are not uncommon. Diverticula of the walls of the tube appearing as hernise occur occasionally, and, like the supernumerary ostia, are of importance because they may be lodging-places for fertilized ova, and thus a cause of tubal pregnancy. This anomaly, as also the preceding, can not be diagnosed except at operation. Hernia. — The tube is found sometimes with the ovary in a hernial 3ac. Such herniae are generally of the inguinal variety and uni- lateral. The condition is not susceptible of diagnosis before opera- tion. Displacement and elongation of the tube may be congenital or acquired. The tube is displaced to a greater or less degree with displacements of t he ovary and uterus, and also, in the case of large ovarian tumors and large tumors of the broad ligament, it is both displaced and elongated. In pregnancy it becomes lengthened enormously as the uterus approaches its size at full term and after labor the lube involutes with the uterus to regain its normal size. SALPINGITIS 327 Sometimes, where the conditions for examination are most favorable, i.e., very thin abdominal walls or separation of the recti, it is possible to palpate an elongated Fallopian tube coursing over a tumor or at the side of a pregnant uterus. Generally the diagnosis can not be made. The cyst or hydatid of Morgagni is a small cyst rarely larger than a pea, attached by a stalk one to one and a half inches (some 2 to 6 centimeters) long, to the fimbriae or to the tube itself. It is en- tirely harmlesss and ha no clinical importance. SALPINGITIS Salpingitis is the chief disease of the Fallopian tubes of interest to the practising physician. The classification of salpingitis from an etiological standpoint is difficult because it is impossible to distinguish the different sorts of bacteria that serve as exciting causes. The streptococcus and the gonococcus are the two most important microorganisms. It is probable that in those cases where the pus in the tubes is ster- ile the inflammation was originally of streptococcic origin but that the organism has died out. These organisms are transmitted to the tubes through the uterus, an endometritis being an almost invariable precursor of a salpingitis. The tubercle bacillus is a not infrequent cause of salpingitis, and rare causes are actinomycosis, echinococcus disease, and syphilis. Hemorrhagic salpingitis may accompany the exanthemata, and there is a mild catarrhal form of salpingitis and perisalpingitis of unknown origin that occurs as a complication of uterine tumors. It is possible for fluids injected into the uterus to pass into the tubes, especially when the tubes have been hypertrophied by pregnancy and when the normal tonus is not present, and thus set up a salpingitis, though this is an academic affair. The lumen of the isthmus of the tube is very small and the irritation caused by foreign fluids sets up a contraction of the circular fibers so that it is seldom that fluid can be made to pass through. Salpingitis may be divided clinically into acute and chronic. Acute Salpingitis. — Pathology. — In the case of catarrhal salpingitis, in the early stages of an acute attack the mucous membrane is 328 DISEASES OF THE FALLOPIAN TUBES swollen so that the redundant folds fill the lumen of the tube. The muscular and peritoneal coats are involved to a greater or less degree and the entire tube is reddened; the tissues are edematous and soft. According to the character of the infecting agent the inflammatory process extends or does not to the ovary and neigh- boring structures of the peritoneum through the ostium abdom- inale. Apparently sometimes the swelling of the mucosa in the tube is sufficient to close the ostium and the disease is limited to the tube itself. In the tube accumulates a certain amount of serous fluid, drainage into the uterus being interfered with by the swelling of the mucosa in a very small canal. In the case of purulent salpingitis all the processes are intensified. The mucous membrane is more swollen and injected; the entire tube is much enlarged and there is pus in its canal. The peritoneal covering of the tube is involved, and, either by direct extension of the inflammation through the wall of the tube, or because of the action of the pus that escapes from the ostium of the tube, ad- hesions of the ampulla to surrounding structures, — bowel, omen- tum, bladder, or uterus, are formed. The mesosalpinx and broad ligament are infiltrated so that they have a board-like feeling. Symptoms. — The symptoms of acute catarrhal salpingitis are so slight that they are overshadowed by the symptoms of the co- existing endometritis. (See page 174.) The symptoms of acute purulent salpingitis, on the other hand, are often severe, consisting of abdominal pain, fever, rapid pulse, uterine hemorrhage, dysuria and painful defecation, and purulent vaginal discharge. Accord- ing to the amount of localized peritonitis are the symptoms more urgent. Where the infection involves the ovary and a tubo- ovarian abscess results the symptoms and signs are those of pelvic abscess. (See page 193.) Diagnosis. — The history is that of endometritis (see page 174) and preceding infection. In the catarrhal form palpation by the bimanual touch may reveal tenderness of the tube, but this is a fine point in diagnosis. In the purulent form, not only tenderness but thickening of the tube may be evident. It is especially to be cautioned that the utmost gentleness be used because of the danger of expressing pus from the ostium of the tube into the peritoneal cavity. Evidences of endometritis arc also present. If there is much SALPINGITIS 329 distention of the tube in the subacute stage the tube may be made out as a sausage-, club-, or retort-shaped body, and it is apt to be in the cul-de-sac of Douglas. (See Pyosalpinx.) Acute purulent salpingitis is a very common affection and the attempt should be made to diagnose the disease early in its course. Chronic Salpingitis. — Pathology. — Chronic salpingitis results from an acute salpingitis. The tube is usually closely adherent to the ovary and surrounding structures; it is apt to be in the cul-de-sac of Douglas; it shows marked convolutions and twists. The walls of the tube are generally thickened and indurated. Sometimes the thickening is in the isthmus, and at others in the ampulla. Now and then one finds nodules the size of a small pea in the struc- ture of the wall of a tube (salpingitis nodosa), these being found generally in the isthmus. On section they show a dense fibro- muscular structure containing glandlike spaces, which sometimes represent the lumen of the tube. Tubes containing these nodes are apt to be impervious. The condition is not to be confused with nodular tuberculosis of the tube. The ostium of the tube is commonly closed by peritonitic adhe- sions or exudate in cases of chronic purulent salpingitis, but often on separating the adhesions it will be found that the fimbriae are free and the ostium is patent. It is probable that these are the cases in which, upon the subsidence of the inflammation and the absorption of the exudate in the peritoneum, the ostia become pervious again. In many cases, especially those due to gonococcus infection, the fimbriae are found adherent and there is true occlusion of the ostium. In the case of chronic salpingitis infection from the tube may be transmitted to the ovary, and a tubo-ovarian cyst or tubo- ovarian abscess may result, or the process may be limited to the tube, salpingitis proper. Symptoms and Diagnosis. — The symptoms are pains in the groins, a sense of weight in the pelvis, exacerbations of fever, irregular- ity of menstruation, dysmenorrhea, and vaginal discharge. The diagnosis is made by palpating enlarged tubes, by the presence of preceding and coincident endometritis, and by symptoms of pain and fever not accounted for by the endometritis. Salpingitis due to the streptococcus is less apt to affect both tubes than is the gonorrheal variety. 330 DISEASES OF THE FALLOPIAN TUBES Gonorrheal Salpingitis. — As a rule it is a long time, months or years, before the gonococci of an endometritis reach the tubes, although they have been found in the tubes within two weeks after the initial infection; therefore the disease is generally de- scribed as being subacute or chronic from the start. The disease is usually bilateral and may be ushered in by a chill, fever, and local tenderness and pain. In the more chronic stages the amount of tenderness is variable and may be wanting, there is generally no fever, and the patient may be in fair health except for anemia and debility; but during the menstrual periods there are dysmenorrhea, local tenderness, irregularities of menstruation, and increased vaginal discharge as troublesome symptoms. Acute attacks of inflammation are apt to occur in the history of chronic gonorrheal salpingitis and whenever a drop of pus escapes into the peritoneal cavity there is inflam- matory reaction. As previously stated, the ostia of the tubes are more apt to be closed by gonorrheal than by streptococcic inflammation, thus accounting for the sterility of prostitutes. Diagnosis. — Unless the gonococci can be found in the discharges from the uterus there is no way of distinguishing this form of salpingitis from any other. The probabilities may point in this direction from a history of gonococcus infection, from the occur- rence of gonorrheal joint affections, or from evidences of past inflammation in the vaginal or inguinal glands. Tuberculous Salpingitis.— The Fallopian tube is the most frequent site of genital tuberculosis in the female. Where careful routine microscopical investigations have been made of all the clinical material furnished by the operating-rooms of hospitals it has been found that from five to ten per cent of all the inflammatory affec- tions of the tubes are tuberculous. Without painstaking investiga- tions it is impossible often to distinguish tuberculous from simple salpingitis. The disease may be primary in the tubes (it is generally bilateral) or secondary to a lesion or lesions at a distance, as in the lungs, or in a contiguous organ, such as a tuberculous ulcer of the intestine. The tubercle bacillus may come to the tube from the vagina by way of the uterus, or from the blood current. The infection may be limited to the tubes, or both uterus and tubes are involved. SALPINGITIS 331 It is possible, and not a very uncommon happening, for the gono- coccus to be associated with the tubercle bacillus. Pathology. — Tuberculosis of the tubes appears in three forms, miliary, caseous, and fibrous. The appearances of the tube vary according as the disease began in the mucous membrane lining its cavity or in the peritoneal coat. The tube may be atrophied or much enlarged and tortuous and a part or the entire tube may be affected. Microscopically tuberculous nodules are found. These consist of a central giant cell surrounded by epithelioid cells and an outer zone of small round cells. Caseous foci are common and the folds of the mucosa are thickened and adherent. The lumen of the tube may be closed by a hyperplastic process affecting the mucosa just as ir the swelling which accompanies infections by K Fig. 136. — Tuberculous Salpingitis. (Dudley.) other organisms. The disease generally is progressive, but may be arrested, the tube being represented in such cases by a thin, impervious, fibrous cord. If the disease progresses one expects to find tuberculosis of the peritoneum. Diagnosis. — Tuberculous salpingitis is seldom seen in an early stage when the diagnosis can be only that of salpingitis. A tuberculous history or tuberculosis elsewhere in the body leads one to suspect the etiological significance of a salpingitis and some- times in the later stages fluid in the peritoneum calls attention to tuberculosis. Pyrexia, recurring every evening and disappearing 332 DISEASES OF THE FALLOPIAN TUBES every morning, loss of weight and strength, rapid pulse, sweating, particularly at night, are symptoms of tuberculosis. Actinomycotic salpingitis is secondary to actinomycosis elsewhere, besides being very rare. The tubes are converted into abscesses in which the characteristic yellow or brownish-black, sago-like granules are readily recognized. Under the microscope the acti- nomyces is recognized in the characteristic granulation tissue. Echinococcus