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.