We will probably not be able to feel the tumor that is forming or has just been formed throbgh the external abdominal walls; these latter are tense and very tender, and palpation is hardly possible. After a few days the first violent symptoms will have passed away, and there is left a dull feeling of pain and pressure in the lower abdomen. Iii many cases there occur exacerbations from recrudescent partial peritonitis or renewed hemorrhages. These are most liable to occur at the menstrual epoch, and they may last for months, though getting less and less violent..
When the first fever and pain and abdominal tension have passed off, we will discover at the pelvic entrance, lying behind the displaced uterus, a tumor, the borders of which can usually not be distinctly mapped out. In most of our cases the tumor did not project more than two to four finger-breadths over the level of the pelvic entrance; and it so surrounded the body of the uterus that its outlines could not be made out, though its superior hardness enabled us to recognize it. As a rule the tumor lay rather to one or the other side. In Voisin's twenty-four observations the tumor lay sixteen times more to the right, and eight times more to the left; while in the cases which Schroder collected the tumor was situated in by far the larger number of the cases, more to the left. As a rule the tumor had attained its greatest size in the first few (lays; but in some cases it continued to grow for over a month. In fifteen of Voisin's cases, the tumor was: and in one case even two finger-breadths above the navel. Occasionally these tumors extend into one or the other iliac fossa. Scanzoni also hap seen the mass extend to the navel in two cases.
The higher the tumor extends the easier will it be to map out its boundaries by percussion. In most of the recorded cases there was a dull percussion note over the visible or palpable tumor. The tumor itself is soft and doughy, and its upper boundaries, at first, at least, difficult to make out. The older it is the more distinctly can its walls be felt, for the pseudo-membranous capsule grows always thicker, and the tumor becomes harder as resorption of the blood serum goes on. Furrows appear as the tumor becomes older; and one part may be harder than another, or even a hard portion may subsequently become soft.
The affection causes quite characteristic vaginal appearances. As a rule we can feel it and make out its lower boundaries per vaginam im mediately after its occurrence, and before the tension and tenderness of the abdominal walls will permit us to make an external examination.
The tumor, varying from the size of an apple to that of a man's head, depresses Douglas's pouch; and only the vaginal wall apparently separates it from the examining finger. The uterus is usually displaced forwards
and somewhat upwards, so that the cervix is at the level of the symphysis and is pressed against it. Often the cervix is hard to reach, though we have never seen it quite unattainable.
If circumstances permit a bimanual examination so early, we will find that the tumor is behind the uterus and rests against it. Its lower phery is usually within two inches of the introitus vagina; Voisin found 1.2, 1.4, 2.4, 2.8 inches distant in four cases. This will depend of course not only upon ttte magnitude of the hemorrhage, but also upon the varying depth of Douglas's cul-de-sac in different persons The feeling of the tumor in the vagina, at first soft, soon becomes hard and tense, and gives one in fresh cases the impression of a rubber ball filled with water. This feeling may remain for weeks. The tumor we found to be always immovable, though Voisin claims that it was mobile in seven of his cases.
The tumor, at first perceptible from the vagina, then recognizable by careful bi-manual examination through the abdominal walls; the connec tion with menstruation; the sudden and violent beginning; these are the most important points in the diagnosis.
There is but little probability that a tumor appearing under such cir cumstances will contain anything but blood. This, however, we cannot decide without a puncture of the most prominent portion of the tumor per vaginam.
We have ourselves done this with an exploring trocar without doing any damage; but the practitioner should be informed that the proceeding is not always devoid of danger, especially without disinfection of the in strument.. Oulemont did it once; a chill followed, and for five weeks the life of the woman was in danger Since the tumor fills a large part of the pelvis and the inflammatory processes render the parts very sensitive, a specular examination is not to be recommended, nor can we get from it any more information than the finger alone will give us. Nonat and Voisin claim that there is a violet discoloration of the fundus vaginie; a statement which, perhaps because we have used the instrument so seldom in these cases, we can neither agree with nor deny. Rectal examination will tell us no more than vaginal. The lumen of the rectum is of course encroached on. An ex amination with the sound, to find out the exact relations of the uterus to the tumor may be undertaken; but it will teach the practised examiner nothing that he has not already ascertained by bi-manual examination.