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Bacteriological studies in salpingitis with special reference to gonococcal viability
BACTERIOLOGICAL STUDIES IN SALPINGITIS WITH REFERENCE TO GONOCOCCAL VIABILITY* J. MASON HUNDLEY,
JR., M.D., WILLIAM K. 111~~IL, RI.D., JOSEPEI W. BAGGOTT, M.D., B.ILTINORE, Mu.
(Prom
the Department
of Gynecology,
Hospital
of the
1Jxicersity
SPECIAL AND
of Maryland)
F
OR many years the problem of salpingitis has played a large role in the However, due to management of gynecological and obstet,rical patients. extensive educational programs conducted by t,he American Tuberculosis Society, the U. S. Department of Public Health, and in a great measure to the untiring efforts of the American physician, there has come about a decline in the incidence of these tubal infections. Added to these splendid educational activities we now have on hand real weapons of destruction, namely, chemotherapy and antibiotics. These “wonder drugs” have truly revolut,ionized the problems presented in the various types of pelvic infections. Physicians have noted the frequency of recurrent pelvic inflammatory disease, which may exist over a long period of time, when the et,iological factor has been the gonococcus. With this organism as the infecting agent, it has been observed that many acute pelvic processes would, in a comparatively short time, become quiescent and asymptomatic ; whereas the urethral, cervical, and Bartholin’s gland infections would exist for months or even years. The main point of interest which stimulated us to carry out this investigation was whether the repeated attacks of salpingitis were due to reinfections, from a distant source, or whether they were recrudescences of a residual infection. From our observations there has been a paucity of invest,igation on this subject and above all no unanimity of opinion. Menge, in 1897, was one of the first t,o report his findings on the incidence of organisms occurring in purulent salpingitis. He found 21.7 per cent of specimens were positive. About the same time Hyde reported an incidence of positive cultures in 18.9 per cent of cases, while Andrews reported 22.0 per cent positive cultures in his series. These quotations are from Crossen, references not given. As will be noted, these reported figures were quite uniform as to incidence. It was not until the work of Curtis1 in 1921, that disagreement was presented as to the high incidence of tubal organisms. Curtis, carrying out, an exhaustive study, found the gonococcus was present in 19 out of 192 specimens investigated, or 9.89 per cent. He also came to the conclusion that the Xeisserian diplococcus in the Fallopian tube was comparatively short-lived, the culture becoming sterile 10 to 14 days after the acute symptoms had abated and that, therefore, the tube was not a focal point of infection, the flare-ups being true reinfection from the lower genital tract. Curtis states that proof of persisting gonococcal infection deep in the tubal wall is lacking. For this reason the Fallopian tubes were thoroughly ground and then cultured. The finding of only 19 positive cultures, obtained by this method, substantiates his views as to the short life span of the organism in the tube. His list of tubal positive White
*Read at the Seventy-Third Sulphur Springs, W. Va.,
May-
Annual Meeting 11 to 13, 1950.
977
of
the
American
Gnwcological
Society.
cultures was 38, of t,hese tlic gonocow~~s was i’ound irl 19 ; nonhemolyt ic* si rep tococcus 5 ; hemolytic streptococcus 4 ; anaerobic streptococcus 5 ; Rf~cilltcs ~0li 3 : mixed growth 3 ; Bacillus proteus 1 ; t,uherculosis 9. To our knowledge no further investigation was carried out on this xub,ject until 1938 when Studdiford and co-workers” published their findings on the longevity of the gonococcus in the Fallopian tube. His rnethod of procedulc is, briefly, as follows: Inflamecl tubes and ovaries were removed at operatiorl from 24 consecutive patients who had heen afebrile for at least two weeks. Cultures were obtained from the lumina of the tubes with a plat~inum loop. small pieces of exudate and tissue were taken, and cultures made from pus, if present. Media used was 5 prv cent horse blood-agar, hydrogen concentration 7.5. P&es were examined in 24 to -IS hours. Gono~~occns complement-fixation tests were performed in 20 of the 24 (assesand were found not a reliable index of infection. Results: Among the 24 cases studied there were 16 positive vutures of gonococcal infection, or, in 66.6 per cent, “Positive cultures were (‘llltures from pus were negaobtained only from pieces of tiysntl and esodate. tive for gonorocci.” Having presented two reports of divergent results we wish to present. 0~11 observations and findings on gonococcal salpingitis. Before present,ing out bacteriological data we wish to discuss the problem of gonococcal salpingitis as it exists in our I)epart,mrnt of (:ynec~logy, at the 1Tniversit.v of Maryland.
Material The following statistics cover a period of 10 years, from 1939 io 1949. During this period, 15,818 neu! patients were screened through our Out-patient Department. Of these we found 5,619 patients with evidence of gonococcal disease, which made a percentage incidence of 35.5. The infection existed in the following categories : Salpingitis, chronic Salpingitis, acute Salpingitis, subacute Pyosalpinx Hydrosalpins Tuboovarian abscess Pelvic inflammatory disease Total
2,980 499 656 50 t’l Xl 1,062 5,619
Of this group, 1,069 were admitted to the hospital for operation of various tapes, always with the thought that conservation should be t,he watchword. I&om these figures it will be noted that the operative index is 18.0 per cent. We feel that the indications for operative interference in gonococcal disease are as follows: (1) menometrorrhagia associated with marked dysmenorrhea; (2) painful, fixed, retrodisplacements ; (3) adhesions wit,h symptoms ; (4) large hydrosalpinx or tuboovarian abscesses ; (5) repeated attacks of infection. When salpingitic lesions are of short, duration and there is little associated fibrosis, splendid results are obl-ained by the use of chemotherapy and antiI)iotics, t,he pat,ient, freyuentlp becoming asymptomat,ic. However, sterilit,y usually ensues. If’ the patient has had only one mild tubal infect,ion it, is possible t&t I)re~lancy may take place if there is event,ual c*omplete regression and The work of the late Franklin I’. Mall,” on f)atericy of tht~ tul)c comt~s aboll tubal disease in relation to ectopic pregna.ncies, tends to support this belief. He reasons as follows: “Tubal pregnancy usuall;v takes place in women who have given birt,h to a child and then have been sterile for EIconsiderable period. The occurrence of tubal pregnancy indicates that the inflammatory process in
60 Sumher 5
BBCTERIOI~OGICAL
Volume
STVDIES
IX
979
SALPINGITIS
the tube is gradually disappearing so that if tubal pregnancy had not t.aken place the chances are that t,he tube would eventually have become healed, thus permitting the fertilized ovum to reach the uterus. ” We now wish to present the results on our studies of the bacteriology oc salpingitis with special regard to gonococcal longevity. The selection of patients was of the greatest importance; obviously we would not operate on frank acute conditions unless there were some definite indication. The therapeutic use of chemotherapy and antibiotics was contraindicat,ed for by such procedures we would definitely change the bacteriological findings. The personnel of our Out-patient Department and Hospital Service is predominantly made up of the Negro race. As the incidence of uterine fibromas associated with gonococcal disease is here very high we selected many of our In our study comprising 80 patients, 71 patients for study from this group. were of t,he Negro race and 6 were white. Uterine myomas were an associated lesion in 51 instances. ESTRATI~BAT, I. 2. 3. 4.
PATHOLOGY
Fibroids Ovarian cysts Chronic cervicitis R,etroversion
31 .12 4 3
63.75% J5.0 % 5.0 % 3.75%
Method of Procedure Smears and cultures were obt,ained with the platinum loop from the urethra, the cervix, and the tubal lumen in all cases. Sections of the tubal wall were also macerated and cultures then made. These procedures were carried out in a glass box, the interior of which was exposed to ultraviolet light in order to obviate atmospheric contamination, the efficiency of which was demonstrated by obtaining sterile cultures after a 30-minute exposure to t,he ultraviolet ray. The cultures of the tubal lumen were made on chocolate agar; the cultures of the macerated tube were made on trypticase soy broth and chocolate agar. All cultures were incubated under 10 per cent carbon dioxide tension and were reported after four days’ incubation. The maceration was carried out, in a sterile mortar using sterilized sand and water. A tabulation of the bacteriological findings in 80 patients now follows: 1. Positive gonococcal cultures Urethra alone Cervix alone Urethra and cervix
and
source
Total 2. Fallopian tubes: Alone One tube, cervix, and urethra Both tubes, cervix, and urethra One tube and cervix 3. 4. 3. 6.
Total Fallopian tubes, Cervix sterile Urethra sterile Number of tubes Number of tubes Number of tubes Number of tubes Number of tubes
sterile
with positive with positive with positive with positive with positive
cultures cultures cultures cultures cultures
of origin
: 4 9 20
5.0 70 11.25% 25.0 gr,
33
41.25y0
0 2 2 1
0 2.5 70 2.5 70 1.25yf~
5 61 2 3
6.25% 76.1 % 2.5 70 3.75yo
of E. coli of staphylococci of streptococcus gamma of gram-plus rod of yeast contaminants
4 9 2 2 1
The pathological investigat.iott of the tubes remove(I presents ;I number o I’ interesting facts. Tuboovarian ahsccsses were found in 9 instances and the bacteriological studies of the tube showed no evidence of the gonococcus. This is in contrast to the findings in t.he lower t,ract for in this group 6 of the patients had positive gonococcal cultures in t.he urethra ant1 eciryix and 2 of these had received courses of sulfonamide therapy and penicillin but. in spite of this thr cultures remained posit,ive. All Iuboovarinn specimens studied showrtl evidence of repeated attacks as demonstrated by the marked fibrosis of thr t,ubal wall. Varying degrees of chronicity were found in 66 tubes; here was found evidence of scarring, fibrosis, lymphold infiltration and oblit,eration of the lumen, with closure of the fimbriated end and isthmica ll(JdoSa.; 7 patients, showed hydrosalpinges. No pus was found in the tubal lumen in any case. There werr i patients in the semiacute stat,us, these having definite reinfections as symptoms had extended over a number of years in each patient. In this group 5 patients had positive gonococcal cullurcs in thtx ecrvix and urt~l bra. Sonc Of illC 7 llitd positive tubal cultures t’or gonorrhea. From this study we find t,hat. persistent, gonor1+hea in women is a diseascx primarily of the lower generative t,ract, as evidenced by the fact, t,hat of the 80 patients carefully studied 33. or 41.25 per cent,, showed positive cultures in the cervix and the urethra. We have also observed that cultures obtained as statctl above are more reliable, as an index of infection, t,han the smear technique. Why is the diplococcus so shortlived in the Fallopian tube and so long lived in the urethra and cervix “! At first glance one might postulate that changes in pH play a role in the maintenance and desiruct,ion of thr gonococcus in the Fallopian tube. This is borne out, in vulvovaginitis in children for the gonococcus grows luxuriantly when the vaginal secretion is alkaline, i.e., pI-I of 7.0 plus! and the vaginal epithelium is immature; whereas, after puberty: the secretion becomes acid in the order of 4.5, due partly to the IKiderlcin bacillus, and the Tt is thought, vaginal epithelium becomes mature and resistant to infect,ion. that such conditions arc inimical t.o the growt-h of the gonococcus and the infecdtion soon disappears. This sounds very plausible wit,h the exception of the fact that a continued low t,ubal pH would sound the death knell for the spermatozoa and sterility Wishing to learn if variat,ion in pH in the would he more likely the rulr. urethra, cervix, and Fallopian tubes had any bearing on the longevity of thP gonococcus we have recently instituted a series of pH studies. The determination of the pH in situ is quite simple and is obtained in a few minutes with thr use of t)he Beckman pH me&. the st,erilc electrode being inscrtcd int,o the urethra, the rervix, and Fallopian tube. To date we have not examined a sufficient number of patients to make a definite statement but, in general, the readings have shown slight aridity! many being nearly neutral and a. few showing alkalinity. Readings obt,ained from the urethra, cervix. and tube are as follows : vaginal readings varied from 4.34 to 6.90 units; caervical readings varied from 6.51 to 7.27 units; urethral readings varied from 5.27 to 7.34 units. Vrom this preliminary obserration it. would appear t,hat variation in pI1 in the adult plays an unimportant role in the presence or absence of the gonococcus. We will continue our investigations on these struct,ures during normal cyclical phases and under various pathological conditions. In summarizing our work on gonococacal infections we feel that every effort should be concentrated upon cradicatin, 0 the infection in the urethra, cervix, and Bartholin’s glands to prevent, ascending disease. One immediately observes the great disparity between the incidence of infection in the lower generative tract and that existing in the tube. The infection in the cervix and urethra may exist for years without tubal involvement.
BACTERIOLOGICAL
STUDIES
IN
SALPINGITIS
981
We know from the work of Lamar and associates4 that human cervical mucus undergoes cyclic penetrability to the spermatozoa and that this phenomenon occurs most markedly at the time of ovulation. They also showed that the menstrual discharge was penetrable by spermatozoa but the mucus of the phase between menstrual and midcycle is relatively impenetrable and that of the phase between midcycle and the subsequent period is ili:penetrable. The period of penetrability was between t,he ninth and the nineteenth days, but this period may be restricted to four days. E’r’om this study we may deduce that there are two optimum times for bacterial ascent, namely, at the time of ovulation and also at the menstrual time. From our observations Falpingitis is more prone to develop during menstruation for the minimal uterine contraction present at this time tends to eject uterine fluid with contained organisms into the Fallopian tubes. Acute endometritis, due to the gonococcus, is rarely seen due to its monthly shedding and rebirth. In order to make our presentation on salpingitis more comprehensive we wish to highlight some of the important findings in tubercular and streptococci infections that hare come to our attention.
Tuberculous
Salpingitis
A few remarks on this subject are of interest to us primarily because of its apparent infrequency. In a survey of 1,069 patients with salpingitis, from 1939 to 1949, there were onlr 19 cases due to the tubercle bacillus, an incidence of 1.7 per cent. The majority of authors state the occurrence of tuberculous salpingitis to be in the order of 5 to 6 per cent; this decline we feel is, in a large measure, due to education of the public as to preventive measures, i.e., routine x-rays of the chest, improved housing facilities, etc. Some years ago the second most common cause of death was tuberculosis, whereas today this disease occupies the fifth position. There is a definite decrease in the incidence of pulmonary tuberculosis, the prime etiological fact,or in t,he development of luherculous salpingitis, as shown by figures obtained from the Department of Health of the State of Maryland. The decrease is striking in the white race I jut not. so significant in t,he Negro. In the years 1921 to 1925 the death rate per 100,000 was 94.3 for whites and 281.4 for Negroes. Many factors play a role in the high Negro rate such as substandard housing, crowding and undernourishment, etc. Now compare these figures to those prevailing from 1941 to 1945; here we find t.he decline in the white race from 94.3 to 39.6 per 100,000 popnlat,ion, whereas the decline in the Negro race is from 281.4 to 184.7 fol the same period. An analysis of our 19 patients with tuberculous salpingitis shows an incidence of 1.7 per cent, which follows the usual pattern. It appears to OCCUI comparatively early in life, 12 patients being in the second decade, 5 in the third, and 2 patients had the disease at 16 and 14 years of age respectively*. The average duration of sterility was 7.7 years. The menstrual histories showed oligomenorrhea, menometrorrhagia, and dysmenorrhea; none had amenorrhea. ,4s is the usual fact most of the diagnoses were made at operation and by microscopic diagnosis. We were fortunate in making a preoperative positive diagnosis in 6 patients. X-rav examinations for pulmonary disease were carried out in all patients and only’2 were found to be positive. The frequency of involvement, of the pelvic organs followed the rule, i.e.. tubes 18, ovaries 4, uterus 1, endomctrium 3, and cervix 1. In our bacteriological study 01’ 80 patiellts, all having smears and cult,ures of macerated tubes, no incidence of tuberculosis of the tnhc was detected. All of the patients were treated by operative procedure and there were no deaths.
Postoperative complicat,iotls showed :I draining ;~.htl~~minal siuuacs whi<*h healed spontaneously. Wound infect,ion occurred In 3. and 1 patient had ;I very serious reaction resulting front a transfusion error.
Infections
Following
Pregnancy
This includes t,he paerperal as well as the postabortal infections. The’ background information for these few remarks on puerperal infection was furnished by Dr. Louis IT. Tjonplass, Professor of Ohst,etrics, liniversity of Maryland. During the past 10 years, 1939 to 1!)49, 26,928 deliveries were performctl on the obstetrical service of the I’niversity Hospital and in this large group the incidence of puerperal infection was in the order of 3.8 per cent. In this clinic, puerperal infect,ion means any elevation of t,emperature to 100.4O F., or more, on any two days post partum. Sulfonamide therapy was t,he important factor in the treatment, of this group of patients during the early years; this, however, was supplanted by thr use of penicillin when it, became available. No pa.tient required operation. On reviewing the gynecological Out-patient Department cases for the period 1939 to 1949, there were found 38 patients with postabortal infection. This group was treated wit,h sulfonamide therapy ; only 2 required operatjion.
Summary A bacteriological survey, with special reference IO the presence of the gonococcus, has been made on 80 patients. We wished to determine whethel ’ ’ flare-ups ’ ’ of acute salpingitis were due to reinfections arising from dormant cells in the tubal wall or from infections existing in the urethra and cervix. No chemotherapy or antibiotics were used preoprratively in this series of cases. Of the patients operated upon, uterine myomas were present in 51 instances and there were varying degrees of salpingitis noted in 73. The bacteriological findings were as l’ollows : posit,ive gonococcal infections of the urethra and cervix, 41.25 per cent; Fallopian tubes showed 6.25 per cent positive. Every tubal infection was associated with infection of the cervix and The Fallopian tubes were sterile in ‘i6.1 per rent; the cervix sterile urethra. in 2.5 per cent ; and the urethra sterile in :L75 1~1. cent. Persistent viable gonococcal infection is a disease of the lower generative tract; the Fallopian tube is not a focal point, for reinfection, reinfection coming I’rom the cervix and Bartholin’s glands, most likely at the time of menstruat,ion for at this period, and also at titne of ovulation, the rervical mucus is penetrable. Our preliminary observations on pH deterrninations of the urethra, cervix. and tubes as yet have shown nothin, w conclusive in relationship to the longevit,) of the gonococcus. In general t,he readings have shown slight acidity, many nearly neutzral, and a few showing alkalinity. In regard to tuberculorts salpingit.is, no evidence of tuberculosis was found it1 this bacteriologica. study. .In a survt~y of 1,069 patients with tltbal disease, t,he incidence of t,uberculosis was only 1.7 per cent. This infrequent occurrence we feel is due to the great decline in pulmonary t,uberculosis. Puerperal infections are also infrequent. being in the order of 3.8 per cent.
BACTERIOLOGICAL
STUDIES
IN
SALPINGITIS
9H3
In conclusion, we believe that gonococcal infection of the tubes is shorllived and repeated attacks of salpingitis arc due to reinfection from the lowe generative t,ract. We also feel it, would not seem too speculative to believe that there will be a decreasing incidence of these infections, brought about by lay education, ever improving obstetrical pract,ice, and above all by the use of chemotherapy and antibiotics. \V\‘e wish to express our appreciation for the wholehearted cooperation of the Department of Clinical Bacteriology, under the direction of Dr. Milton Sachs, Hospital of the T-niversity of Maryland. 1Ve are especially indebted to Miss Audrey Funk, Chief Technician in the Department of Bact,eriology, for her splendid services which have, in a great measure, made this paper possible.
References 1. Curtis! Arthur H.: Surg., Gynec. & Obst. 33: 621, 1921. 2. Rtuddrford, W. E., Casper, W. A., and Scadron, E. N.: 1938. X. Mall, Franklin P.: Hurg., Gynec. & Obst. 21: 289, 1915. 4. Lamar, J. K., Rhettles, L. B., and Delfs, Eleanor: Am.
Surg.,
Gynec.
J. Physiol.
& Obst. 129:
234,
67:
176,
1949,
Discussion DR. FREDERICK II. FALLS, Chicago, Ill.-it is obvious from Dr. Hundley ‘s rrport that the early enthusiastic predictions that, with the discovery of penicillin and other antibiotics, gonorrhea was to become a thing of the past, have not come to pass. That we were to suffer the same rude awakening as to their shortcomings as we did with the sulfonamides and the wonder drug 606 in the treatment of syphilis early in the century might be expected. Five thousand six hundred nineteen gonorrhea1 cases out of 15,818 admitted to the Maryland Clinic tells the story. Evidently the gonococcus is still prevalent. True, the clinical course of the disease has been modified until those of us who knew the disease B.S. and B.P. (before sulfonamides and before penicillin) hardly recognize its clinical course now as it is influenced by these drugs. Still these cases are seen in our clinics and the problems as to their treatment both immediate and remote have to be met. As pointed out by Dr. Hundley, the gonococcus tends to disappear from the Fallopian tube pus a few weeks after the acute stage of the disease. This is thought by some to be due to the modern methods of treat,ment. They forget that the very same thing happened when Curtis did his work before 1921, and it was well known clinically long before that. It was common practice at the County Hospital in Chicago, to close these incisions without drainage after spilling the pus from a pyosalpinx, and this was done at a time when most surgeons drained the abdomen for other pyogenic infections. Of even more importance is the fact which has, I believe, been generally overlooked, that in these cases which we describe as gonorrhea1 salpingitis we are dealing with a localized pelv-ic peritonitis described by most writers of textbooks, but in addition we have a general peritonitis which extends up to the diaphragm causing the “fiddle string” adhesions between the liver and the diaphragm to which Curtis called our attention a number of years ago. The real significance of this finding has not been appreciated. It is that the gonococcus biologically is a very delicate organism. One has only to attempt to grow it and to keep the culture alive to appreciate this. In order to survive it must have This implies the proper nutrition, oxygen conditions ideal for its growth and reproduction. tension, moisture, heat, and light. These favorable circumstances are met only within certain tissues, cervix, Bartholin’s glands and Skene’s ducts. They are not provided in the peritoneal cavity or tube for very long after the reaction to the infection has taken
place. If one adds to these facts the effect of inmune lmdies stimulated by lhr l~rim:rr) invasion of the organisms the reason for rpontxneons rerovery and the sterility of tht tubal cultures becomes apparent. As regards tuberculous ralpingitis, it has always seemed to me t,hat the figure of 7 per cent as given by Curtis was too high. We agree with Dr. Hundley and have had an incidence of only 2 per cent at Research and Educational Hospitals and no higher at Cook County Hospital. To be carefully differentiated berause of its great importance to the patient, although of much rarer incidence, is carcinoma of the Fallopian tube. These are much mare frequently found in older women and may ljt: considerably larger than the average pus tube. They are often unilateral and may be associated with postmenopausal uterine bleeding. On two occ*asionx we havca mado the differential diagnosis on positive Papanicolaou smears. Another lesion that is rare and usually misdiagnosed as gononhPal salpingitis is actinomycosis of the tube and r,\ary. The gross appearance is very similar. It differs in the fact that it is practically al~v-xys found to be unilateral, located on the right side, and the ovary is morca involved in the inflammatory process than the Iub~k. ‘I%(~ importance of differentiating theye lesions is that unless the uterus and other tube and ovary are removed they will l)ecomc involved and a fatal result is almost inevitable. We have recently treated a acrics of cases of luberc~ulous salpingitis and peritonitis In general the results were I-erj- good as conlat Cook County Hospital with streptomycin. pared with other methods of management previously c~mplnycd. We were struck 1)~ thr general improvement of the patient and also 11~ the lytic> effect on the dense local adhesions in the pelvis and loner abdomen. This rcnderrd :~C’CCY‘Z~to the tuljes and thcxir surgical removal very much easier and less dangerous. DR. WALTE;K DANNREUTHEK. New York, N. Y.--I c’an certainly agree with Dr. Hundley regarding the present lower incidence of gonococrxl salpingitis as contrasted with that of some twenty-five years ago. The survival of gonococci in the endocervix, Bartholin’s and Hkene’s glands, is explained by the fact that these are compound racernose glands in the deep recesses of which the organisms tend to conceal themselves whereas the endometrium is composed of simple tubular glands. It has been difficult to demonstratch that infection reaches the tubes by continuity of surfare and that there is ever any tIur gonococcal infection of the endometrium. It, seems logical to assume that many of these recrudescences are due to lpmphogenous spread from the endocervix. In regard to tuberculous salpingitis, 1 believe that, if salpingectomy is to be done. the uterus should he included in the operation. I have seen several instances in which salpingectomy has been performed elsewhere, and within one to five years the patient. has presented herself with bleeding. Endornetrial and cervical biopsies are usually negative, but hysterect,omg shol?Ts extensive tuberculous involvement of the endometrium. DR. HUNDLEP (Closing).--We are heartily in accord with Dr. Falls’ statement as to the importanc,e of medical therapy prior to operation. All patients showing gonococcal disease received bed rest and chemotherapy. As we all know, time plays a great role in the elimination of gonocoecal salpingitis. As aho\-e stated, our operative incidence fat, gonococcal disease is 18.0 per cent. it is possible that in the future, with more concentrated use of penicillin, this operative index may be considerably lowered. We, in our rlinic, arr great believers in the conservative approach to all gonororcal problems. In regard to Dr. Dnnnreuther’s remarks regarding gonococcal infection of the tube occurring by way of the lymphatic system, I have always been of the opinion that the gonococcus migrated upward over the endometrium and thus involved the tubal mucosa. The cyclical shedding of the endometrium and its rebirth from the basal glands accounts for the infrequent occurrence histologically. If the migration of the organism is by the lymphatic channels the infection would be prone t,o be perisalpingitic and not mucosal. As we all know, repeated attacks of salpingitis occasion fibrosis of the tubal wall but the initial attack is primarily confined to the mucosa.
JR., M.D., WILLIAM K. 111~~IL, RI.D., JOSEPEI W. BAGGOTT, M.D., B.ILTINORE, Mu.
(Prom
the Department
of Gynecology,
Hospital
of the
1Jxicersity
SPECIAL AND
of Maryland)
F
OR many years the problem of salpingitis has played a large role in the However, due to management of gynecological and obstet,rical patients. extensive educational programs conducted by t,he American Tuberculosis Society, the U. S. Department of Public Health, and in a great measure to the untiring efforts of the American physician, there has come about a decline in the incidence of these tubal infections. Added to these splendid educational activities we now have on hand real weapons of destruction, namely, chemotherapy and antibiotics. These “wonder drugs” have truly revolut,ionized the problems presented in the various types of pelvic infections. Physicians have noted the frequency of recurrent pelvic inflammatory disease, which may exist over a long period of time, when the et,iological factor has been the gonococcus. With this organism as the infecting agent, it has been observed that many acute pelvic processes would, in a comparatively short time, become quiescent and asymptomatic ; whereas the urethral, cervical, and Bartholin’s gland infections would exist for months or even years. The main point of interest which stimulated us to carry out this investigation was whether the repeated attacks of salpingitis were due to reinfections, from a distant source, or whether they were recrudescences of a residual infection. From our observations there has been a paucity of invest,igation on this subject and above all no unanimity of opinion. Menge, in 1897, was one of the first t,o report his findings on the incidence of organisms occurring in purulent salpingitis. He found 21.7 per cent of specimens were positive. About the same time Hyde reported an incidence of positive cultures in 18.9 per cent of cases, while Andrews reported 22.0 per cent positive cultures in his series. These quotations are from Crossen, references not given. As will be noted, these reported figures were quite uniform as to incidence. It was not until the work of Curtis1 in 1921, that disagreement was presented as to the high incidence of tubal organisms. Curtis, carrying out, an exhaustive study, found the gonococcus was present in 19 out of 192 specimens investigated, or 9.89 per cent. He also came to the conclusion that the Xeisserian diplococcus in the Fallopian tube was comparatively short-lived, the culture becoming sterile 10 to 14 days after the acute symptoms had abated and that, therefore, the tube was not a focal point of infection, the flare-ups being true reinfection from the lower genital tract. Curtis states that proof of persisting gonococcal infection deep in the tubal wall is lacking. For this reason the Fallopian tubes were thoroughly ground and then cultured. The finding of only 19 positive cultures, obtained by this method, substantiates his views as to the short life span of the organism in the tube. His list of tubal positive White
*Read at the Seventy-Third Sulphur Springs, W. Va.,
May-
Annual Meeting 11 to 13, 1950.
977
of
the
American
Gnwcological
Society.
cultures was 38, of t,hese tlic gonocow~~s was i’ound irl 19 ; nonhemolyt ic* si rep tococcus 5 ; hemolytic streptococcus 4 ; anaerobic streptococcus 5 ; Rf~cilltcs ~0li 3 : mixed growth 3 ; Bacillus proteus 1 ; t,uherculosis 9. To our knowledge no further investigation was carried out on this xub,ject until 1938 when Studdiford and co-workers” published their findings on the longevity of the gonococcus in the Fallopian tube. His rnethod of procedulc is, briefly, as follows: Inflamecl tubes and ovaries were removed at operatiorl from 24 consecutive patients who had heen afebrile for at least two weeks. Cultures were obtained from the lumina of the tubes with a plat~inum loop. small pieces of exudate and tissue were taken, and cultures made from pus, if present. Media used was 5 prv cent horse blood-agar, hydrogen concentration 7.5. P&es were examined in 24 to -IS hours. Gono~~occns complement-fixation tests were performed in 20 of the 24 (assesand were found not a reliable index of infection. Results: Among the 24 cases studied there were 16 positive vutures of gonococcal infection, or, in 66.6 per cent, “Positive cultures were (‘llltures from pus were negaobtained only from pieces of tiysntl and esodate. tive for gonorocci.” Having presented two reports of divergent results we wish to present. 0~11 observations and findings on gonococcal salpingitis. Before present,ing out bacteriological data we wish to discuss the problem of gonococcal salpingitis as it exists in our I)epart,mrnt of (:ynec~logy, at the 1Tniversit.v of Maryland.
Material The following statistics cover a period of 10 years, from 1939 io 1949. During this period, 15,818 neu! patients were screened through our Out-patient Department. Of these we found 5,619 patients with evidence of gonococcal disease, which made a percentage incidence of 35.5. The infection existed in the following categories : Salpingitis, chronic Salpingitis, acute Salpingitis, subacute Pyosalpinx Hydrosalpins Tuboovarian abscess Pelvic inflammatory disease Total
2,980 499 656 50 t’l Xl 1,062 5,619
Of this group, 1,069 were admitted to the hospital for operation of various tapes, always with the thought that conservation should be t,he watchword. I&om these figures it will be noted that the operative index is 18.0 per cent. We feel that the indications for operative interference in gonococcal disease are as follows: (1) menometrorrhagia associated with marked dysmenorrhea; (2) painful, fixed, retrodisplacements ; (3) adhesions wit,h symptoms ; (4) large hydrosalpinx or tuboovarian abscesses ; (5) repeated attacks of infection. When salpingitic lesions are of short, duration and there is little associated fibrosis, splendid results are obl-ained by the use of chemotherapy and antiI)iotics, t,he pat,ient, freyuentlp becoming asymptomat,ic. However, sterilit,y usually ensues. If’ the patient has had only one mild tubal infect,ion it, is possible t&t I)re~lancy may take place if there is event,ual c*omplete regression and The work of the late Franklin I’. Mall,” on f)atericy of tht~ tul)c comt~s aboll tubal disease in relation to ectopic pregna.ncies, tends to support this belief. He reasons as follows: “Tubal pregnancy usuall;v takes place in women who have given birt,h to a child and then have been sterile for EIconsiderable period. The occurrence of tubal pregnancy indicates that the inflammatory process in
60 Sumher 5
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STVDIES
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the tube is gradually disappearing so that if tubal pregnancy had not t.aken place the chances are that t,he tube would eventually have become healed, thus permitting the fertilized ovum to reach the uterus. ” We now wish to present the results on our studies of the bacteriology oc salpingitis with special regard to gonococcal longevity. The selection of patients was of the greatest importance; obviously we would not operate on frank acute conditions unless there were some definite indication. The therapeutic use of chemotherapy and antibiotics was contraindicat,ed for by such procedures we would definitely change the bacteriological findings. The personnel of our Out-patient Department and Hospital Service is predominantly made up of the Negro race. As the incidence of uterine fibromas associated with gonococcal disease is here very high we selected many of our In our study comprising 80 patients, 71 patients for study from this group. were of t,he Negro race and 6 were white. Uterine myomas were an associated lesion in 51 instances. ESTRATI~BAT, I. 2. 3. 4.
PATHOLOGY
Fibroids Ovarian cysts Chronic cervicitis R,etroversion
31 .12 4 3
63.75% J5.0 % 5.0 % 3.75%
Method of Procedure Smears and cultures were obt,ained with the platinum loop from the urethra, the cervix, and the tubal lumen in all cases. Sections of the tubal wall were also macerated and cultures then made. These procedures were carried out in a glass box, the interior of which was exposed to ultraviolet light in order to obviate atmospheric contamination, the efficiency of which was demonstrated by obtaining sterile cultures after a 30-minute exposure to t,he ultraviolet ray. The cultures of the tubal lumen were made on chocolate agar; the cultures of the macerated tube were made on trypticase soy broth and chocolate agar. All cultures were incubated under 10 per cent carbon dioxide tension and were reported after four days’ incubation. The maceration was carried out, in a sterile mortar using sterilized sand and water. A tabulation of the bacteriological findings in 80 patients now follows: 1. Positive gonococcal cultures Urethra alone Cervix alone Urethra and cervix
and
source
Total 2. Fallopian tubes: Alone One tube, cervix, and urethra Both tubes, cervix, and urethra One tube and cervix 3. 4. 3. 6.
Total Fallopian tubes, Cervix sterile Urethra sterile Number of tubes Number of tubes Number of tubes Number of tubes Number of tubes
sterile
with positive with positive with positive with positive with positive
cultures cultures cultures cultures cultures
of origin
: 4 9 20
5.0 70 11.25% 25.0 gr,
33
41.25y0
0 2 2 1
0 2.5 70 2.5 70 1.25yf~
5 61 2 3
6.25% 76.1 % 2.5 70 3.75yo
of E. coli of staphylococci of streptococcus gamma of gram-plus rod of yeast contaminants
4 9 2 2 1
The pathological investigat.iott of the tubes remove(I presents ;I number o I’ interesting facts. Tuboovarian ahsccsses were found in 9 instances and the bacteriological studies of the tube showed no evidence of the gonococcus. This is in contrast to the findings in t.he lower t,ract for in this group 6 of the patients had positive gonococcal cultures in t.he urethra ant1 eciryix and 2 of these had received courses of sulfonamide therapy and penicillin but. in spite of this thr cultures remained posit,ive. All Iuboovarinn specimens studied showrtl evidence of repeated attacks as demonstrated by the marked fibrosis of thr t,ubal wall. Varying degrees of chronicity were found in 66 tubes; here was found evidence of scarring, fibrosis, lymphold infiltration and oblit,eration of the lumen, with closure of the fimbriated end and isthmica ll(JdoSa.; 7 patients, showed hydrosalpinges. No pus was found in the tubal lumen in any case. There werr i patients in the semiacute stat,us, these having definite reinfections as symptoms had extended over a number of years in each patient. In this group 5 patients had positive gonococcal cullurcs in thtx ecrvix and urt~l bra. Sonc Of illC 7 llitd positive tubal cultures t’or gonorrhea. From this study we find t,hat. persistent, gonor1+hea in women is a diseascx primarily of the lower generative t,ract, as evidenced by the fact, t,hat of the 80 patients carefully studied 33. or 41.25 per cent,, showed positive cultures in the cervix and the urethra. We have also observed that cultures obtained as statctl above are more reliable, as an index of infection, t,han the smear technique. Why is the diplococcus so shortlived in the Fallopian tube and so long lived in the urethra and cervix “! At first glance one might postulate that changes in pH play a role in the maintenance and desiruct,ion of thr gonococcus in the Fallopian tube. This is borne out, in vulvovaginitis in children for the gonococcus grows luxuriantly when the vaginal secretion is alkaline, i.e., pI-I of 7.0 plus! and the vaginal epithelium is immature; whereas, after puberty: the secretion becomes acid in the order of 4.5, due partly to the IKiderlcin bacillus, and the Tt is thought, vaginal epithelium becomes mature and resistant to infect,ion. that such conditions arc inimical t.o the growt-h of the gonococcus and the infecdtion soon disappears. This sounds very plausible wit,h the exception of the fact that a continued low t,ubal pH would sound the death knell for the spermatozoa and sterility Wishing to learn if variat,ion in pH in the would he more likely the rulr. urethra, cervix, and Fallopian tubes had any bearing on the longevity of thP gonococcus we have recently instituted a series of pH studies. The determination of the pH in situ is quite simple and is obtained in a few minutes with thr use of t)he Beckman pH me&. the st,erilc electrode being inscrtcd int,o the urethra, the rervix, and Fallopian tube. To date we have not examined a sufficient number of patients to make a definite statement but, in general, the readings have shown slight aridity! many being nearly neutral and a. few showing alkalinity. Readings obt,ained from the urethra, cervix. and tube are as follows : vaginal readings varied from 4.34 to 6.90 units; caervical readings varied from 6.51 to 7.27 units; urethral readings varied from 5.27 to 7.34 units. Vrom this preliminary obserration it. would appear t,hat variation in pI1 in the adult plays an unimportant role in the presence or absence of the gonococcus. We will continue our investigations on these struct,ures during normal cyclical phases and under various pathological conditions. In summarizing our work on gonococacal infections we feel that every effort should be concentrated upon cradicatin, 0 the infection in the urethra, cervix, and Bartholin’s glands to prevent, ascending disease. One immediately observes the great disparity between the incidence of infection in the lower generative tract and that existing in the tube. The infection in the cervix and urethra may exist for years without tubal involvement.
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We know from the work of Lamar and associates4 that human cervical mucus undergoes cyclic penetrability to the spermatozoa and that this phenomenon occurs most markedly at the time of ovulation. They also showed that the menstrual discharge was penetrable by spermatozoa but the mucus of the phase between menstrual and midcycle is relatively impenetrable and that of the phase between midcycle and the subsequent period is ili:penetrable. The period of penetrability was between t,he ninth and the nineteenth days, but this period may be restricted to four days. E’r’om this study we may deduce that there are two optimum times for bacterial ascent, namely, at the time of ovulation and also at the menstrual time. From our observations Falpingitis is more prone to develop during menstruation for the minimal uterine contraction present at this time tends to eject uterine fluid with contained organisms into the Fallopian tubes. Acute endometritis, due to the gonococcus, is rarely seen due to its monthly shedding and rebirth. In order to make our presentation on salpingitis more comprehensive we wish to highlight some of the important findings in tubercular and streptococci infections that hare come to our attention.
Tuberculous
Salpingitis
A few remarks on this subject are of interest to us primarily because of its apparent infrequency. In a survey of 1,069 patients with salpingitis, from 1939 to 1949, there were onlr 19 cases due to the tubercle bacillus, an incidence of 1.7 per cent. The majority of authors state the occurrence of tuberculous salpingitis to be in the order of 5 to 6 per cent; this decline we feel is, in a large measure, due to education of the public as to preventive measures, i.e., routine x-rays of the chest, improved housing facilities, etc. Some years ago the second most common cause of death was tuberculosis, whereas today this disease occupies the fifth position. There is a definite decrease in the incidence of pulmonary tuberculosis, the prime etiological fact,or in t,he development of luherculous salpingitis, as shown by figures obtained from the Department of Health of the State of Maryland. The decrease is striking in the white race I jut not. so significant in t,he Negro. In the years 1921 to 1925 the death rate per 100,000 was 94.3 for whites and 281.4 for Negroes. Many factors play a role in the high Negro rate such as substandard housing, crowding and undernourishment, etc. Now compare these figures to those prevailing from 1941 to 1945; here we find t.he decline in the white race from 94.3 to 39.6 per 100,000 popnlat,ion, whereas the decline in the Negro race is from 281.4 to 184.7 fol the same period. An analysis of our 19 patients with tuberculous salpingitis shows an incidence of 1.7 per cent, which follows the usual pattern. It appears to OCCUI comparatively early in life, 12 patients being in the second decade, 5 in the third, and 2 patients had the disease at 16 and 14 years of age respectively*. The average duration of sterility was 7.7 years. The menstrual histories showed oligomenorrhea, menometrorrhagia, and dysmenorrhea; none had amenorrhea. ,4s is the usual fact most of the diagnoses were made at operation and by microscopic diagnosis. We were fortunate in making a preoperative positive diagnosis in 6 patients. X-rav examinations for pulmonary disease were carried out in all patients and only’2 were found to be positive. The frequency of involvement, of the pelvic organs followed the rule, i.e.. tubes 18, ovaries 4, uterus 1, endomctrium 3, and cervix 1. In our bacteriological study 01’ 80 patiellts, all having smears and cult,ures of macerated tubes, no incidence of tuberculosis of the tnhc was detected. All of the patients were treated by operative procedure and there were no deaths.
Postoperative complicat,iotls showed :I draining ;~.htl~~minal siuuacs whi<*h healed spontaneously. Wound infect,ion occurred In 3. and 1 patient had ;I very serious reaction resulting front a transfusion error.
Infections
Following
Pregnancy
This includes t,he paerperal as well as the postabortal infections. The’ background information for these few remarks on puerperal infection was furnished by Dr. Louis IT. Tjonplass, Professor of Ohst,etrics, liniversity of Maryland. During the past 10 years, 1939 to 1!)49, 26,928 deliveries were performctl on the obstetrical service of the I’niversity Hospital and in this large group the incidence of puerperal infection was in the order of 3.8 per cent. In this clinic, puerperal infect,ion means any elevation of t,emperature to 100.4O F., or more, on any two days post partum. Sulfonamide therapy was t,he important factor in the treatment, of this group of patients during the early years; this, however, was supplanted by thr use of penicillin when it, became available. No pa.tient required operation. On reviewing the gynecological Out-patient Department cases for the period 1939 to 1949, there were found 38 patients with postabortal infection. This group was treated wit,h sulfonamide therapy ; only 2 required operatjion.
Summary A bacteriological survey, with special reference IO the presence of the gonococcus, has been made on 80 patients. We wished to determine whethel ’ ’ flare-ups ’ ’ of acute salpingitis were due to reinfections arising from dormant cells in the tubal wall or from infections existing in the urethra and cervix. No chemotherapy or antibiotics were used preoprratively in this series of cases. Of the patients operated upon, uterine myomas were present in 51 instances and there were varying degrees of salpingitis noted in 73. The bacteriological findings were as l’ollows : posit,ive gonococcal infections of the urethra and cervix, 41.25 per cent; Fallopian tubes showed 6.25 per cent positive. Every tubal infection was associated with infection of the cervix and The Fallopian tubes were sterile in ‘i6.1 per rent; the cervix sterile urethra. in 2.5 per cent ; and the urethra sterile in :L75 1~1. cent. Persistent viable gonococcal infection is a disease of the lower generative tract; the Fallopian tube is not a focal point, for reinfection, reinfection coming I’rom the cervix and Bartholin’s glands, most likely at the time of menstruat,ion for at this period, and also at titne of ovulation, the rervical mucus is penetrable. Our preliminary observations on pH deterrninations of the urethra, cervix. and tubes as yet have shown nothin, w conclusive in relationship to the longevit,) of the gonococcus. In general t,he readings have shown slight acidity, many nearly neutzral, and a few showing alkalinity. In regard to tuberculorts salpingit.is, no evidence of tuberculosis was found it1 this bacteriologica. study. .In a survt~y of 1,069 patients with tltbal disease, t,he incidence of t,uberculosis was only 1.7 per cent. This infrequent occurrence we feel is due to the great decline in pulmonary t,uberculosis. Puerperal infections are also infrequent. being in the order of 3.8 per cent.
BACTERIOLOGICAL
STUDIES
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9H3
In conclusion, we believe that gonococcal infection of the tubes is shorllived and repeated attacks of salpingitis arc due to reinfection from the lowe generative t,ract. We also feel it, would not seem too speculative to believe that there will be a decreasing incidence of these infections, brought about by lay education, ever improving obstetrical pract,ice, and above all by the use of chemotherapy and antibiotics. \V\‘e wish to express our appreciation for the wholehearted cooperation of the Department of Clinical Bacteriology, under the direction of Dr. Milton Sachs, Hospital of the T-niversity of Maryland. 1Ve are especially indebted to Miss Audrey Funk, Chief Technician in the Department of Bact,eriology, for her splendid services which have, in a great measure, made this paper possible.
References 1. Curtis! Arthur H.: Surg., Gynec. & Obst. 33: 621, 1921. 2. Rtuddrford, W. E., Casper, W. A., and Scadron, E. N.: 1938. X. Mall, Franklin P.: Hurg., Gynec. & Obst. 21: 289, 1915. 4. Lamar, J. K., Rhettles, L. B., and Delfs, Eleanor: Am.
Surg.,
Gynec.
J. Physiol.
& Obst. 129:
234,
67:
176,
1949,
Discussion DR. FREDERICK II. FALLS, Chicago, Ill.-it is obvious from Dr. Hundley ‘s rrport that the early enthusiastic predictions that, with the discovery of penicillin and other antibiotics, gonorrhea was to become a thing of the past, have not come to pass. That we were to suffer the same rude awakening as to their shortcomings as we did with the sulfonamides and the wonder drug 606 in the treatment of syphilis early in the century might be expected. Five thousand six hundred nineteen gonorrhea1 cases out of 15,818 admitted to the Maryland Clinic tells the story. Evidently the gonococcus is still prevalent. True, the clinical course of the disease has been modified until those of us who knew the disease B.S. and B.P. (before sulfonamides and before penicillin) hardly recognize its clinical course now as it is influenced by these drugs. Still these cases are seen in our clinics and the problems as to their treatment both immediate and remote have to be met. As pointed out by Dr. Hundley, the gonococcus tends to disappear from the Fallopian tube pus a few weeks after the acute stage of the disease. This is thought by some to be due to the modern methods of treat,ment. They forget that the very same thing happened when Curtis did his work before 1921, and it was well known clinically long before that. It was common practice at the County Hospital in Chicago, to close these incisions without drainage after spilling the pus from a pyosalpinx, and this was done at a time when most surgeons drained the abdomen for other pyogenic infections. Of even more importance is the fact which has, I believe, been generally overlooked, that in these cases which we describe as gonorrhea1 salpingitis we are dealing with a localized pelv-ic peritonitis described by most writers of textbooks, but in addition we have a general peritonitis which extends up to the diaphragm causing the “fiddle string” adhesions between the liver and the diaphragm to which Curtis called our attention a number of years ago. The real significance of this finding has not been appreciated. It is that the gonococcus biologically is a very delicate organism. One has only to attempt to grow it and to keep the culture alive to appreciate this. In order to survive it must have This implies the proper nutrition, oxygen conditions ideal for its growth and reproduction. tension, moisture, heat, and light. These favorable circumstances are met only within certain tissues, cervix, Bartholin’s glands and Skene’s ducts. They are not provided in the peritoneal cavity or tube for very long after the reaction to the infection has taken
place. If one adds to these facts the effect of inmune lmdies stimulated by lhr l~rim:rr) invasion of the organisms the reason for rpontxneons rerovery and the sterility of tht tubal cultures becomes apparent. As regards tuberculous ralpingitis, it has always seemed to me t,hat the figure of 7 per cent as given by Curtis was too high. We agree with Dr. Hundley and have had an incidence of only 2 per cent at Research and Educational Hospitals and no higher at Cook County Hospital. To be carefully differentiated berause of its great importance to the patient, although of much rarer incidence, is carcinoma of the Fallopian tube. These are much mare frequently found in older women and may ljt: considerably larger than the average pus tube. They are often unilateral and may be associated with postmenopausal uterine bleeding. On two occ*asionx we havca mado the differential diagnosis on positive Papanicolaou smears. Another lesion that is rare and usually misdiagnosed as gononhPal salpingitis is actinomycosis of the tube and r,\ary. The gross appearance is very similar. It differs in the fact that it is practically al~v-xys found to be unilateral, located on the right side, and the ovary is morca involved in the inflammatory process than the Iub~k. ‘I%(~ importance of differentiating theye lesions is that unless the uterus and other tube and ovary are removed they will l)ecomc involved and a fatal result is almost inevitable. We have recently treated a acrics of cases of luberc~ulous salpingitis and peritonitis In general the results were I-erj- good as conlat Cook County Hospital with streptomycin. pared with other methods of management previously c~mplnycd. We were struck 1)~ thr general improvement of the patient and also 11~ the lytic> effect on the dense local adhesions in the pelvis and loner abdomen. This rcnderrd :~C’CCY‘Z~to the tuljes and thcxir surgical removal very much easier and less dangerous. DR. WALTE;K DANNREUTHEK. New York, N. Y.--I c’an certainly agree with Dr. Hundley regarding the present lower incidence of gonococrxl salpingitis as contrasted with that of some twenty-five years ago. The survival of gonococci in the endocervix, Bartholin’s and Hkene’s glands, is explained by the fact that these are compound racernose glands in the deep recesses of which the organisms tend to conceal themselves whereas the endometrium is composed of simple tubular glands. It has been difficult to demonstratch that infection reaches the tubes by continuity of surfare and that there is ever any tIur gonococcal infection of the endometrium. It, seems logical to assume that many of these recrudescences are due to lpmphogenous spread from the endocervix. In regard to tuberculous salpingitis, 1 believe that, if salpingectomy is to be done. the uterus should he included in the operation. I have seen several instances in which salpingectomy has been performed elsewhere, and within one to five years the patient. has presented herself with bleeding. Endornetrial and cervical biopsies are usually negative, but hysterect,omg shol?Ts extensive tuberculous involvement of the endometrium. DR. HUNDLEP (Closing).--We are heartily in accord with Dr. Falls’ statement as to the importanc,e of medical therapy prior to operation. All patients showing gonococcal disease received bed rest and chemotherapy. As we all know, time plays a great role in the elimination of gonocoecal salpingitis. As aho\-e stated, our operative incidence fat, gonococcal disease is 18.0 per cent. it is possible that in the future, with more concentrated use of penicillin, this operative index may be considerably lowered. We, in our rlinic, arr great believers in the conservative approach to all gonororcal problems. In regard to Dr. Dnnnreuther’s remarks regarding gonococcal infection of the tube occurring by way of the lymphatic system, I have always been of the opinion that the gonococcus migrated upward over the endometrium and thus involved the tubal mucosa. The cyclical shedding of the endometrium and its rebirth from the basal glands accounts for the infrequent occurrence histologically. If the migration of the organism is by the lymphatic channels the infection would be prone t,o be perisalpingitic and not mucosal. As we all know, repeated attacks of salpingitis occasion fibrosis of the tubal wall but the initial attack is primarily confined to the mucosa.