PHYSICAL SIGNS.--A tumor will be felt by vaginal touch, usually, though not always, posterior to the uterus and vagina, and partially occluding the latter. This will, if the examination be made very early, be found to be soft and obscurely fluctuating, but it soon becomes a smooth, dense, and solid body. The uterus is very generally found pressed upward and forward, so that the body lies against the abdominal wall and the cervix is on a level with or a little above the symphysis {243} pubis. In some rare cases the blood-tumor is anterior to or obliquely to one side of the uterus, but these are very rare. Abdominal palpation reveals the presence of a tumor of varying size, and which sometimes extends up to the navel in peritoneal hæmatocele, but in the subperitoneal variety no tumor whatever may be discoverable by these explorations, unless conjoined manipulation be added to it for the sake of deeper and more thorough search. DIFFERENTIATION.--Hæmatocele may be confounded with pelvic cellulitis or abscess, retroversion, extra-uterine pregnancy, fibroid tumor, and dislocated ovarian cyst. The tumor of cellulitis develops slowly, with great pain; is hard at first, and then softens; is tender from the first; does not elevate the uterus or press it forward; and is not often accompanied by metrorrhagia. Retroversion will readily be detected by the uterine sound, conjoined manipulation, and the absence of anæmic symptoms. The development of extra-uterine pregnancy is slow and gives the signs of gestation. Fibrous tumors grow slowly, are painless, and move with the uterus, and they are hard, irregular, and do not lift the uterus against the symphysis. Displaced cysts are painless, non-hemorrhagic, cause no metrorrhagia, and yield fluctuation readily to palpation. COMPLICATIONS.--The complications to be feared in this disease are septicæmia, suppuration and abscess, and peritonitis. COURSE, DURATION, AND TERMINATION.--The hemorrhage may be so severe as to destroy life immediately. Five such instances have been recorded by Voisin; I have met with one; and Ollivier d'Angers mentions two in which death occurred in half an hour from a varicose utero-ovarian vein. Such a termination is, however, very rare. As a rule, absorption takes place unaided by art; in some cases suppuration occurs, and the mass is discharged as if it were a large abscess by the vagina, rectum, bladder, or abdominal walls; and at other times septic absorption, accompanied by septic peritonitis, destroys the life of the patient.