Menu:ton:a s. Thrombus Vagince.—This is rarer, and is characterized by the formation of a tumor in the vagina, which is usually limited by the diaphragm of the pelvis, and never extends into the vulva A thrombus vaginae is always a serious matter; and its extent can only be judged of by the extent of the patient's anemia and the size of the vaginal tumor. It usually does not project above the pelvic brim, but sometimes it breaks through all anatomical limitations and extends up to the kidneys.
It is not usually absorbed. After a few days it generally opens into the lower portion of the vagina, or into the rectum Hismatoma Periuterinum s. Ligamenti lati s. Thrombus Ligamenti lati.—Post-partum, but few hemorrhages occur from the broad ligaments, while the cervix is intact. It occurs mostly as an extra-peritoneal blood effusion unconnected with pregnancy or the puerperal state; we will con sider it later under its more usual designation of hematocele extra-perito nealis.
Hematoma s. Thrombus atm Vespertilionis.—This i3 practically unim portant. Most frequently we can differentiate between these various forms of blood-tumor but occasionally hemorrhage occurs in more than one place at once, and in the severest cases the mass of blood may ex tend from the ischio-rectal fossa to the para-renal connective tissue Etiology.--The causes of the affection are not quite clear. Vulvar thrombi occur before delivery, when the head is yet in the centre of the pelvis, and we see them after the simplest confinements.
Varicosities do not seem to be of influence in the causation of the hemorrhages A. Kucher, from the records of Spath's clinic, gives a frequency of 4 cases in 6000; Winckel 1 in 1600 Treatment.—This will depend largely upon whether the affection occurs before or after childbirth. In the former case it is best to deliver quickly, if possible. Together with Dr. Kernecker, we extracted with the forceps a living child, which presented by the face, after a thrombus the size of one's fist had appeared in the right labium. The thrombus broke, and the hemorrhage was severe. Manual pressure continued for several hours, stopped it, and the walls of the thrombotic cavity quickly grew together. Probably the same result could be accomplished by the tamponade of the cavity with ferreted absorbent cotton or iodoform gauze.
If the thrombus is formed immediately after delivery, the birth of the placenta must be accelerated by pressure, and, following C. v. Braun, an ice-bag introduced into the vagina, while the uterus is carefully kept contracted. Clysters of cold water, and the introduction of small pieces of ice into the vagina, will aid us in our efforts. But the thrombus for mation often continues until it reaches its anatomical limits.
All the thrombi which we have observed, with the exception of small ones, which were absorbed, opened in a few days. Those of the vulva broke sooner than those of the vagina. We several times successfully cleared out all the blood clots, and then thoroughly washed out the cavity three to four times a day with disinfectant solutions. In some cases we could introduce the tube to the depth of four and a half inches or more.
But incision and clearance of the cavity is always to be postponed for several days, until one is certain that no more hemorrhage is occurring. A 2 to 3 per cent. carbolic acid solution, or one containing iodoform, may be employed.
b. Unconnected with Pregnancy or hemor rhages into the pelvic connective tissue only occur in non-pregnant women after traumatism of the broad ligament by instruments.
But though rare, all the above-mentioned forms of blood-tumor may occur. Hemorrhages below the diaphragm of the pelvis are seen after such injuries as falls upon the edge of a chair, etc. They are seldom larger than an egg in size.
We ourselves have seen two such traumatic thrombi, and several cases have recently been described by G. H. Benjamin Chunn.
The most frequent of these hemorrhages occur between the layers of the broad ligament and in the uterus and the vagina, more especially in the connective tissue behind them. They attain a size twice to four times that of a man's fist, occupy one or both broad ligaments, displace the vaginal vault more or less to one side, and sometimes project half a hand's-breadth or more above the pelvic brim.
On account of the great practical importance of this latter form we will describe it more in detail.