HEMORRHAGES INTO THE PELVIC CONNECTIVE TISSITE.
a. In connection with Pregnancy and Childbirth.—Injuries to the genital tube during delivery may extend into the pelvic connective tissue. This is especially the case with incomplete ruptures, when the cellular tissue is lifted up to a large extent from its base, most often in the neigh borhood of the neck of the uterus and the upper part of the vagina. In spite of the open wound there often occur extensive hematomata.
But hemorrhages may occur in various portions of the peri-genital connective tissue during childbirth, even without injuries of the genital canal; and the clinical picture will vary with the position of the ruptured vessels, as will also the extent and prognosis of the affection. If the reader will consider the injections latterly made into the peri-vulvar and . .
vaginal tissue by W. Schlesinger, and the tumors he thus produced, he will at once comprehend the difference. We will give a short résumé of these experiments: Puncture a few centimetres above the vaginal entrance, in a direction obliquely against the vaginal wall, and above the diaphragma pelvis. —When the canula was forced between the fascia pelvina, and C. Lau ger's fascia endo pelvina, a tumor was formed which bellied forward the corresponding portion of the vagina, being bounded above by the fascia endo-pelvina, and below by the levator ani with the fascia pelvina.
Only after it had flowed for some time, and an infiltration had formed between the vagina and rectum, did the injection mass pour over the fascia endo-pelvina into the sub-serous cellular tissue.
Puncture into the space was first filled, and then the injection-mass easily passed through a fissure formed by the fascia of the R. obturator with the lower covering of the levator ani, with out destroying the levator ani or the fascia covering it, into the sub-peri toneal cavum pelvis; and when it grew larger, it pushed its way in be tween the bladder and the uterus.
Puncture of the Middle of the Labium Mains. tumor formed was
exactly similar to that seen in hematoma labium majus.
Puncture of Left Vaginal Wall .4 inches beyond the Hymen, in a Woman dead four weeks —A tumor was at once formed, which soon ren dered the vagina impassable to the finger, and reached behind the uterus towards the anus. In the anterior part of the pelvis the peritoneum was lifted up by the mass, flowing into the posterior portion of the left iliac fossa, and from thence into the mesentery of the S. romanum; towards the end the left ischio-rectal fossa was also infiltrated. The external genitals, the ala vespertilionis, and the upper portion of the broad liga ment, and a portion of the neighborhood of the uterus, remained free from the injection mass.
Most authors have made a clinical distinction between thrombus vulvae and vaginEe, making the boundary line between the two the diaphragm of the pelvis with its fascia; further clinical experience must tell us whether we can make further distinction.
We can distinguish the formation of blood-tumors in four places of the pelvic connective tissue: • Hematoma s. Thrombus Vulvae s. Labii tumor is usually egg to fist-sized, and is situated in the labium and vestibule, extending in extreme cases above to the mons veneris, and below to the perineum. Sometimes the location of the tumor is in the lower part of the labia; and from the bluish-red discoloration of the skin, in the neighborhood of the anus, we can recognize the fact that sanguineous effusion into the ischio-rectal space has occurred.
The vulvar thrombi never extend higher up into the vagina, since they are hindered by the muscular and tendinous structures of the dia phragma pelvis accessorium s. urogenitale, which are attached to the arch of the pubis.
The thrombus vulva is the most frequent of the non-dangerous forms. In tumors of smaller size the blood is often absorbed; in larger ones rup ture into the vestibule usually occurs in a day or two.