DISEASES OF THE UTERUS. 



absorption take place as the weeks or months go by, it becomes very 

 hard and uneven, and at the same time shrinks, becoming smaller 

 and smaller, until it finally vanishes altogether, save a small lump 

 close to the back of the womb. In unfavorable cases, as when the 

 hcematoma is very large, the size and tension of the tumor continue 

 to increase ; the fever, the tenderness upon pressure, and other signs 

 of local peritonitis are aggravated ; so that a distinction between an 

 inflammatory exudation and a hsematocele may at this period be 

 very difficult, unless the sudden onset of the attack and the precur- 

 sory signs of internal hemorrhage can be taken into account. In 

 such cases the blood is generally discharged spontaneously through 

 the rectum or vagina, and the sac may finally close up after grad- 

 ually evacuating its black, grumous, tarry contents. In exceptional 

 cases a haematoma proves fatal through sloughing of the sac-wall 

 and blood-poisoning, or through general peritonitis after bursting 

 of the sac into the abdominal cavity ; for it would seem that the 

 altered blood is far more irritating to the peritoneum than that 

 which is recently effused. Long-continued suppuration of a fistu- 

 lous sac may finally wear out the patient. 



The treatment of a haematoma requires, above all, perfect and 

 continued rest, and avoidance of anything which can accelerate tho 

 circulation. If the bleeding persists or recurs, we must apply ice 

 to the abdomen or insert it into the vagina, at the same time giving 

 the liquor ferri sesquichloridi internally, and injecting ergotin be- 

 neath the skin. Should the symptoms of haemorrhage threaten life 

 itself, transfusion of blood or milk is indicated, as in all other 

 haemorrhages. Pain is best allayed by hypodermics of morphine. 

 The inflammatory symptoms and local peritonitis are to be met by 

 striving, by full doses of opium, to arrest movement of the bowels, 

 and thus to favor the adhesions by which the haematoma is becom- 

 ing enclosed. Only after the inflammation has abated should the 

 bowels be cautiously moved by enemata or by irrigation (Hegar's 

 method). Gynecologists differ as to the merit of evacuation of a 

 haematoma by puncture. Since opening the sac entails the danger 

 not only of renewal of the bleeding, but also of putrefaction within 

 the sac and its consequences, it should not be lightly attempted, nor 

 until all hope seems lost of resorption, or else until violent symp- 

 toms make it seem hazardous to await spontaneous evacuation. 

 The sac is to be punctured with a small trocar or, better still, by 

 the aspirating needle the entrance of any air being carefully pre- 

 vented. Puncture is most commonly made through the vagina or 

 rectum. Should the contents prove to be suppurating or putrid, 

 the opening must be freely enlarged, and the putrescent matter as 



