HEMORRHAGES INTO THE PERITONEAL CAVITY.
Hematocele Retro-Uterina.—Voisin, to whom we owe the most com plete monograph on this subject, believes this affection to have been known to Hippocrates and also to Galenus. From his history of this disease we learn that Pelletan reported a case of intra-peritoneal rhage in 1810 under the heading " hemorrhage in consequence of ovarian aneurism." Recamier also observed several cases of retro-uterine hemor rhage. Two of these cases have been reported by II Bourdon, 1841, under the heading " blood cysts of the pelvic cavity" and " blood tumor entirely filling the true pelvis." In these two cases and in another, which was not recognized as a blood tumor, Recamier made an incision through the posterior fornix of the vagina and evacuated large quantities of blood. At the same time 011ivier d'Angers and Dr. Bernutz reported several cases of intra-peritoneal hemorrhage. These reports make it evident that the occurrence of blood tumors was a fact known long before Nelaton more exactly described them; but this does not diminish his merit, for it is to his reports and those of his students, that we owe our exact know ledge which enables us to make a positive and quick diagnosis in these cases.
Nelaton, in 1850, named the disease in question hematocele retro uterina, meaning by this encapsulated blood extravasation in the peritoneal cavity of the true pelvis occurring usually during menstruation. The name hematocele peri-uterina was chosen by several other authors, and we do not approve of it because it implies the idea of a tumor equally sur rounding the uterus on all sides, which is not the case, for as we learn from thirty-five out of thirty-six cases collected by Voisin and according to our own observations, the tumor is usually so situated as to dislocate the uterus anteriorly and upwards, and to be palpable through the vagina at its anterior and to a considerable extent at its lateral periphery.
Since hematocele retro-uterina has been recognized it was largely dis cussed whether the blood tumor is intra- or extra-peritoneal. Nelaton, held from the beginning that the swelling was intra-peritoneal, and this by the researches of Virchow has recently been confirmed. C. Schroder
proved that up to the time of his report only one case of extra-peritoneal blood extravasation occurred in the absence of child-birth. It was in a twenty-eight year old shop-girl who died of typhus fever.
But even at the present time several authors, as Hewitt, Thomas, Gallard, Olshausen, Scanzoni and others, express their opinion that extra peritoneal blood extravasations may, though rarely, take place. Besides the fact that it is anatomically possible and that blood extravasations into the broad ligaments, the pelvic connective tissue, ischio-rectal fosse and in the neighborhood of the labia majora, after delivery and in rare cases also before delivery, frequently take place, this opinion has been supported by a treatise published by Jacob Kuhn of Frankeuhauser's clinic in 1874. In two cases extra-peritoneal blood extravasation was diagnosed during life and confirmed by necropsy.
However, extra-peritoneal blood extravasations not dependent upon delivery and childbed seem to be of more frequent occurrence than was formerly believed, for a considerable number of such cases have been reported by A. Martin, Olshausen, P. Zweifel, Konrad, Diivelius, Baum gartner, and others. A. Martin, W. Schlesinger and W. A. Freund have treated extensively of this form of blood extravasations.
Pathological Anatomy. —Hematocele in women rarely causes death, and therefore we owe our knowledge of this disease mostly to clinical observations. There are certainly cases in which women have died from hematocele, but only late in the disease, when the source of the bleeding could not be determined and when the extravasated blood and its peritoneal covering had undergone changes, and the pseudo-membranes encapsulat ing the blood clot and matting together the convolutions of the intestine had assumed such an appearance that it was impossible to ascertain the time of their occurrence and duration. We, therefore, cannot obtain from the dissecting table such a clear picture of hematocele retro-uterina as from our observations on the living, in the beginning of the affection.