Nelaton's description of the affection has been confirmed by Voisin, who in seven necropsies found his diagnosis, made during life, correct, and by C. Schroder who found the same in eight necropsies. We have no personal experience in this direction, as none of our cases have died, and • therefore we will give the pathology of this disease according to Voisin and Schroder.
In all cases there was more or less extensive peritonitis of long stand ing as shown by the numerous pseudo-membranes and strong adhesions between the abdominal organs. The peritonitis evidently started in the pelvis. In place of Douglas's cul-de-sac a large cavity, from the size of a fist to a child's head, was found; one case has been reported in which an enormous sac surrounded by pseudo-membranes was found between the uterus and rectum extending towards the abdominal walls, and partially towards the iliac fosse. In some cases two or three smaller sacs com municated with one another and formed the blood cavity.
The lateral walls of the cavity and its floor were formed by perito neum, the anterior, posterior and upper walls by the uterus, broad liga ments and sigmoid flexure, connected more or less intimately by pseudo membranous adhesions. In large cavities the roof was sometimes formed by convolutions of intestine matted together with neighboring structures. In rare cases pseudo-membranous bands extended over the uterus and bladder to the anterior abdominal wall.
The inner surface of the cavities was rarely smooth, but usually had a shaggy appearance caused by fibrinous deposits. Trabecuke in the cavity were frequently formed by pseudo-membranous bands and plates.
The contents of the cavities consisted of more or less changed blood.
Sometimes blood was found varying in amount to ten ounces, residues of blood of tar consistency and appearance, blood coagula mixed with pus. Breslau and Rindfleisch found in the blood of hematocele many serrated and shrunken blood corpuscles and only a few normal ones, numerous cells resembling white corpuscles or pus oells, and single epithelioid granular cells. Heurteaux found also hematin and hematoidirie crystals, oil drops and crystals of ammonia magnesium phosphate (Voisin).
The uterus was nearly always so displaced by the hematocele that its vaginal portion pointed upwards towards the symphysis pubis. Some times the body of the uterus was displaced to one side, usually to the left and anteriorly, and in a few cases it was retroverted by pseudo-mem branous masses. In size and appearance the organ was usually normal. Elongation and increase in size, found in some cases, seem to have had no connection with this affection. The uterine appendages present more or less marked changes, most frequent in the ovaries. In many cases the latter are so changed that they may readily be considered the source of the hemorrhage. In fifteen necropsies one or the other ovary presented marked morbid changes, in six cases blood, small blood cysts or clots, and in a few small pus centres. Still in many instances the ovaries are normal.
The Fallopian tubes are nearly as frequently changed as the ovaries, and besides various adhesions of the same with the neighboring organs they are sometimes rendered impervious or dilated with blood or pus. The broad ligaments also often show, besides thickening and adhesion to the retro•uterine sac, blood clots between their layers, and Muller describes a case in which a blood clot as large as a pigeon's egg was found in the right broad ligament and near it a tear three lines in length; in a case, also, reported by Silvestre, a bloody tumor was found in the right broad ligament communicating with a retro-uterine blood cavity. Ferber fre quently found in the pelvic peritoneum ecchymotic spots, and in rare cases bands and areas of congested capillaries, and sometimes recent resi dues of slight hemorrhages into the pelvic peritoneum which evidently gave rise to no symptoms during life and had terminated in resolution. Similar findings were also reported by Olshausen and others, and we have seen fibrinous deposits on the pelvic peritoneum which evidently resulted from blood extravasations.
Furnished with these pathologico-anatomical results, we will give an account of the various opinions about the source of the hemorrhage, and the etiology of the affection in question.