Even if we must admit that we are unable to recognize the position, shape and contents of slight changes in the tubes, fortunately diagnosis is not so difficult when the changes have become more marked and a palpable tumor has appeared. The opinion that tubal tumors cannot be distinguished clinically has lost some validity, since our methods of ex amination have become more perfect, and necropsies and continuous clinical observation have shown us the connection of many formerly iso lated symptoms.
The exploratory method of Simon of examination of the pelvic organs through the rectum, and the recognition of morbid processes there from the bladder, after dilatation of the urethra, and the method of examina tion elaborated by Noeggerath of New York, have contributed a great deal to the recognition and differential diagnosis of the slighter changes in the uterus and its appendages. Noeggerath drew down the uterus with a tenaculum, and, with one forefinger in the bladder and the other in the rectum, explored by conjoined manipulation. It is possible, if the vagina is relaxed and the uterus movable enough, to feel the uterus, the ovaries and the tubes, and it is thus certainly possible under favorable circum stances, to appreciate very slight changes in the pelvic organs. Noeggerath was able by this method, in one case, to clearly outline the left tube, which was irregularly swollen to the size of a goose-quill, and to follow it outwards a certain distance from the uterus. At the same time swelling and softening of the corresponding ovary and the normal state of the right Fallopian tube was appreciated.
Even without the aid of Noeggerath's method it is in many cases easy to palpate the annexa of the uterus, and when the abdominal walls are thin and relaxed, it is often possible by ordinary bi-manual examination to recognize the normal ovaries and tubes or very slight changes in them. In recent times the publication of cases in which during life diseases of the tubes were diagnosticated and confirmed by necropsy has become more frequent. We cannot therefore doubt the possibility of diagnosing tubal maladies, especially when they reach an extent such as to imperil life. It is to be hoped that in some cases at least certainty of diagnosis will be attained, and that we may thus occasionally by a timely surgical interference prevent a tubal sac, filled with pus or blood, from emptying its pernicious contents into the abdominal cavity, and hinder an ovum which is developing in the tube or in its abdominal end from a further growth and rupture which imperils and iu most cases destroys the life of the woman.
Even already, five years after the first appearance of this work, great progress has been made in diagnosis and treatment in this field. To men tion only one thing, salpingotomy, or the removal of all the uterine annexe, has been perfected in very many cases; thus J. Veit performed laparotomy successfully after diagnosing a tubal pregnancy of three mouths duration.
On the Entrance of Fluid into the Tubes.—The finding of spermatozoa on the ovary and the occurrence of graviditas extra-uterina has proved that fluid can reach the abdominal cavity from the uterus through the tube.
The serious accidents which have followed the injections of medicinal fluids into the uterus or vagina, with an occasional fatal result, render it certain that a portion of the injected fluid, especially when thrown in without proper care, often reaches the tubes and passes through them into the cavity of the abdomen.
We ourselves have seen a woman suddenly attacked with an acute colicky pain, so severe as to cause her to sink to the ground and render her incapable of stepping into bed, after a vaginal injection which she gave to herself while sitting over a wash-basin. As the pains continued for a whole day over one side of the uterus, it appeared probable to us that a bubble of air had in some way reached the uterus and tube.
Oldham believes that the entrance of fluid is possible when the inner passages are patent from stiffness of their walls; but it is also possible to imagine that an accidental movement of the muscular tissue of the uterus might cause such a suction that a bubble of air might reach the tubes. In one case Haselberg proved by autopsy that a solution of the chloride of iron had reached the abdominal cavity through the tubes. In another case Dr. Ernst Sprith observed the entrance of a solution of acetate of lead into the abdominal cavity. A healthy woman, who had been confined ten weeks before, gave herself vaginal injections for ten days in a crouching position with a common fountain syringe. At the eleventh injection there was most severe pain in the lower part of the abdomen and a faint ing fit set in; seventy-four hours later the woman died of peritonitis. The necropsy showed irregular, roundish, grayish-black accumulations which were but slightly adherent and did not correspond to any injection either of the serosa or mucosa. They covered the serous surface of the large intestine up to the umbilicus and were scattered throughout the entire hypogastrium, sometimes forming masses of from to of an inch in diameter. These masses .proved to be sulphate of lead.