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.