Thus, according to Nelaton, the hemorrhage is the primary occurrence, and the peritonitis, pseudo-membranous adhesion of the organs and en capsulation only secondary phenomena.
Schroder, on the other hand, holds that a tumor palpable from the vagina, can only be formed from blood accumulation after Douglas's cul has been closed from above by a partial adhesive peritonitis. There will always be a history of pain and menstrual disturbance to correspond to this preliminary peritonitis. Thus a hemorrhage into this lower closed portion of the peritoneal cavity, will give us a more or less large and tense tumor. In a later monograph (1873) Schroder admits that the blood tumor may arise in either one of these two ways.
It is worthy of mention here that Fritsch attempted to obtain experi mental evidence as to the mode of formation of hematocele. He attempted to find out whether coagula exercised an irritant influence upon the peri toneum, and in what way. He therefore injected non-defibrinated rabbit's blood into the peritoneal cavity of a rabbit. Even after three to six hours only a small portion of the blood was left, and no inflammatory processes were set up. Nevertheless Fritsch believes that the human peritoneum is much more vulnerable than that of the lower animals; and he holds that in most cases of hematocele the hemorrhage is the primary and the inflammation the secondary process.
cases, when left to themselves, end in cure. The most common result is absorption of the tumor; more rarely the tumor breaks through into the rectum, vagina, or peritoneal cavity; and sometimes it ends in suppuration.
Absorption of the almost every case which we have had an opportunity to observe, the affection began with considerable violence; within a few days after the first appearance of the symptoms a tumor the size of a fist or a child's head could be felt in the posterior vaginal vault. The severe pain and the subsequent fever usually kept the patient in bed. Only in exceptional cases was the tumor formed slowly and of small size, the patient being able to be up during the formation and ab sorption of the hematocele. In a few cases they were able even to do all their usual work, while a fairly large hematocele was being collected. If left to itself, the tumor gradually loses its fluctuating feeling, and in a few days becomes quite hard. Voisin's dictum: " The tumor from the
moment of its formation shows a tendency to diminish in size," is correct The fluid portions of the effused blood are absorbed, and the inflamma tory effusions upon the pelvic walls become harder and dryer. Voisin says that he has observed that the process of diminution in size takes place by fits and starts, being especially apt to be marked at the menstrual epoch. The hardening does not take place evenly throughout the mass. Through the posterior vaginal vault we may observe that some places long preserve their fluctuation, as Olshausen has noticed, while others rapidly become harder. Small hemorrhages have usually condensed in eight to ten days into harder tumors; larger ones remain soft and fluctuating, and give a tarry blood on puncture two and three months after their occurrence, as we have seen them. In some cases the tumor increases in size instead of diminish ing, renewed hemorrhages or inflammatory processes, or both, occurring at the menstrual epochs. As the tumor diminishes the pain decreases, the fever lessens, the vesical and rectal symptoms disappear, and the patients often feel so well in a week or two that they want to leave their beds. But a long period of time must usually elapse before resorption is complete. In twenty-four cases drawn from the clinical records of Pro fessor C. v. Braun, 12 cures by absorption took place, taking two to six months time. Absorption occurred in 15 out of 25 of Voisin's cases which were let alone; the time occupied in the process is given in seven cases— Rupture of the into the Rectum, the Vagina or the General Peritoneal does not always occur as we have de scribed; there may set in circumscribed or diffuse inflammations of the walls of the sac, leading to ulceration and rupture into some other part. The contents of the sac may be but little changed. and the inspissated blood is gradually poured out. But sometimes there occurs, previously to this, suppuration of the entire contents of the sac; the thickened blood becomes transformed into pus, and causes, even before rupture, the usual symptoms of pus retention.