In chronic salpingitis the condition of the Fallopian tubes is revealed by bimanual examination. The tube usually falls below its normal level, and may be felt by the vaginal finger lying beside the uterus, or behind it, in Douglas’s pouch. By careful palpation the connection of the tubal tumor with the uterus may be traced. Bimanual examination is most satisfactory in the quiescent stages of the disease. During an exacerbation or during one of the acute attacks of inflammation the tenderness prohibits thorough palpation, and the surrounding inflammatory infiltration masks the condition of the tube. The tube may be felt as a hard cord, or as a cystic tumor with the ovary lying in its concavity, or as a tortuous, sausage-shaped mass. In old chronic cases the tube and ovary may be felt as a hard, knot-like mass adherent to the side of the uterus or coiled about the cornu (Fig. 151). In nearly every case the isthmus is rendered hard and cord-like by inflammatory infiltration. This indurated condition of the isthmus is a feature of tubal disease that is usually readily determined, and it is of decided diagnostic value. The connection, by such a cord, of the mass felt in the pelvis with the uterine cornu is the most valuable proof that the tumor is tubal in character. =Diagnosis.=--The diagnosis of chronic disease of the Fallopian tubes must be made from a study of the history, the symptoms, and by physical examination. The history is always of value. Careful questioning will usually show that the ovarian pain dates from a criminal abortion, from an attack of fever after a miscarriage or labor, or from a suspicious coitus. Women who have been infected with chronic gonorrhea by their husbands attribute the origin of the disease to their marriage. The woman will often say that for some days after marriage she suffered with irritation and burning of the external genitals, with dysuria, perhaps with a slight vaginal discharge, and that after this, very gradually, the ovarian pain developed. She may have had one child or a miscarriage, but with this exception is usually sterile. The history of attacks of local peritonitis, confining the women to bed for several days or weeks, can also usually be obtained. The character and the situation of the pain and the character of the dysmenorrhea usually point strongly to salpingitis. The physical examination is not by any means always satisfactory. The small flaccid tubal tumors are often difficult to palpate, especially in fat women, and the gross forms of the disease may be obscured by surrounding adhesions and inflammation. The examination, however, when taken in connection with the history and the symptoms, will usually enable one to make the diagnosis. Inflammatory tumors in the female pelvis are very generally tubal in origin.