Cases in which tubal tumors have been recognized during life are not rare. Puistienne felt the left dilated tube from the vagina; Schroder detected by touch several small tumors in the neighborhood of the ostium uterinum, and Noeggerath in the above-mentioned case felt the healthy and diseased tube through the bladder and rectum. The possi bility of a diagnosis is proved by a case in which Prof. Frankenhauser diagnosticated during life bilateral salpingitis with fluid, possibly pus, in the tubes and which was afterwards corroborated by autopsy. Hausam mann's case was a girl aged twenty-four, who formerly menstruated always regularly and for three months complained of severe metrorrhagia and intense pain over the symphysis, no fever; on palpation only slight ten derness in the left hypogastrtc region, and no increased resistance; on percussion no dullness. Internal examination showed the fundus of the uterus a little to the right, the uterine cavity deepened of an inch and the entire organ pushed against the symphysis. In the vaginal vault, very high up could be felt two small round tumors about a finger's breadth apart. These tumors extended principally towards the'brim of the pelvis, so that they could not be thoroughly mapped out. That portion of the tumor turned towards the vault of the vagina showed intestine-like swellings. Both were tender to the touch, the left plainly fluctuating; the right showed a cone-like hard projection. The uterus was 3} inches long, was slightly movable with the tumor, and followed the rotation of the introduced sound, as did the tumors. The vagina was very narrow, the vaginal portion virginal. After dilatation with com pressed sponge the uterus was found empty. The patient died with increasing pains in left hypogastrium and peritonitis symptoms; a per foration was suspected fourteen days after the first examination.
The necropsy showed widespread peritonitis. The uterus was united to the rectum by old and firm bands.
At the left side in Douglas's pouch, in the midst of numerous old and recent adhesions, was a collection of pus, and with this there communi cated by a hole the size of a cent a sac about the size of a man's fist, which still contained a small amount of yellow pus. The virgin uterus was somewhat lengthened and had a very narrow cervical canal. The right ostium tuba' uterinum was occluded; on the left side, however, an ordinary sound could be passed through the entire thickness of the uterus with ease, up to a stoppage just beyond the organ. Thence ran the left oviduct growing gradually larger, until about 2i inches from the uterus it was suddenly bent forwards and downwards and changed into the above described perforated sac. This sac was two inches in length, 24 in breadth and height; a mucosa could be distinctly seen on its inner sur face. At the point of bending was the perforation, and the dilated tube was adherent to the floor of the pelvis and the posterior wall of Douglas's pouch; in the midst of numerous adhesions lay the walnut-sized and cystic left ovary.
The right tube showed some constrictions and dilatations and was adherent to uterus and rectum.
The girl therefore had hydrosalpinx; consecutive inflammation changed this into pyosalpinx, and this caused a fatal perforation peri tonitis.
The diagnostic points are: (1) the shape of the tumor, it being intes tine-like and showing swellings and constrictions not found with other pelvic tumors and an inconstant fluctuation; (2) seat of the tumor, which may be in Douglas's pouch or raised above the pelvic brim; or it may be seated at the level of the cervix uteri. Between this and the tubal swell ing there is usually a furrow. The bilateral appearance of the disease, as Kiwisch has noticed, can give us some points for the diagnosis. The uterus is displaced to a variable degree; it is crowded to the side opposite to that of the larger swelling, or a large tumor fills Douglas's pouch, the uterus is pushed forwards and upwards exactly as occurs in the case of hematocele retro-uterina. (3.) The nature of the connection between the tumor and the uterus. There is usually a larger or smaller portion of less dilated tube between the uterus and the tumor which is felt as a constriction.
If hydrops tuba profluens is present, we have one diagnostic symptom more. We can observe the periodic outflow of quantities of fluid and the consequent periodical decrease in size of the tumor; or we may even be able, as Professor Frankenhauser was, to express fluid from the tubal sac into the uterus and out, and feel the tumor becoming smaller under our hands. This second case of Frankenhauser is mentioned also by Hausam mann and is so interesting and important, that I will relate it briefly, although it was not verified by autopsy: Girl, twenty-seven years old, nulliparous, sought relief for inetror rhagia. Examination showed a fist-sized soft tumor in the left ileo-ctecal region. Uterus immovable, and latero, anteflexed; sound penetrated two and two quarter inches. In the left vaginal vault was an elastic, immov able, painful and pointed tumor. Some clear serous fluid was trickling from the cervix, and pressure upon, the tube caused half an ounce of clear bloody serum to flow into the vagina.
Five days later Professor Frankenhauser expressed one and a half ounces of the same fluid. Diagnosis of probable hydrops tub profluens. The tumor emptied itself gradually, especially at night; in twenty-four days it was the size of a small apple. The bleeding had ceased, and the patient was discharged.
Seven and a half months later metrorrhagia again set in, accom parried with intense abdominal pain. The uterus was now four and two-fifth inches long, turned to the right, and there was a tumor the size of a man's fist. It projected deep into Douglas's pouch, and there was a distinct furrow between it and the uterus. Both moved together. Pressure caused evacuation of a sero-mucus clear fluid. The further course and treatment of the case will be related under the head of thera peutics of the disease.