IIEMATOMA PERI-UTERINUM S. LIGAMENT' LATI S. THROMBUS MENTI LATI S. ITEMATOCELE EXTRA-PERITON EALIS.
We have seen that the vessels of the broad ligament may be the source of the hemorrhage in hematocele retro-uterina, and some of the autopsies recorded mentioned the presence of small effusions of blood between the layers of the ligamenti lati. From our own clinical experience we have no doubt that such hemorrhages often occur and are not diagnosticated. Voisin long ago described the condition under the name which Nelaton bad introduced, " Thrombi of the broad ligaments." He saw many women in consequence of a coitus or sudden exertion affected with a tumor situated exactly upon one or upon both sides of the uterus. Most often the left side was involved. The tumors were soft and doughy, varied from the size of a nut to that of a foetal head at term, were seldom accompanied by much pain, and did not always compel the patient to remain in bed Small tumors of this kind situated in the broad ligaments cause very different symptoms from tumors situated deep in the connective tissue surrounding the vagina and uterus. They may vary much in hardness, in size, in position, and in motility. In spite of all the diagnostic aids of which we can avail ourselves, their recognition will always be very difficult, since the tubes and ovaries lie so near them, and an encapsulated exudate near the broad ligament or a little cyst of the ovary may cause a very similar tumor.
II. Beige] accidentally found a very beautiful example of the affection under consideration, while examining the uterus of a woman who had died of pneumonia at the age of thirty-two. He described it as hemato cele aim vespertilionis sinistne. In the left broad ligament, at the lower part of the vascular ala vespertilionis, was an elongated, oval tumor, which began at the fundus uteri, and lay between the left tube and the round ligament of that side. The tumor was 3.2 inches long, measured at its broadest portion one inch, and was a mass of doughy substance, enclosed in a sac formed by the two layers of the broad ligament. The doughy
substance was coagulated blood, and had not, apparently, been set very long.
The hemorrhages into the pelvic connective tissue occurring outside of pregnancy, childbirth, and the pity' poi 'um are more important.
The name of hematoma peri-uterinum is very appropriate, since most of them encircle the lower portion of the uterus more or less. Their symptoms vary with their size and position, and are often so like those of hematocele retrc-uterina, that the two lesions can hardly be distinguished one from the other. There are but few pathological observations of this form of hemorrhage on record, since patients rarely succumb to it..
Schroder could cite but a single case of an extra-peritoneal blood effu sion, which was confirmed by autopsy. The case was reported by Ed. Ott, and was accidentally found in a woman twenty-eight years old, who had died of typhus; and Luschka had made a median section of her pelvis. The effusion was as large as a small apple, and lay in the recto-vaginal septum towards the vagina, an inch or so from the bottom of Douglas's pouch. The remaining recorded cases of extra-peritoneal blood effusion by Prost (mentioned by Bernutz and Engelhardt), Trousseau, Simpson, Betschler and Robert, he considers unreliable in spite of the autopsies, since the records do not make it clear that the peritoneum formed the upper boundary of the tumor. The investigations of Kuhn in Professor Frankenhaftser's clinic in Zurich, have done much to elucidate the patho logical anatomy of the condition, and have rendered the diagnosis of it possible under favorable conditions. In two of the reported sixteen cases, the diagnosis was made during life and verified at the autopsy.
A drawing of the specimen in question accompanies one of the cases, and enables us to understand the peculiar results of palpation.
We will give an abstract history of this case, and the drawing which accompanies it is reproduced in Fig. 31.