Rupture occurs most frequently into the rectum.
This I found was the course of the disease twice in the records of Pro fessor C. v. Braun's clinic, occurring in one case after the tumor had ex fisted four weeks, and in the other after it had been present three months. In both a thickened, but otherwise little altered blood passed for sev eral days per rectum. In both cases an opening three inches above the rectum could be distinctly felt with the index finger. The first patient was cured in six weeks, while the second one took three months longer before she got well. Voisin observed this mode of termination six times in twenty-seven cases.
Now since five out of these six cases recovered, we cannot regard the occurrence as one fraught with much danger. Nevertheless it is worthy of our attention, since suppuration might take place in the emptied cavity, and the life of the patient be imperilled. Voisin relates that in one case symptoms of putrid infection showed themselves a short time after the mass had been evacuated per rectum, and the patient died hav ing chills and high fever. Voisin mentions also a second fatal case, after rectal perforation from Guerard's division.
Rupture into the vagina is rarer; we have never seen it occur, nor does it appear in the clinical records. Voisin states that it happened three times in twenty-seven cases. The result was favorable in every case, pro bably because the facilities for drainage were excellent whatever position the patient assumed.
Rare also is the termination by rupture of the capsuie and evacuation into the abdominal cavity. We know nothing about it ourselves. Ac cording to Voisin it occurred four times in his twenty-seven cases; and in every case the decomposed purulent blood caused a fatal peritonitis.
Symptoms and symptoms will vary as the hemor rhage is slow or rapid, and the amount of blood poured into the recto uterine excavation is large or small.
In most cases there is irregularity of menstruation and pain at the period for several months before the affection begins. These irregulari
ties may consist in a superabundant flow or amenorrhoea for several months. Sometimes there is pain alone either at the menses, or between times. But in many cases, according to Voisin in twenty-five per cent., the affection begins without any prodromata, and we have ourselves ob served some cases in which the women said that they had never been sick before. As a rule the trouble begins at a menstrual epoch, with more or less pain in the lower abdominal region. The first attack of pain is often accompanied with a sense of fear and agitation, nausea, vomiting, chills, etc. A fairly constant symptom is the discoloration of the skin, pointing to an internal hemorrhage; and, according to the amount of blood lost, is there a greater or less feeling of thirst. Usually the menses, if flowing, cease when the pains come on, to reappear after a few days as a moderate, long-continued outflow.
The pains are mostly confined to the pelvis and its neighborhood. Usually they are so violent as to compel the patient to go to bed; some times they are bad enough to cause collapse; but occasionally the woman does not lie down at all. They are distinctly rhythmical in their char acter, and may cease for a time, to reappear with renewed violence. Sometimes they are. colicky. Usually there is a feeling of weight or heaviness in the pelvis, and, as when the child's head is at the outlet, the women fool as if they wanted to make water or to go to stool. This feeling may be so marked as to amount to rectal and vesical tenesmus, and often lasts for some time after the tumor is found.
After the first attacks of pain there ensue febrile symptoms due to the pelvic-peritonitis which accompanies the formation of the hematocele. The temperature may go up to 101° or 102°, and the pulse to 100 or 120. The abdomen, especially in its lower parts, is slightly swollen.
The sudden pain during menstruation and the subsequent peritoneal symptoms are important points in the diagnosis of hematocele.