PELVIC HÆMATOCELE.
BY T. GAILLARD THOMAS, M.D.
HISTORY.—Prior to the present century the pathological condition which we are about to investigate had no place in the category of diseases peculiar to the sexual organs of the female. Very slowly have its pathogenic features, its etiology, and its importance as a not uncommon factor in pelvic disorders, assumed a systematic basis, and even now considerable diversity of opinion exists upon these points. The reasons for this are not far to seek. In the first place, hæmatocele is a symptom of an accident occurring in the pelvis and resulting in hemorrhage; in the second, the source of the flow which creates the hæmatoma or tumor of blood cannot ordinarily be recognized by any diagnostic measures known to science; and in the third, death rarely occurring from the accident and as a direct consequence of it, autopsic evidence is wanting upon which to base accurate and scientific data.
Although these statements are undoubtedly true, it may nevertheless be asserted with confidence that we are to-day no longer in the dark as to the general pathology of this interesting disorder, and that we are in position to map out a plan of treatment which meets the indications which present themselves in an intelligent and reliable manner. There are, however, several sources of hemorrhage which result in pelvic hæmatocele, and it is highly probable that the day will never come when that one which has created the accident can be ascertained with certainty. But while such accuracy of diagnosis would be gratifying to the ambition of the modern diagnostician, neither the prognosis nor treatment of the disorder would be influenced by it.
Long before our day practitioners had recognized by touch the occasional presence of tumors, more or less marked by fluctuation, which occupied the pouch of Douglas, and by their mechanical influence pushed the uterus out of its normal place; but it was not until the early part of our century that it was discovered that these tumors were sometimes, and that not rarely, composed entirely of coagulated blood; and, curious though it may appear, it was not until the year 1850 that pelvic hæmatocele became a well-recognized disorder.
As early as 1737, Ruysch of Amsterdam appears to have come to the verge of discovering it, but it was left for Récamier, to whom gynecology owes so much besides, to make it known when in 1831 he opened a post-uterine tumor, gave vent to a large accumulation of coagulated blood, and described the case in the Lancette Française for that year. In 1850 the subject attracted the attention of Nélaton, became a recognized pathological condition, and has since received a great deal of attention in all the civilized countries of the world.
DEFINITION AND SYNONYMS.—Pelvic hæmatocele—which has likewise received the names of retro-uterine hæmatocele and uterine hæmatoma—may be defined as an effusion of blood into the pelvic cavity of the female, either into or under the peritoneum. Some authors have limited this definition to blood escaping from utero-ovarian vessels and to blood enclosed either by anatomical structures or by previously-existing inflammatory products. I do not adopt these restrictions, because their assumption appears to me to be unwarranted and the validity of the reasons given for their adoption more than doubtful. The location of the blood-mass differs widely in different cases: sometimes, and usually, it is behind the uterus—high up when obliteration of Douglas's pouch has occurred, low down and near to the perineum where such obliteration has not occurred; at other times it exists both behind and in front of the uterus; and at others still, in front of the uterus alone, adhesions preventing its percolation to the posterior parts of the pelvis.
FREQUENCY.—It may be said, in general terms, that this affection is by no means rare, every one of large experience in gynecology meeting necessarily with a large number of cases of it. But no reliable statistics of its frequency have been collected up to the present time. Olshausen of Halle declares that in 1145 gynecological cases he saw 34 hæmatoceles; Beigel in 2000 cases found 38; Schroeder, 7 in 1000; and Seiffert of Prague reports 66 seen in 1272 cases of female pelvic diseases. Barnes says that in ten years' practice he met with 53 cases, and in twenty years Tilt has seen but 12.
Without doubt, the validity of the statistics of this disorder is vitiated by erroneous diagnosis, as is the case with all affections which generally end in recovery. Here cases of cellulitis, pelvic peritonitis, imprisoned cysts, etc. offer prolific sources of error, as I can aver from the results of my own experience.
PATHOLOGY.—It is a fact, thoroughly proved by physiological experiment, that blood injected into serous cavities very soon encysts itself by the enveloping influence of lymph which is poured over it, forming false membranes, or, as the French term them, néo-membranes. The clot, once formed, clings to the serous membrane in contact with it, and soon becomes roofed over by lymph, which, according to Vulpian, begins to show traces of organization as early as the end of twenty-four hours. Should the effused blood be poor in fibrin, the coagulation and encysting do not occur, a rapid absorption taking the place of these processes.
Pelvic hæmatocele consists, as has been already stated, in the collection of a mass of blood in the pelvis, either above or below its roof, without reference to the source of the flow. Such a flow ordinarily occurs from one of the three following sources: first, rupture of vessels in the pelvis; second, reflux of blood from the uterus or tubes; third, transudation of blood in consequence of dyscrasia or pelvic peritonitis.
From this it becomes evident that hæmatocele is not a disease, but a symptom which marks a number of different pathological conditions of quite various significance. As, however, we cannot discover the original accident or pathological condition, we are forced to compromise with taking its most prominent sign as the exponent of a state which is beyond the powers of diagnosis.
Autopsic evidence has revealed the following as the special and most frequent sources of the hemorrhage:
| 1st. | Rupture of blood-vessels in the pelvis: | |
| Utero-ovarian; Varicose veins of broad ligaments; Vessels of extra-uterine ovisac. | ||
| 2d. | Rupture of pelvic viscera: | |
| Ovaries; Fallopian tubes; Uterus. | ||
| 3d. | Reflux of blood from the uterus: | |
| Menstrual blood. | ||
| 4th. | Transudation from blood-vessels: | |
| Purpura; Scorbutus; Chlorosis; Hemorrhagic peritonitis. | ||
It is then clear that the mere presence of a large clot of blood in the pelvis, apart from general symptoms, is a matter of very doubtful significance, since on the one hand it may be the result of a mere regurgitation of menstrual blood due to imperviousness of the cervical or tubal canal, or on the other of the rupture of a Fallopian tube which has become the nidus of an extra-uterine foetus.
Whatever be the source of the blood which escapes, it coagulates, unless very poor in fibrin, either in the most dependent part of the peritoneum or in the pelvic areolar tissue beneath it. Here the watery portions of the mass are gradually absorbed, leaving a hard, small tumor remaining; or, suppurative action being excited, the hard mass is softened down and discharged into the rectum, vagina, bladder, or peritoneum as a grumous material somewhat resembling currant-jelly in appearance.
CAUSES.—These must be divided into predisposing and exciting, for it is rare to meet with the disease in a woman who has previously been in perfect health. The predisposing causes which can be cited with confidence are—the period of ovarian activity (fifteen to forty-five years); disordered blood-state, plethora or anæmia; the menstrual epoch; chronic ovarian or tubal disease; pelvic peritonitis; and the hemorrhagic diathesis. The exciting causes have been found to be sudden checking of the menstrual flow; blows or falls; excessive or intemperate coition; obstruction of cervical canal; obstruction of Fallopian tubes; violent efforts; and ectopic gestation.
VARIETIES.—The two great classes of the affection are the peritoneal and the subperitoneal. In the former the blood collects in the peritoneal cavity and becomes encysted there; in the latter it collects in the cellular tissue beneath the peritoneum, and there forms a solid mass.
Some authors have opposed the consideration of these two varieties under the same head; among them, Aran, Bernutz, and Voisin. But from a clinical standpoint such a consideration appears to me to be valid. Not only have distinct instances of subperitoneal hæmatocele been recorded by such observers as Barnes, Simpson, Olshausen, and Tuckwell, but cases have been met with in which the subperitoneal variety has ruptured the peritoneal roof of the pelvis, and thus broken down the theoretical barrier which pathologists have been inclined to establish between the two varieties.
Of the two varieties, there can be no doubt that the peritoneal is that which presents itself the more frequently. In 41 autopsies Tuckwell found the tumor to be peritoneal in 38.
SYMPTOMS.—As a rule, long before the occurrence of pelvic hemorrhage the patient will have complained of more or less decided symptoms of disease, or at least of disorder, of the genital system. The symptoms which mark blood-dyscrasia or pelvic peritonitis or menstrual irregularity will probably have attracted attention.
When the accident occurs the gravity of the symptoms will depend in great degree upon the character of the lesion which has taken place. Sometimes the blood-accumulation takes place so insidiously that the existence of the tumor created by coagulation takes the practitioner by surprise. At other times what Barnes has called a cataclysm occurs, and in a few hours puts the unfortunate patient beyond the sphere of hope or the resources of art.
In portraying the symptoms of this affection a writer can therefore merely approximate the truth, satisfying himself with the description of a case of ordinary severity, avoiding the description of cases in either extreme, and guarding the reader against supposing that all attacks give the same intensity of symptoms.
Most prominent among the immediate symptoms are—severe and sudden pelvic pain; pallor, faintness, and coldness of the extremities; a sense of exhaustion; nausea and vomiting; metrorrhagia; uterine tenesmus; enlargement of the abdomen; interference with the bladder and rectum; small and rapid pulse; subnormal temperature.
These are the symptoms of invasion, those which may be termed immediate, and which depend upon loss of blood and a sudden traumatic influence exerted upon living tissues. Very soon, generally within forty-eight hours, a reaction occurs which is sometimes slight, and at other times decided. The secondary symptoms are usually the following: tendency to chilliness; constipation; suppression of urine; tympanites; high temperature; rapid pulse; and tenderness over abdomen.
These symptoms are due to a combination of two causes—loss of vital fluid and the invasion of the peritoneum or pelvic areolar tissue by a mass of blood which becomes coagulated and irritant, on the one hand, and inflammatory processes resulting from such invasion on the other. Half of them might be produced by metrorrhagia, and half by sudden and complete retroversion; but a union of the whole will point toward hæmatocele and prompt a physical examination.
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 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.
PROGNOSIS.—The prognosis will depend in great degree upon the severity of the constitutional symptoms. As a rule, it is decidedly favorable unless the surgical tendencies of the attending practitioner alter its natural inclination. The prognosis of the peritoneal form is graver than that of the subperitoneal, and when the tumor is very large the danger is greater than when it is small. A large tumor argues great loss of vital fluid, which may in itself destroy life, and the necessity for the absorption of a large amount of coagulated material which may poison the blood.
The usual causes of death are loss of blood, shock from sudden invasion of the peritoneum, peritonitis, secondary discharge of the encapsulated mass into the peritoneum, or septicæmia.
TREATMENT.—Should the physician be called in the inception of the attack, the patient should at once be placed in the recumbent posture, all excitement around her be quelled, the head be kept low, warmth be applied to the soles of the feet, and perfect quiet enjoined. An effort should be made to check the flow by applying bladders of ice or cloths wrung out of hot water over the hypogastrium, pain and tendency to shock met by the use of morphia hypodermically, and ammonia and brandy freely administered by the mouth. This is all that promises benefit, and further efforts should be avoided as calculated to do absolute harm.
After reaction has occurred let it be borne in mind that the factors which tend to the production of death are—1st, peritonitis; 2d, septicæmia; 3d, suppuration and discharge through some dangerous outlet; and let all efforts be directed toward the prevention of these events.
All pain should be quieted by opium or one of its salts, hypodermically or by mouth or rectum; the patient should be thoroughly nourished by milk and strong animal broths, given as often as every two hours; febrile action should be controlled by the coil of running ice-water and quinine; and strict quietude observed, all unnecessary examinations being avoided, as belonging to the most pernicious class of perturbing influences.
Should the case progress favorably, no surgical procedure looking toward the artificial evacuation of the accumulated blood either by bistoury or by the aspirator should be thought of, however large the accumulation be; for experience has proved that cases left to nature, as a rule, do better than those interfered with.
On the other hand, the great value of surgical interference in those cases in which suppurative action occurs, or in which septicæmia develops itself either in acute or chronic form, must not for a moment be lost sight of. Should the case not progress toward recovery, should the symptoms of septicæmia develop as a sharp attack or as the insidious hectic fever, the accumulated blood or pus and blood should at once be evacuated, and the nidus from which it is discharged be thoroughly washed out with a 2½ per cent. solution of carbolic acid or a solution of the bichloride of mercury, 1 to 2000 of water. Should the accumulation be attainable, tuto, cito, et jucunde, by the vagina, an exploring-needle should be carried into it, and as soon as the fluid is seen to flow a sharp-pointed bistoury should be slid along this and a free opening be made, all the contents of the sac evacuated, and antiseptic washing be at once practised by means of Davidson's syringe and a glass tube.
Should the accumulation point toward the abdominal walls, the opening may with perfect safety be accomplished there. I have operated thus upon 3 cases, with recovery in all, but the accumulation had at the time of operation assumed the character rather of an abscess than of an hæmatocele. A. Martin of Berlin has operated by abdominal section upon 8 cases, with 6 recoveries and 2 deaths, and Baumgärtner of Baden Baden has done so upon 1 case, with recovery. Zweifel has collected 30 cases operated upon by free vaginal incision, with a result of 3 deaths, giving a mortality of 10 per cent. Mere puncture through the vagina he found followed by a mortality of 15 per cent.
The question of surgical interference in pelvic hæmatocele is still sub judice. In my judgment, the rule of practice may, with the present light which we have to guide us, be safely formulated thus: So long as the symptoms are good and the case progresses toward recovery, avoid surgical interference of all sorts, however great be the sanguineous effusion. So soon as symptoms of decided septicæmia or septic peritonitis develop themselves, evacuate the accumulation by a free opening practised by the safest outlet which presents itself, and use antiseptic washings thoroughly.