The septic variety of salpingitis, as has already been said, is more frequently acute from the beginning. Within ten days or two weeks after a criminal abortion, or after a miscarriage or labor, a large tubal abscess may be formed; or the septic organisms may pass through the tube before the ostium has been closed, and produce within a few days a general fatal peritonitis. On the other hand, septic salpingitis is often slow, a mild attack of puerperal sepsis being the beginning of years of invalidism, of gradually increasing suffering, until gross tubal disease is produced. The slowest forms of salpingitis are those that result from chronic endometritis, such as accompanies subinvolution, laceration of the cervix, retro-displacements, or uterine fibroid. Simple catarrhal salpingitis is often found in these diseases; or the abdominal ostium may be closed, and a small hydrosalpinx will be present; or the isthmus may be sufficiently open for drainage, and no tubal distention result. Hydrosalpinx is very often found with uterine fibroids. Cancer of the cervix or the body of the uterus is a frequent cause of salpingitis, of hydrosalpinx, and of pyosalpinx. The endometrial inflammation secondary to the cancer extends into the tubes. The progress of salpingitis is beset with danger. [Illustration: FIG. 150.--Chronic salpingitis with general adhesions of tubes, ovaries, and uterus (Bandl).] At any time a pyosalpinx may rupture and a rapid fatal peritonitis result. Unusual effort, vaginal examination, or slight operations upon the cervix or body of the uterus may cause this accident. Not infrequently, such rupture has been produced by even gentle bimanual examination. I have seen a fatal peritonitis occur from rupture of a pyosalpinx during the replacement of a prolapsed uterus. For this reason the operator should always determine by careful examination the presence or absence of tubal disease in every case before performing any of the minor gynecological operations or manipulations, such as trachelorrhaphy or the replacement of a retroverted uterus. Purulent disease of the tubes is a contraindication to all such procedures, unless an immediate subsequent celiotomy is to be performed. Great care must be exercised in any of the less dangerous forms of salpingitis. In any case of salpingitis, however mild, an acute attack may be excited by reinfection or by rough manipulation. [Illustration: FIG. 151.--Chronic salpingitis: both Fallopian tubes are closed and adherent.]