The left Fallopian tube ran along the furrow which marked externally the place of division between the two tumors; and the left ovary lay on top of the posterior sac.
Thus all three cavities were in communication. It was evident that the process had begun on the left side, where the adhesions were firmest and the coagula oldest. Possibly the ovary, which was intimately united to the walls of the sac, was the source of the hemorrhage. Not only was the entire uterus lifted out of the pelvis by the effusion, but it was turned concavely backwards over the top of the sac. The uterus was 4.4 inches long, and somewhat twisted upon its own axis. The left sac had the thicker wall, it containing everywhere a muscular coating.
The right tumor was as large as a goose's egg; the left a little smaller; while the third was as large as a hen's egg. The fact that adhesions to the pelvic peritoneum are seen only over the left posterior tumor show that very probably during previous menstruation the left ovary and the left broad ligament had been united to the pelvic peritoneum by peri tonitic adhesions; for no signs of peritonitis were seen during the present sickness till shortly before death.
According to their situation and to the intensity of the hemorrhages the effusion will be found in the broad ligament, or in the cellular tissue in front of or behind the uterus. The effusions on either side may com municate by a narrow, tongue-like bridge either before or behind the womb. The tumor will be partially or entirely dumb-bell-shaped, as is represented in several schematic drawings in Kuhn's monograph.
The fascia endopelvina will limit these hemorrhages below; while more considerable hemorrhages will distend the vagina, dilate the orifices and cavities of this fascia, and, pressing the elevator ani downwards, will finally be limited by it. A. Martin has done much by his laparatomies to in crease our knowledge of these tumors, and has laid stress upon their frequent unilateral occurrence.
So far as we know the etiology of the affection is almost the same as that of hematocele retro-uterina, and does not give us much assistance in diagnosis.
According to Kuhn the early retrograde metamorphosis of the internal genitals is of influence. In three-quarters of the reported cases of hrema toma the women were prematurely aged individuals of from thirty to forty five years, while hematocele is most frequent from the twenty-fifth - to the thirty-fifth year. Undoubtedly traumatic influences much more frequently lead to hEematoma. Nor are the symptoms of luematoma exactly the same as those of retro-uterine hematocele. Both affections occur suddenly, are accompanied by great pain, are followed by anaemia, arid happen at a menstrual epoch after a period of profuse and painful menstruation; but the pains of lueniatoma are said to be rhythmical even when very severe. This Frankenhailser holds to be characteristic of peri-uterine hEematomata. It is also to be noted that there occgrs no rise of temperature after the hemorrhage. A second attack, and often a third, follows at successive menstrual epochs, and the hannatomata take two months or more to disappear, according to their size. They need not entail sterility, since the uterus may regain its complete mobility.
is not the slightest doubt that a hemorrhage into the female pelvis once recognized, it is possible under favorable circum stances to decide whether the effusion is intra- or extra-peritoneal.
We will follow Frankenhafiser in the diagnosis between and hematocele. He holds that it is easy to decide if the blood is extra-peri toneal, if the patient is seen early in the sickness. He succeeded in proving the intra-peritoneal position in several cases by putting the patient in the knee-and-elbow position. The blood flowed out of Douglas's to resume its place when the patient lay upon her back. If the blood is extra-peritoneal, it forms from the very beginning a consistent tumor, and is accompanied by the above-mentioned severe bearing-down pains. But the physician will hardly be in a position to make so thorough an examination of the patient during the first hours of the sickness, and the point has little practical interest.