As an example of hematosalpinx, we will give one of our own cases with drawings (Fig. 8). The case shows a rare variety of hematosalpinx, its dangers and also the possibility of making a diagnosis.
An eighteen year old girl, who for three years has menstruated regu larly but scantily, for the last two and a half years has suffered from severe pain. For one year and a half these pains were principally con fined to the menstrual period; but during the last year they increased in severity and later became unbearable.
On examination the pelvis was found to be filled with a tumor the size of a child's head, which reached to the lower border of the ischium. The wide open uterus was held up by the tumor, pushed slightly forward, and could easily be felt through the abdominal wall. The right cervix could be plainly felt at the height of the symphysis, the left was entirely within the wall of the tumor and could only be indistinctly felt as a seam. The upper partition of the cavity was thinned (marked C. S. in Fig. 8), and during life was situated entirely within the vagina, and formed the right wall of the tumor. The left uterine body was situated behind like a cap. We had no idea of the existence of hematosalpinx, perhaps on account of the pain produced by examining. The principal tumor was hard, and, excepting the severe pains, we had seen several cases of fibroma that gave similar symptoms, and for that reason the principal tumor was taken for a fibroma of the cavity. In attempting to enucleate, the mistake in the diagnosis was discovered. Through the incision a pint of tar-like blood escaped. After emptying the entire contents, the sac became markedly retracted, as shown in the preparation. Two days later the patient died from sepsis.
At the necropsy made by Dr. Kundrat the right kidney was found enlarged, with pelvis and ureters dilated, and their walls thickened; the left kidney, including ureter and vessels was absent. The right half of the uterus (R. IL) was normal; in the left the walls were double their normal thickness. The cavity was spherical, the size of the fist, formed into a sac with walls about half an inch in thickness, filled with a dirty thick brown fluid, and with its inner wall covered with a dark brown pig ment. This dark brown pigment ended with a sharp line at the uterine body, the inner surface of which was normal in color. The sac formed a hemispherical tumor that reached nearly to the fornix of the vagina. Both cervical canals were separated by a septum pushed to the right, and the inch long incision made at the operation extended to the external orifice.
The left tube rested on the ilium, was six inches long, its outer half was changed into a thick-walled sac, the size of a goose-egg, filled with a dirty, chocolate brown, thick fluid. In places the wall of the sac was thin. The inner half of the tube was markedly thickened, and dilated sufficiently to allow the passage of a rather thick sound into the cornea of the uterus. The left ovary was three inches long, four-fifths of an inch wide, dense, covered with follicles, was included with the tube-sac and, the left adnexa in a rust-brown pigmented false membrane, and they were also adherent to the rectum and uterine wall. The right tube was four arid a half inches long, large with thick walls; the right ovary was two inches long, one and a fifth inches wide, containing a cyst the size of a hazel nut, in the neighborhood of which were numerous follicles the size of hemp seed.
accumulations of blood in the tubes, that may occur without closure of the genital canal, will permit of little descrip tion. We know of no symptoms peculiar to large accumulations of blood in the tubes, as they are generally associated with accumulations of blood in the uterus or vagina, and their symptoms obscure those from the accumulations in the tube. The shape of hematosalpinx is similar to
that of hydrosalpinx.
accumulations of blood may be absorbed or stimulate the formation of hydrosalpinx. After studying the reported cases, it appears that accumulations of blood can remain for a long time in the tube without danger, and according to Blebs under the influence of the tube secretion, it remains fluid for a long time. The longer blood-cysts of the tube exist the larger they seem to become. As the contents in crease, the walls become thin, by increasing inflammation, the contents become changed, the walls become partly fatty and are prepared to burst. The inflammation of the tube-sacs also affects the surroundings, and adhesions are often formed with the adjacent structures, as has been shown in the above case. Rupture may occur into any organ with which the sac becomes adherent. Gangrene of the blood sac or decomposition of its contents rarely occurs; but if it does death follows. Also blood can escape into the recto-uterine space, and form an ha?matocele. Most hematosalpinges remain stationary until the accumulated blood in the uterus or vagina becomes excessive. If they become very much enlarged their walls are consequently thinned and can easily be ruptured; they are usually bound to their surroundings by false membranes. Spontaneous bursting, which occasionally occurs in atresia hymenalis—Farre lost a patient in this manner—or emptying the tumor by operation, unfortu nately often results unfavorably. After emptying, often a cavity the size of a child's head must contract, frequently causing great strain on the thinned tubal cysts, so that they often rupture, or by marked displace ment cause an unfavorable change in the contents, or give rise to more extended inflammation. Hennig counts only three recoveries in sixteen operations for hematometra, and we ourselves know of three; only a few of these cases were operated upon under the use of antiseptics.
Diagnosis. —Although hematosalpinx does not give positive symp toms, by careful bi•manual examination it can be diagnosticated.
We have already shown that hydrops tubas could be determined by bi manual examination, which can also be said of hematosalpinx. Occa sionally, where we suspect its existence, the diagnosis may be reached, even though there be no adhesions to the neighboring structures. The possi bility of this diagnosis has already been declared by Germanu, Hennig, Wilms and others. The shape of the tumor is the same as has already been described for hydrosalpinx. On examination, mostly from the vagina, and occasionally when necessary from the rectum, it must be remembered that too strong pressure on a thin tubal sac may cause its rupture.
a necropsy on a girl that suffered from hematoelytron and large hematosalpinges, one of the tubal tumors bursting after operation for the hematoclytron, Rokitansky said: " The gynecologists unfortu nately discover the nature of these diseases too late." It is well to re member that girls suffering from these complaints never seek medical advice early enough. In order, however, that we may institute an early operation for retention of menstrual blood, and so prevent the danger of the formation of hernatosalpinx, it is necessary that the physician's atten tion should be early drawn to these parts.
We often find between the blood-containing tube and 'the distended uterus a shorter or longer part of the tube which is markedly contracted or entirely occluded, so that after an operation for hematometra, the tubsl blood sacs rarely empty themselves. Owing to the great risk from hema tosalpinx, one can only think of a direct surgical procedure, which Hausa mann and F. Wiuckel have already demonstrated to be correct.