A second characteristic lies in the shape of the tumor, and its relations to the uterus, as Martin has noticed. If a tumor suddenly appears at one side of the uterus from which a bridge appears to stretch to the other aide, there is very probably an extra-peritoneal blood effusion. This bridge may be in front of or behind the uterus, and if it unite two lateral tumors which project above the level of the organ, it is characteristic of hlema toma. It is very important when the tumor is unilateral to decide whether there is a bridge which can be followed towards the other side, as was the fact in the case shown in Fig. 31 and in two other recorded cases.
The surfaces of the tumor, and especially the lower one, may be im portant for the diagnosis. From the irregular distribution of the blood in the connective tissue, the lower side of a ha'matoma is uneven and rough, and the tumor may project far down into the vagina, getting smaller as it descends. In hematocele, on the contrary, the lower surface is at first entirely flat. From the abdominal walls htematoma appears smooth, since the loosened peritoneum forms a sharp boundary for it; and the uterine adnexa will be demonstrable at its apex. In hematocele, on account of the inflammatory reaction that occurs, there is seldom a sharp outline perceptible.
The position of the uterus itself may be higher or lower in different cases of either disease. But in unilateral hEematoma the uterus is not only pushed to one side, but will be found placed upon the tumor; though occasionally when Douglas's pouch is large and the vagina wide, the same condition of things will be found in hematocele.
Finally, it is stated that the neck of the uterus is mechanically elongated by the tension of the effusion, and retains its mobility to some extent; and that in hiematoma there is no fever or other symptom of peritonitis.
prognosis and treatment of hemorrhages under the pelvic fascia coincide exactly with that of thrombi after child-birth. For smaller tumors situated over the fascia pelvis, the principles are the same as those laid down for hematocele retro-uterina. In the case of larger tumors, when rupture into the abdominal cavity is threatened, Frankenhatiser recommends puncture from the vagina, or incision. The proposal of Zweifel will also be found useful if operative interference is considered necessary.
Laparotomy in Iiiematomata.—In the case of large pelvic haEma tomata, when an operation is indicated, A. Martin has given some very good and sufficient reasons for the performance of laparotomy. He has always found extra-peritoneal blood, and has several times recognized the covering as peritoneum under the microscope. Now whether there is a peritoneal coat in the covering or not is not of much importance for the vaginal operation, since hematoceles, even when of long standing, are usually separated by strong pseudo membranous layers from the ab dominal cavity; but laparotomy in the case of hematoceles, and we must be prepared to meet them in these cases, is difficult, if not impossible.
A. Martin's results, especially those published by Diivelius, are very remarkable. Of the first four cases operated on, which belonged to a less strictly antiseptic period, two died; of the last four operated on, none died. The course of the operations was simply this: Laparotomy; eventration; loosening and division of adhesions between tumor and intestines; open ing of tumor; cleansing of cavity from blood coagula; scraping of the walls and corners of the cavity; drainage, with cross pieces through the vaginal vault; attempt to close the cavity from the abdominal cavity by suture (usually fails from the softness of the walls).