Thus, as we see, the diagnosis can be slowly arrived at, although the disease may be confounded with many other troubles.
The differential diagnosis in many cases is most difficult and at times impossible. They may be mistaken for tumors of the tube; sub-peritoneal fibroids of the uterus after they have become pediculated, and lie against the broad ligament and contain cyst cavities. Ordinarily they can be dis tinguished by their characteristic hardness, roundness and distinctly branched form. Martin described a preparation of Lehnert's before the Berlin Obstetrical Society, in which there was hydrops of both tubes. This was of special interest, because Langenbeck had operated on the case for fibroma; shortly after an immovable dense tumor developed, which gave the impression that a new fibroma had formed, but by necropsy it was proved to be a considerable collection of fluid in the tube. Tubal dropsy may also be confounded with exudations and accumulations of blood in the broad ligaments. Exudation is ushered in by marked fever and pain. Accumulations of blood develop suddenly with marked pain, and cause great prostration; opposed to this, diseases of the tubes are of slow advent and can not be felt to exist until the disease is thoroughly developed. To prevent this confounding, bi-manual examination should be made; exudation very soon fixes the uterus. The more rare affection, hsematocele, closely surrounds the uterus, pushing the vaginal vault downwards. After what has been said, an exudation or luematocele can be differentiated from tumors of the tube; but under certain circum stances, as when an exudation or hiematocele is movable and located in one or the other broad ligaments, in spite of all deliberation and care a positive diagnosis can not be made. I accidentally found an egg-sized coagulum of blood in a broad ligament, which had been removed from the pelvis with the adnexa of the uterus. The surroundings of the ex travasation showed no particular adhesions, so that this hwmatocele would, during life, by bi-manual examination, surely have given signs similar to those of hydrops tubie.
Further, we must differentiate cysts of the broad ligaments and small ovarian cysts. Cysts of the broad ligament are seldom bilateral, and usually do not show the characteristic intestine-like swelling. They can not be diagnosticated from two or three small cysts adherent to each other, so as to simulate a tumor of the tube. Small movable ovarian tumors are
often situated in Douglas's pouch, elevating the uterus and pushing it forwards, and providing they do not lock the entrance of the pelvis, they can not be differentiated from hydrops tubEe, and from other conditions. It is absolutely impossible to differentiate a hydrops from a single ovario tubal cyst that is situated in the abdominal end or the wall of the tube.
Courty believes that in similar cases the tumor can only be distinguished as tubal, when the healthy ovary can be felt inside of it. Other sources of error are liEematometra and hydrometra lateralis, due to duplication and congenital closure of half of the organ. By hi-manual examination a cornea of the uterus dilated with blood can be felt to pit on pressure, as in hydrops tubiu lying against the uterus, and only a careful recalling of the facts, scanty menstruation with gradually increasing pains, the finding of indications of duplication in the vaginal portion or in the vagina, will assist perhaps; in very difficult cases, differentiation can only be accomplished by exploratory puncture. Breisky, in 1873, described a case of hydrometra lateralis, which was verified by necropsy. He was so careful in his research that we can hardly doubt the correctness of the diagnosis. In this case was discovered a ring-like gap in the vault of the vagina, the edges of a projecting seam in the os uteri could be plainly seen, and a walnut-sized cavity was found under the os uteri, that was taken for a rudimentary vagina, to which a rudimentary uterus was attached After emptying and shrinking of the sac, Breisky was at last positive that the enlarged right aide of the uterus was a unicornis, the tube of which and accompanying ovary were found to be situated normally. From the neck of the uterus extended a band-like bridge to the left side of the pelvis, and to a little flat tumor were attached the adnexa of the left side. The ovary and tube of this side were not to be separated, how ever; one was hard and the other soft, like a small flabby cyst, which formed the principal part of the tumor. Below and a little in front of this adjoining tumor was situated a small cylindrical opening through which a sound passed into the uterus.