Since it takes months, as a general thing, before the blood-tumor en tirely disappears, the patient should be very careful of herself, especially when menstruating, sexual intercourse being of course forbidden.
Most modern authorities agree in a general way with Nelaton in this conception of the course to be pursued, though Zweifel advocates more energetic proceedings, and Martin has eight times done laparotomy for extra-peritoneal blood effusion. Schroder, who appears to have tried opening and evacuation of hematocele several times, says that he is con vinced that the course of the affection is not at all shortened by incision and drainage. According to our own experience surgical treatment of the blood-tumors is only proper under the following two conditions: 1. When a large blood-tumor remains unchanged for weeks, and shows no signs of absorption.
2. When symptoms of suppuration appear.
In the first case we are confronted with the probability that sooner or later the mass will break into other cavities, or undergo a purulent change. The evacuation of the tumor will relieve the patient from the teasing pain, and the danger of suppuration will be averted. This latter is no slight danger; for if once chills and high fever show that the con tents of the mass are undergoing suppuration, we do not know whether the woman will get well, even after evacuation. But the time for evacu ation is to be postponed as much as possible, lest a new hemorrhage occur into the empty cavity. When a blood-tumor has been present several weeks, and when a menstrual 'period has been passed, this danger is prob ably only slight. It is a fact that especially many cases which are treated operatively shortly after the hemorrhage has occurred, end unfortunately.
In the second case evacuation is urgently demanded, and is not to be postponed; the more the injurious matters are taken up into the blood the greater are the dangers to the woman.
As to the mods of evacuation, some surgeons puncture and empty the cavity gradually, while others make a free incision and clean the sac out as thoroughly as possible. Or again, an aspirator like those of Dieulafoy or Leiter may be employed; they are so constructed that air cannot pos sibly enter the cavity.
The method to be employed will depend upon the case. Any one done antiseptically will ease the patient, hasten a cure, and avert threat ening symptoms.
seems in many cases to he just as efficacious as in cision. If it reveals the presence of pus, it should be immediately fol lowed by a free opening. It is most conveniently to be done with a medium-sized curved or straight trocar, through the most prominent portion of the posterior vaginal vault, under the guidance of the finger in the vagina. As much of the thickened blood as the tension of the walls of the sac and abdomen expel is permitted to flow out. It is better to rest satisfied with this, since the equable pressure of the walls of the sac and abdomen prevent air from entering the cavity. We have seen several cases treated in this way, and have ourselves several times taken away three to six ounces of inspissated blood without any ill consequences. Sometimes the contents of the sac are so thick, or the pressure in it so small, that the contents only flow out drop by drop; in these cases the canula may safely be allowed to remain in situ for several hours, when a considerable quantity will have been passed. Iodoform-gauze is to be laid over the puncture or the ope 11.11g ei tile (llntilL. The ally feel lighter after the evacuation, and the tumor soon begins to grow smaller. Latterly C. v. Braun seems inclined to favor more active meas ures, and advises in his book that if but little blood exudes through the puncture, it is to be enlarged in a sagittal direction with Greenhalgh's metrotome, the cavity cleared out, and antiseptic irrigation instituted. In twenty-two years there have been observed thirty hematoceles, some as large as a man's head, in his clinic; cure followed puncture in fifteen cases, and was spontaneous in fifteen cases. It was but seldom necessary to en large the puncture.
There is danger in attempting to squeeze out the entire contents of the sac after puncture; adhesions may be torn apart, and the walls being elastic and fixed, will, when the pressure is remitted, aspirate air into the cavity, giving rise possibly to a peritonitis or to decomposition of the contents of the sac and a fatal septicaemia.