Retro-flexion of the Pregnant Uterus at the time (third month) when it commences to cause pressure symptoms in the pelvis. The position of the body of the uterus and its relation to the 'cervix and vagina, are similar to those of hematocole; and a superficial examination with one hand only might lead to error. But the retro-flexed pregnant uterus can always be recognized on careful bi-manual examination It has occurred that harm has been done by attempts to replace a hematocele, under the supposition that it was the retro-flexed uterus; and a retro-flexed pregnant uterus has been punctured from the vagina under the same mistaken diagnosis.
Treatment.—Shortly after the affection was recognized in France by , N(laton, many attempts were made to cure the affection quickly by puncture or incision through the posterior vaginal wall, and evacuation of the contents of the tumor.
But even before IsTOaten described the disease, Recamier, whose rule it was to puncture all pelvic tumors, twice pierced tumors through the posterior vaginal vault which were undoubtedly hematoceles. &seamier used a pharyngotome, and made a longitudinal incision. Then he passed one or two fingers into the wound, cleared out the blood-clots, put on a tight abdominal bandage, and washed the cavity oat three times a day with warm water.
Nolaton himself adopted a somewhat different mode of procedure. He punctured with a medium-sized trocar, evacuated the blood, injected the sac with warm water under gentle pressure, and a few days later threw in a warm iodine solution. Nonat did the same, but in addition put in a drainage tube.
But a few fatal cases soon led Nelaton to revoke the dictum, " every hematocele is to be treated surgically;" and surgeons soon stopped operating upon it. This is especially the case since the appearance of Voisin's comprehensive monograph, which contains statistics of the twenty cases treated surgically, of which five, or twenty-five per cent. died, while several of those that recovered had been in imminent peril. When we read that a woman treated by Malgaigne and N elaton died from the wounding of a retro-uterine artery, that one of Hugier's patients suc cumbed to peritonitis twelve hours after the injection of 3i ounces of Water into the sac, we do not wonder at the hesitation manifested by practitioners to interfere.
All modern authorities agree that with recent hematocele we must carefully avoid all operative interference; and only proceed to it when suppuration, or rupture into neighboring organs or the peritoneal cavity, or long-continued and severe pain, had set in. Thus the treatment
resolves itself in an expectant, symptomatic, and a surgical treatment.
The expectant symptomatic treatment consists first in an attempt to control the hemorrhage; the less blood is lost, the sooner will the woman get well. The patient should remain quietly in bed; an ice-bag is to be laid over a wet cloth which is folded six to eight times and spread upon the abdomen, and cold vaginal, or, better, rectal injections are to be em ployed. This latter appears to us to be especially useful. Rectal irriga tion by means of a double catheter and an irrigator will be the best.
The blood tumor once formed we must endeavor to prevent renewed hemorrhage, and, while combating the peritonitis and the anemia, en deavor to procure the absorption of the tumor which is there.
For these purposes the patient must stay some weeks in bed, and the cold applications must be continued for a long time. Since the danger of hemorrhage and renewed inflammatory reaction is admittedly greatest at the menstrual epoch, treatment should certainly be persisted in over that period. It has been recommended to elevate the pelvis, so as to favor the reflux of the blood. The flexed lower extremities should rest upon cushions, and the abdomen should be protected by a cradle from the pressure of the bed-clothes; and inunctions of equal parts of chloro form and oil with or without morphine will relieve the pain. Attention must be paid to the regular evacuation of rectum and bladder. The French surgeons especially recommend local depletion over the lower ab domen and at the anus, often using sixty to eighty leeches. We consider this quite superflous. Weakness and aniemia should be combatted by a light nutritious diet and wine. Lukewarm sitz and general baths have a favorable influence upon the process of resorption; but they are not to be employed until the abdominal pain and fever have ceased. A bath used too early not infrequently excites renewed inflammation. and causes more pain. We have never seen any great influence exercised upon the resorptive process by the customary inunction with iodine, iodide of potassium, unfit. cinereum, or the use of suppositories containing these drugs.