When the blood tumor has hardened, the pressure exercised by it causes the rectal and vesical symptoms to come into prominence. The urine is burning and painful, and is voided ten to twenty times in the twenty-four hours. Sometimes, when the tumor presses upon the vesical neck, there is retention, and the catheter must be used. But while this symptom may be wanting, constipation with swollen abdomen and painful defecation are constant symptoms. The symptoms showing pressure upon nerves and vessels are of rare occurrence; though there are often pains in the lower extremities along the course of the crural and sciatic nerves, and anesthesia of the skin. Sometimes there occurs later in the course of the malady oedema of one or the other extremity.
. These pressure symptoms are often accompanied by the signs of hy peremia and inflammation of the neighboring organs. There is often a moderate discharge of blood from the uterus; in fact it was absent in but few of our cases. A bloody mucus may be voided from the rectum, and bloody urine is often noticed.
The longer the blood tumor persists, the more do its characteristic ap pearances diminish; since its fluid portions continually diminish and its capsule becomes thicker and stronger. When the tumor in Douglas's pouch has once lost its elasticity, it may easily be confounded with other conditions.
The differential diagnosis lies between estra•nterine pregnancy, especially when this has been in existence for several months without giving rise to any special symptoms, and suddenly makes its presence known. If slight menstruation has persisted, if the breasts are not markedly changed, if the extra-uterine sac lies in Douglas's pouch, and if a sudden hemorrhage from some portion of the ovum has given rise to the symptoms, a diagnostic mistake can easily be made. Physicians who have had much experience in these affections have made them.
Under the above circumstances the diagnosis can hardly be made at all, and we must watch the case before we can come to any conclusion.
Under certain circumstances we may just as easily confound with hematocele: Partial peritonitis, situated in the pelvis and its immediate neighbor hood. If an attack of this nature has pursued a chronic course for some time, and if with much pain it suddenly forms a tumor behind the uterus, the vaginal appearances may be exactly like those of hematocele. The tumors in these cases occur from the collection in a space in the recto uterine cavum, closed in by pseudo-membranous adhesions, of serous, bloody, or purulent fluid. As a rule these processes occur, however, in connection with the puerperium; they are not so apt to occur at a menstrual period; no anemic appearance follows their advent; all these things speak against hematocele. But these cases sometimes resemble the
disease we are considering very closely, and the most experienced gyne cologist may be mistaken. So also there may be confounded with hema tocele: Ovarian cysts, while they are still not too large to sink behind the uterus in the pelvic cavity. If inflammatory processes set in and they become adherent, and if a sudden increase of inflammation with pain occurs, they may seem very like a fresh hematocele to vaginal touch. The same is true of cysts of the broad ligaments and neighboring parts. Long-continued observation is needed before a diagnosis can be made; if the tumor remains unaltered in consistency and size, it is probably a cyst.
Less likely to lead to a mistake in diagnosis are: Aifyotnata of the Coition Uteri.—If a fibroid is developed at the point of junction of the vagina and uterus, and if it is very soft or contains a cystic space, it may resemble a hematocele. We have several times Fern tumors situated at the posterior side of the uterine neck, in which the womb was dislocated upwards and forwards, exactly as in the cases that we are considering. But even if inflammatory symptoms set in, we ought with care to be able to appreciate the connection between the uterus and the tumor, and to recognize that the cervical lip is continuous with the myomatous tumor, and that a large part of the vagina is intimately con nected with it.
Lateral Hwmatometra with Duplexity of the Uterus. —The rudimentary closed cornu or vagina is gradually dilated by the accumulating menstrual blood until it forms a tumor in the pelvic canal, which may very much resemble a hematocele. The normal uterus is often displaced so greatly laterally, and so twisted upon its axis, that the tumor is often found in front of the womb. A number of these cases have been described as hematocele ante-uterina. Simon has done much to clear up the diagnosis of the affection. Schroder refers these cases to their real cause, proving that in all the instances described as hematocele ante-uterina, the relations and seat of the tumor and the nature of the pain were quite different from that of hematocele. The youth of the women, the gradual increase of the pain with each successive menstruation, the deep and lateral seat of the tumor, are not in accordance with the symptoms of hematocele, and point to a lateral hEematometra and luematokolpos, and to duplexity of the utero-vaginal tube. Hematocele rarely if ever occurs in young girls who have never had children. Sometimes also the uterine body on the occluded side will be found intact, placed like an appendix upon the bleod-distended cervix and vagina.