DISEASES OF THE FALLOPIAN TUBES (Continued).
TUBERCULOSIS.
Tuberculosis attacks the Fallopian tubes much more frequently than any
other part of the genital apparatus. The disease may be associated with
tuberculosis of the peritoneum or with tuberculosis of the ovaries and
the uterus. As has already been said, tuberculosis of the uterus often
originates in the tubes and extends thence to the endometrium.
The tubercular Fallopian tube varies much in appearance according
to the nature and stage of the disease. The strictly tubercular
lesions may be masked by those of ordinary inflammation. There may be
peritoneal adhesions, often very dense and widespread, between the tube
and adjacent organs, and the ostium abdominale may be closed, as in
non-tubercular salpingitis.
In some cases these simple inflammatory adhesions probably existed
before the tubercular infection took place, the tuberculosis occurring
in an old diseased tube. In other cases it is probable that the
inflammatory adhesions and products occurred as a result of the
tuberculosis, which attacked a tube previously healthy. In the latter
case such adhesions may be viewed as a conservative process.
The tubercular tube is often very much enlarged from infiltration of
its walls and dilatation of its lumen. It may be filled with typical
caseous material, and when this is removed the mucous membrane will be
found the seat of deep, jagged, ulcerated areas.
If the abdominal ostium is not entirely closed, the cheesy material may
project into the abdominal cavity. If the disease has extended to the
peritoneal coat, the covering of the tube will be found studded with
typical tubercles (Fig. 152). Such tuberculosis of the peritoneum may
be confined to that covering the tube, or it may extend to the uterus
and throughout the abdominal cavity.
In peritoneal tuberculosis that has originated in the tube the lesions
are found to be most widespread in the pelvic peritoneum.
[Illustration: FIG. 152.--Tuberculosis of the Fallopian tubes.
The disease has extended to the peritoneum, which is covered with
tubercles.]
In some cases the ostium becomes closed, and the tubes are found
distended with pus, forming tubercular pyosalpinx. Such tubes sometimes
attain enormous size, containing a quart or more of purulent material.
In less extreme cases than those just described the tubercular area
may be limited to a portion of the tube, and gives rise to one or
more nodular enlargements (Fig. 153). In other cases there is no
gross change in the shape or size of the tube, and only a few miliary
tubercles are found scattered throughout the mucous membrane.
In a very large number of the cases of tuberculosis of the Fallopian
tubes, the lesions resemble in all respects those of ordinary
salpingitis, and are not in any way recognizable by the naked eye as
characteristic of tuberculosis. There are no cheesy contents; there
are no tubercles upon the peritoneum; the mucous membrane shows no
macroscopical changes that would lead to the suspicion of tuberculosis.
In these cases the tubes are usually closed at the abdominal ostium;
there may or may not be cystic distention; and the adhesions, which are
usually very firm, distort the shape of the tube and bind it to the
posterior aspect of the broad ligament, the uterus, or other pelvic
structure. Until recent years such cases were supposed to be simple
cases of salpingitis. Careful microscopic examination, however, has
shown that this forms one variety of tubal tuberculosis, and that a
certain proportion of such cases of salpingitis are tubercular. The
term “unsuspected tuberculosis” has been applied by Williams to such
cases.
[Illustration: FIG. 153.--Tuberculosis of the Fallopian tubes: _A_,
tubercular nodules.]
Cases of tuberculosis of the Fallopian tubes may be divided into three
classes: Miliary tuberculosis; chronic diffuse tuberculosis (cheesy
tubes); and chronic fibroid tuberculosis.
_Miliary tuberculosis_ of the tubes may be a part of a general miliary
tuberculosis, or it may occur primarily in the tube. Microscopic
examination shows giant epithelioid cell-tubercles scattered throughout
the mucous membrane.
Miliary tuberculosis is the first stage of tuberculosis of the tubes.
The process may progress no farther, or it may become converted into
one of the other varieties.
In _chronic diffuse tuberculosis_ the mucous membrane is infiltrated
with epithelioid cells, miliary tubercles, and areas of caseation.
The tube may be filled with cheesy material or with pus, and in time
the mucous membrane becomes completely destroyed. In this form of
tuberculosis the gross appearances are usually characteristic, and are
those which have already been described.
In _chronic fibroid tuberculosis_ there is a great increase of
connective tissue between the tubercles. The lumen of the tube is
distorted, and a few miliary tubercles are found scattered through the
mucous membrane. This form of the disease is very slow and chronic, and
represents a usual method of spontaneous cure.
Since the discovery of so-called unsuspected tuberculosis of the
Fallopian tubes the disease has been found to be much more frequent
than was formerly supposed.
Williams found tuberculosis of the tubes in one out of every twelve
operations for the removal of tubes and ovaries that were the seat of
past or present inflammatory disease.
Dr. Beyea and I have found tuberculosis of the tubes present in
18 per cent. of the cases that were subjected to the operation of
salpingo-oöphorectomy for inflammatory disease of the tubes.
It may be said, therefore, that tuberculosis is present in from 8
to 18 per cent. of all cases of inflammatory disease of the uterine
appendages. It is impossible, however, to say whether or not
tuberculosis is the cause of the disease in all cases, or whether
tuberculosis has been grafted upon a previous non-tubercular affection.
Other organisms, along with the tubercle bacillus, are frequently found
in the Fallopian tube.
Tuberculosis of the Fallopian tubes may be primary or secondary.
In primary tuberculosis the tubes are the primary seat of the disease,
being affected before other structures of the body.
In secondary tuberculosis the tubes are affected from a tubercular
focus in some other part of the body.
Tuberculosis of the tubes is usually secondary.
Infection takes place in a variety of ways. Infection through the blood
is the most usual way.
Infection may take place from a tubercular ulcer of the intestine or
bladder becoming adherent to the tube. The tube may become involved by
extension of tuberculosis of the peritoneum to it. In many cases the
reverse order happens: the tube is first involved by the tuberculosis,
and the disease extends thence to the peritoneum. In other cases it
is the peritoneum that is primarily affected. It seems probable that
tubercle bacilli, having gained entrance to the peritoneum from a
tuberculous mesenteric gland or from an intestinal ulceration, fall
to the pelvis and are drawn into the Fallopian tubes, there producing
tuberculous lesions without first affecting the peritoneum.
It seems probable that in a good many cases of tuberculosis of the
tubes the infection takes place from without by way of the genital
tract. Dirty instruments, syringes, or the examining finger may
cause it in this way. Infection may also occur from clothing or
bed-sheets soiled by sputum or other tubercular discharge. Coitus
with men affected with genito-urinary tuberculosis or any other form
of tuberculosis may be an occasional cause. It has been shown that
tubercle bacilli may be present in the testes and prostate glands of
consumptives without any evidence of genito-urinary tuberculosis being
present.
Tubal tuberculosis may occur by way of the genital tract from infection
from the discharges from some other tubercular focus in the woman, as
in the lungs, bladder, or intestinal tract.
The =symptoms= of tuberculosis of the Fallopian tubes are not at all
characteristic. Most cases of tubal tuberculosis have been discovered
at the autopsy or have been unexpectedly found at operation.
The symptoms resemble those of non-tubercular salpingitis. There is the
same ovarian pain and dysmenorrhea. Bimanual examination reveals the
enlarged or nodular and distorted condition of the tube. The adhesions
are often very firm and dense, and the tubal tumor is often of stony
hardness.
The =diagnosis= of uncomplicated tubal tuberculosis is difficult,
and in many cases impossible. If the peritoneal covering of the tube
is involved, the small tubercles may sometimes be felt by vaginal or
rectal palpation. Or, if the condition has extended to the posterior
aspect of the uterus, the tubercles may be felt here, by dragging
the cervix down with a tenaculum and palpating the posterior uterine
surface with a finger in the vagina or the rectum. The association of
salpingitis with pulmonary tuberculosis would lead the physician to
suspect that the salpingitis might be tubercular. If the woman has
tuberculosis of the peritoneum, and the tubes are found enlarged, it is
most probable that they are tubercular. A knowledge of a genito-urinary
lesion of tubercular nature in the husband should lead us to fear tubal
tuberculosis in the wife.
=Prognosis.=--Tubal tuberculosis is a dangerous disease. There are
several methods of termination. It very often leads to tuberculosis of
the peritoneum. For this reason peritoneal tuberculosis is more common
in women than in men.
A tubercular abscess may be formed in the pelvis, and the woman may die
as the result of prolonged discharge and suppuration, as in the case of
non-tubercular pyosalpinx. General tubercular infection may arise from
the tubercular focus in the tubes.
Tuberculosis of the tubes may, and probably often does, undergo
spontaneous cure. The fibroid changes that have been described lead
to this end. In some cases calcification occurs, as in tuberculosis
elsewhere, and the disease is cured in this way. Fig. 154 represents
an old tubercular pyosalpinx that was filled with calcified plates.
Even though these conservative changes take place and all danger from
the tuberculosis has disappeared, the woman will continue to suffer
pain and dysmenorrhea from the tubal and ovarian adhesions.
=Treatment.=--The treatment of tubal tuberculosis is celiotomy, with
removal of the tubes and ovaries. If the uterus is involved, it should
also be removed. Removal of the tubes, however, is the important
feature of the operation. I have seen perfect and permanent recovery
occur after removing the tubes, even though the disease had extended
into the uterine cornua. As the disease very rarely extends below the
internal os, the uterus may be amputated at any convenient point of the
cervix.
[Illustration: FIG. 154.--A tubercular pyosalpinx. To the left are
three calcified plates that were found in the tube.]
Tuberculosis of the peritoneum is an indication for, rather than
a contraindication to, the operation. The most extensive cases of
peritoneal tuberculosis have been cured by opening and draining the
abdomen. If the tubes are rendered inaccessible from the involvement of
surrounding structures, the operator must content himself with opening
and draining the abdomen.
=Adenoma= of the Fallopian tube is a rare disease; but a few cases have
been described in medical records. The presence of primary adenoma
in the Fallopian tube is strong proof of the glandular character of
the mucous membrane--an anatomical point which, as has already been
said, has been denied by some writers. In adenoma the tube becomes
distended with the typical adenomatous mass, which may protrude from
the abdominal ostium.
In some of the reported cases there has been found a considerable
quantity of free fluid in the peritoneum, though the peritoneum itself
was not diseased. It seems probable that this secretion originated in
the tube and escaped at the ostium.
=Myoma.=--Notwithstanding the frequency of myomatous tumors of the
uterus, the condition is exceedingly rare in the Fallopian tubes. The
tumors originate in the muscular coat, and are usually so small as to
create no disturbance.
=Cancer.=--Primary cancer of the Fallopian tubes is an extremely rare
disease. A very few isolated cases have been reported.
Cancer of the tubes secondary to cancer of the body of the uterus
occurs more frequently.
=Sarcoma= of the tube is a very rare disease.
=Actinomycosis= of the Fallopian tubes has been described.
=Syphilitic gummata= occasionally attack the Fallopian tube in women
who are the victims of constitutional syphilis.
The diagnosis of these unusual lesions of the Fallopian tubes is
impossible with our present knowledge. The conditions have usually been
found post-mortem or have been unexpectedly discovered at operation.
The subjective symptoms throw no light upon the subject of differential
diagnosis. Examination reveals merely a tubal tumor.
As the rule is to operate in all cases of tubal tumor, the proper
treatment will probably be applied, notwithstanding the uncertainty or
mistake of diagnosis.