Diseases of women / by Lawson Tait.

  • Tait, Lawson, 1845-1899.
Date:
1886
Catalogue details

Licence: Public Domain Mark

Credit: Diseases of women / by Lawson Tait. Source: Wellcome Collection.

    100/216 (page 80)
    diagnosis will be most difficult, in fact it will be mere guess-work, and anj operative interference hardly justifiable. Even in the case already referred to, Mr. Hall-Wright's case of tubai rupture, where we were certain of the fixation of the uterus in a clot with- in the peritoneum, but which did not appear as a tumor above the brim, and where we suspected a renewal of the haemorrhage, and had even some indication as to its cause, we did not venture upon any operation, and the post-mortem showed we were right in our reticence (see extra-uterine pregnancy). Suppose that the peritoneum be tapped or opened from the vagina, is it likely either that the clots can be removed or the hemorrhage arrested ? And there is the immense risk of setting up peritonitis where it did not exist, or of aggravating it if already initiated. To open the abdomen in the middle line is a proceeding which first of all demands the justification of clear grounds of diagnosis. If the case be one of tubal pregnancy, the doubt of a favorable issue to the operation for the arrest of haemorrhage is, in my opinion, so great as to place it out of the ques- tion. If the source of the bleeding be of some other kind, abdominal sec- tion in the living body is not likely to discover it. Briefly, then, I think that all cases of intra-peritoneal hgematocele should be left alone save un- der the most exceptional circumstances, and should be treated on general principles only. The diagnosis of extra-peritoneal hsematocele is, on the contrary, very simple, and its treatment is based upon the soundest principles. If seen in the early stage, the history of the case, together with the presence of a tumor outside the uterus and intimately attached to it, more or less fixed in the pelvis, and always to be felt from above as a distinct tumor, and the absence of febrile symptoms, make the diagnosis easy. The tumor is generally soft or semi-fluctuating; but as it always embraces the uterus more or less, and prevents the organ moving, it is not likely to be con- founded either with an ovarian cyst or a solid fibroid, always supposing, as I do, that a careful examination is made under ether. If the practitioner feels justified in using the sound—but he has no need to do so unless the symptoms are really urgent and an immediate diagnosis is necessary—he will find the uterus of normal length, unless there has been a recent labor. Examination by the rectum will help him greatly by usually displaying the fact that the tumor seems to become lost right and left of the tube, and not to present the distinct contour of an ovarian or fibroid tumor, or as is presented by a blood clot in Douglas' pouch. Here let me just point out an error which is somewhat common, yet *so absurd as to be hardly credible save by those who frequently see it as I do. It is that inexperi- enced practitioners sometimes mistake the cervix felt from the rectum for a tumor of some sort; and only a few weeks ago I had much difficulty in persuading a practitioner of his mistake. Indeed, I did so only by mak- ing him feel the uterus with a sound in it. The size of an extra-peritoneal hajmatocle is a very important feature in the diagnosis, still more especially in the treatment. I have seen one containing some pints of clot, and reaching not far short of the umbilicus. This case occurred in the practice of Mr. Hoare, of Aston, and had been pronounced a fibroid tumor by another consultant before I saw her. The symptoms were urgent, for she had complete intestinal obstruction. Plac- ing her under an ansesthetic, I found the rectum quite flattened by a soft boggy mass, which was lost on either side, and appeared above the pelvis as a round, smooth, and fluctuating tumor. The uterus seemed to be quite in its centre, and of normal length, so that I had no hesitation in