THROMBUS OF THE VULVA AND VAGINA.
Under the name thrombus we designate an extravasation of blood into the cellular tissue surrounding the vulva and vagina. This extravasation may not be limited to these parts, but may extend high up on the abdo men. We are then dealing with a true hemorrhage. This accident is rare, since Deneux, in a practice of forty years, only observed three cases, Dubois three cases in 1,400 deliveries, Winckel one in 1,600, while in our clinic only one case was noted in 1,800. It may occur in the non-preg nant state, but is most common in the pregnant woman after delivery. Extravasations are most common at the vulva, the swelling being uni lateral. In the vagina they are usually situated in the lateral and pos terior walls, rarely in the anterior. The extravasation begins, as a rule, during labor, but does not actually appear until after delivery. Laborie has shown that the location of the swelling is determined by the anatomi cal structure of the parts: thus, if it is beneath the skin of the perineal region, it may extend to the thighs or abdomen, but if beneath the super ficial fascia, it does not spread beyond the nymplue. An extravasation beneath the deep layer of fascia may spread to the iliac fossfe or sacro• sciatic notch; if effused between the pelvic fascia and peritoneum, blood may either collect in one spot or extend throughout the pelvis, in the broad ligaments and oven to the mesentery and diaphragm. If the ex travasation is in the vaginal wall, it is shut in by the fibrous layer and does not spread to surrounding parts. The causes may be predisposing or determining.
1. Predisposing may be, according to Blot, either re mote or direct. Pregnancy is the most important, since it results in general congestion and edema of the genital tract. Primiparce seem to be predisposed to intra-pelvic extravasations, while thrombus, on the other hand, appears to be more frequent in multiparEe. Narrowness of the vagina, pelvic deformities, and varices, have been regarded by all authorities as essential causes. Varices, however, do not seem to possess extreme importance, because Perrot noted this condition only twice in 43 cases of thrombus; they seem, indeed, to play a secondary part in the production of these hemorrhages. Disturbances of the circulation, and in the composition of the blood in pregnant women, are also included among the predisposing causes.
2. Determining Cauees.—Among these are to be mentioned the bruis ing caused by the foetal part, by instruments, or even by the hand, when it is necessary to introduce the latter into the canal to perform version; also unusual size of the foetus, repeated and awkward examinations, vio lent expulsive efforts, or even coughing or vomiting. Finally, local in
juries, from falls, the jolting of a carriage, and external violence, are to be added. In few instances do thrombi appear after deth;ery without some appreciable cause.
Mode of Occurrence.—In consequence of the venous obstruction, the veins become dilated and their walls thinned; under the influence of one of the above-mentioned causes, rupture occurs at some point in the vessel wall, and the blood escapes into the cellular tissue, its spread being fa vored by the looseness of the latter. When this accident takes place dur ing pregnancy, it is almost alway due to external violence. During labor the congestion is increased by the pressure of the venous plexuses between the foetal head and the bony walls of the pelvis; hence the greater frequency of intra-pelvic thrombus. After delivery the mechanism is the same; it is even possible, as Dubois affirms, that the vessels may be so contused that necrosis of their walls results, rupture following when the sudden efflux of blood takes place after delivery. From the rapidity with which the tumor develops, it is probably due to arterial, as well as venous, hemorrhage. • Symptoms.—The first is pain, which, however, is not invariably pre sent; it usually precedes the formation of the thrombus by a brief inter val, and is sharp and lancinating, radiating from the vulva and vagina to the loins and lower limbs. According to Perret, it is accompanied by a feeling of tenesmus and a bearing-down sensation. A tumor then ap pears either at the vulva or in the vagina, the latter being recognized by the touch; it is smooth, circumscribed when small, but diffuse when it is very extensive, and to the fingers an elastic feeling, with or with out fluctuation. It is generally of a dark livid color, and, after an in terval, ecchymoses appear, either in the vicinity of the tumor, or on the buttocks and upper part of the thigh. If the swelling appears before de livery, it may offer a mechanical obstacle to the expulsion of the foetus; it may at the same time cause symptoms of pressure, referable to the bladder or rectum, or may oven displace the uterus. Finally, these tumors may retard expulsion of the placenta and cause later retention of the lochia. If the tumor does not rupture, it may give rise to all the symptoms of grave internal hemorrhage; if it does rupture, external hem orrhage, more or less profuse, may be added to the internal. The symp toms are of course directly proportionate to the severity of the hemor rhage; finally, symptoms of accompanying peritonitis, abdominal pains, nausea, vomiting, etc., may appear.