H2EMATOMA OF THE VAGINA.
In _L _L the recorded cases of the affection there is no distinction made between vaginal and vulvar hEematomata. But luematoma of the genitals in general is very raro; and Winckel, calculating on the basis of 50.000 births, says that there occurs only one in every 1600 cases. Bidder and Sutugin found only one hiematoma limited to the vagina'in 3285 child births. In my clinic in Prague there has been one case of hwinatoma vag. in 2126 births. Spath saw in two years at the clinic four cases of thrombus vag. in 6000 deliveries. (Wucher.) They do not differ in regard to their mode of origin from hEematoma of the external genitals. Both probably occur but very rarely save in pregnancy, and then only in consequence of direct traumata. All the cases of which I have a his tory were primipara3, and several of them were old ones. The posterior wall was usually affected, though sometimes the tumor was seated on the anterior wall. Once only did I see the entire length of the vagina affected.
The hyperplasia, loosening of tissue, and vascularization which accom pany pregnancy, furnish the predisposing causes. Varices are not neces sarily present. Marked and suddenly increased venons stasis from ab dominal pressure will sometimes alone cause extravasation in pregnant women; but traumata are often the cause in spontaneous or artificial deliveries. This may be due, like the hEematomata of pregnancy, to increase of pressure in the veins of the vaginal wall involved; or from so great a local contusion of the vessels that pressure-necrosis and subsequent hemorrhage occurs; or, probably most frequently, from direct rupturo of the vessels from tension and displacement.' In the latter ca,se the dis placement and compression of the vaginal walls by the child's head ex _ plains how it is that the blood-tumor only developes post partum.
There have been too few investigations made as to the immediate origin of the hemorrhage for us to decide as to their anatomical relations. In any case the veins will be more exposed to pressure and subsequent stasis than will the more elastic arteries. The hemorrhage is usually freer
than would come from capillaries, and has no systolic impulse; hence it is most probably venous. Of course, however, smaller arterial twigs may be involved.
The tumor always forms rapidly. In pregnant women, if there has been no traumatism, it appears after exertion, a fit of coughing, or other action which involves a sudden abdominal pressure. During childbirth it only exceptionally appe,ars before delivery is complete; as a rule it forms either immediately thereafter, or in a few hours or days, exactly as does luematoma vulvre. The symptoms depend upon its seat and extent. A part of the tumor usually appears as a bluish-black or bluish translucent tumor; it will not be seen, of course, when the hrematoma is small, or is confined to the upper segment of the vagina. Occasionally there is cedema of the vulva. As a rule there is sudden hypogastric pain, a feel ing of bearing-down, and, when the tumor is large and affects the poste rior wall, painful attempts at defecation. Symptoms of acute anremia, fainting, and collapse have been observed a number of times, especially when the luematoma formed while external hemorrhage was in progress.
If in addition to these symptoms there are those of tension and separa tion of the walls of the septum recto-vag., with elevation and anteflexion of the uterus and dragging upon the walls of the rectum, the trouble may become very great, and the pain far exceed that which attended the pre cedent delivery. The course of vaginal luematoma is usually to a sponta neous rupture, and, with appropriate treatment, generally terminates in recovery. But repeated hemorrhages, and suppuration of the contents of the sac, with septic infection, may occur. The dangers of vaginal luematomata are greater than those of the vulvar form, inasmuch as the tumor spreads more rapidly to the parametrium and thus causes pelvic thromboses and recto-vaginal fistulie.