RETROUTERINE H^EMATOCELE. 1(37 



may form. Rupture of varicose veins of the broad ligaments may 

 lead to intra- or extra-peritoneal hsematoma, according as the blood 

 passes into the pelvic cavity or into the areolar tissue between the 

 serous folds. Finally, the pelvic peritonaeum itself is a not unfre- 

 quent source of the bleeding. Dolbeau first announced that the 

 blood might flow from vessels in a pseudomembrane, the product 

 of a slow peritonitis. Virchow shares his views, which are in some 

 measure supported by the fact that in a slighter degree a similar 

 process may take place in men. The predisposing factors in pelvic 

 haemorrhage are the catamenial periods, the disorders giving rise to 

 the so-called haemorrhagic diathesis, scurvy, purpura, icterus gravis, 

 and the haemorrhagic exanthemata. Gynecologists differ greatly as 

 to the frequence of the affection. Schroeder found it in five per 

 cent, and Seyfert in seven per cent, of his cases. JBeigcl thinks 

 that mild cases are very common, but that they run their course un- 

 detected except by accident. The disease is liable to arise at any 

 time throughout the whole period of sexual activity ; it is most 

 common between the ages of twenty -five and forty, and in women 

 who have borne children. 



The formation of a pelvic haematocele is usually preceded by 

 symptoms arising from the remoter fundamental disturbance which 

 causes the haemorrhage. The establishment of the haematoma itself 

 is in most cases attended by unmistakable signs of internal bleeding, 

 sudden pain in the belly, faintness, pallor, feeble pulse, coldness of 

 the extremities, nausea, vomiting, and the like. Sometimes these 

 symptoms recur again and again, whenever, as may happen from 

 time to time, the bleeding is renewed. The history of an obscure 

 case of this kind may furnish important data toward forming a 

 diagnosis. The haemorrhage having taken place, there ensues a 

 more or less severe peritonitis, excited by the presence of the effused 

 blood. This has the effect of encapsulating the effusion, unless in- 

 deed it be already included within an envelope, the result of ancient 

 adhesions. Then follow the symptoms of pressure and crowding of 

 neighboring organs by the tumor, tenesmus or impediment at stool, 

 vesical pressure, and neuralgia from pressure upon the nerves of the 

 lower extremities or engorgement of the dislocated womb, some- 

 times of such intensity as to cause metrorrhagia. The most impor- 

 tant diagnostic test is by vaginal and rectal touch, whereby we may 

 detect a retrouterine tumor of rapid growth, which often rises above 

 the pelvic brim, but which also bulges downward into Douglas's cul- 

 de-sac, and more or less against the posterior vaginal wall. The tu- 

 mor is soft, elastic, even fluctuating to the touch, but grows more 

 firm after a few days, when the blood has coagulated. Should re- 

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