But all these symptoms are exactly similar to those that we observe in pelvic tumors, ovarian cysts, cysts of the broad ligament, sacculated exudations in the pelvic space, fibroids and inflammatory processes. We must, therefore, admit that dropsy of the tubes is not accompanied by very characteristic symptoms.
Even the periodic hydrorrcea of hydrops tubre profluens may be simu lated by the periodical expulsion of secretion from the uterus, vagina or their neighborhood.
If the tubal sac reaches a certain size rupture may occur from any slight cause. If the contents are mucous or serous, lethal peritonitis does not necessarily follow. Beigel relates a case in which he observed in a sterile Irish woman of thirty-five years of age, a tumor the size of a man's arm at the right side of the uterus and running towards the ilium. This tumor had already existed for several years and dated from the puer perium; and when Beigel saw the woman again in four months the tumor had disappeared, and the woman only noticed the rupture from a peculiar and quite painless sensation, a diarrhoea that lasted several days and in creased urinary secretion. Without feeling certain that a dropsical tube did burst in this case, it is nevertheless certain that a tumor of long stand ing may empty its contents into the peritoneal cavity without necessarily killing the woman. Carus, Bonnet, Simpson and Spiegelberg have observed and described the bursting of ovarian cysts and recovery with out special peritoneal manifestations. I myself took a twenty-year old girl, for the first time pregnant, into the institution. Besides a uterus at the eighth lunar month she had near but distinctly separated from it a swelling of about the same size, with thin walls and fluctuating contents. The girl was spontaneously prematurely confined, and the diminution of the uterus during the eight days of confinement in bed and the unaltered size of the tumor could be easily appreciated. On the ninth day I was Called to the young woman because of sudden sickness and fainting attacks. Her face was pale, she had pain in the abdomen, which was fiat and showed on both sides an accumulation of fluid of about a hand's breadth; the cyst had undoubtedly burst and a considerable hemorrhage must have also occurred. In five weeks the girl was well, a swelling the size of the two fists being present at the right side of the uterus; a year later there was a tumor only half the size of the fist at the same place. Once we saw the entire contents of a unilocular ovarian cyst the size of a head flow into the abdominal cavity without causing any morbid symp toms. Only a'little thin, clear fluid had been evacuated by an exploratory
trocar, and after withdrawal of the trocar the entire tumor disappeared in the course of the day to refill itself in five weeks.• If tumors so large rupture without causing the death of the woman we may believe that tubal dropsy may sometimes be cured in this manner; but this termination appears to be moderately rare; as also it seems seldom to happen that a dropsical tube attaches itself to the intestine or bladder and pours its contents into these organs. It is otherwise if there is in flammation of the dropsical tube or its neighborhood; its contents become purulent and increase rapidly in amount; the walls of the sac become at tenuated and softened; and the danger of rupture or slower perforation is always threatening. When a pyosalpinx empties into the peritoneal cavity it almost always causes a fatal peritonitis; the symptoms are vari ous and are soon masked by those of the rapidly arising peritonitis. From Hausammann's thesis we gather: the rupture may appear in the guise of a gradually increasing peritonitis (Dessauer), or with bearing down pains, diarrhoea and disappearance of the tumor (Andral); or sudden and violent lancinating pains at one point and extraordinary tenderness over one hypogastric region (Frankenhiiuser). Perforation may occur into the intestine or bladder, as is the case with para and perimetritic abscesses; we then see numerous lactic, purulent, diarrhceal stools (An dral), or pyuria Dupnytren has described a case in which recovery occurred after rupture of a pyosalpinx into the bladder.
Diagnosis.—The certain diagnosis of a hydrops tubas is only possible in the very rarest cases when there is a coincidence of many favoring circumstances. Since we have seen that tubal dropsy had no character istic symptoms, and since we can only suspect it when women complain of pain in the lower abdomen, we can only obtain a diagnosis by the bi manual examination. This will only be certainly possible in those cases where the tubal tumor has no special adhesion to its surroundings, so that we can detect the seat of the tumor and the nature of its connection with the uterus. If the tubal tumors are sunk into Douglas's pouch, if they are adherent, or if inflammatory processes lead us to examine the patient, the characteristic form of the tumor is usually lost and it may be mistaken for various conditions, such as small ovarian tumors, soft fibroid, sacculated exudations, etc.