The Source of the Hemorrhage.—N6laton considered hematocle retro uterina as an accident of menstruation, and thought that the hemorrhage was caused by spontaneous escape of the ovum. Laugier agrees with Nelaton, Only he thinks that hemorrhage into Douglas's cul-de-sac takes place when the spontaneous escape occurs under conditions which abnor mally increase the congestion of menstruation.
By lifting heavy weights, dancing, coitus during menstruation, one or more ovarian follicles may remain gaping and be the source of hemor rhage, in which the vessels of the follicular wall, corpus luteum and ova rian tissue participate.
The changes in the ovary were called by Laugier apoplexy, later in creased congestion. Scanzoni also speaks of apoplexy and ovarian hema toma as the cause of hematocele rotro-uterina, and refers to a case of a girl eighteen years of age, who suddenly died during menstruation with symptoms of internal hemorrhage. Post-mortem revealed on the right ovary a sac as large as an egg filled with coagulated blood, the posterior wall of which showed a rent about an inch in length through which a large quantity of blood had escaped into the abdominal cavity. Puech reports similar cases. Smaller or larger blood-clots or small cysts are fre quently found in the ovaries; their occurrence is usually preceded by swelling and softening of the surrounding parenchyma, and we therefore can easily understand that if to an ovary changed in this way abnormal menstrual congestion is added, the rupture of a Graafian follicle may be followed by considerable hemorrhage into Douglas's cul-de-sac.
In many post-mortems the ovaries were found normal and the tubes the seat of the described changes; the question arises, What was the cause of the hemorrhage from the tubes ? Virgas advanced the theory that hematocele is caused by tubal pregnancy, the rupture of the young ovum causing the hemorrhage. Gallard brought this theory to the notice of the profession. Schroder and Veit accepted this idea. Indeed this opinion seems to be correct, since we find, during life and on the cadaver, many phenomena common to hematocele and extra-uterine pregnancy. So we find both usually in multiparce; both usually arise long after the last pregnancy, and we sometimes find with hematocele amenorrhoea of one or two months. In the cadaver we often find both narrowing or
plugging of a tube. Out of eight cases of Schroder's this was found in three, while in two other cases dilatation of a tube is reported. This is also supported by a statement made by Ferber He says: Frequently menstruation ceases without causing any complaint, the patients believ ing themselves pregnant. Suddenly profuse uterine hemorrhage takes place accompanied by symptoms of peritonitis, and the patient believes she has aborted, while a tumor rapidly developes in the neighborhood of the uterus. Although we do not agree with Gallard that every hema tocele is the result of extra-uterine pregnancy, still we believe that some are. The objection made to this opinion, that in no case of hematocele diagnosed during life, was a decidua found in the uterus or a foetus or parts of an ovum exterior to it, does not prove anything, for we know how rapidly absorption of the young fcetus may occur, and the thin deci dua could have been easily carried off by the hemorrhage; and again, in many cases of abortion at the first three months we can not find trace of a foetus.
Since the occurrence of extra-uterine pregnancy is a fact, and as it must be admitted by everybody that the delicate coverings of the ovum as well as the delicate decidua may be lost between the pseudo-membranous adhesions, this opinion is certainly justified. It also frequently occurs that in the course of late extra-uterine pregnancy the covering of the ovum, or a blood-vessel near its attachment ruptures. In this way hema tocele may develop with extra-uterine pregnancy Considerable hemor rhage from the tubes may also take place under other conditions. As proved by Lee, Pouchet, Raciborsky, and others, the tubes are also a source of the menstrual flow, and so it is possible that, when the proximal opening of one or the other tube is obstructed, with abnormal men strual congestion a larger amount of blood should escape into the abdomi nal cavity and form hematocele. The process may exist for several men strual periods, and after adhesions have formed hematosalpinx may be developed, which may rupture at the succeeding menstrual epoch, and ancient blood may flow from the tube and recent blood from the borders of the rent into Douglas's fossa, and cause an hematocele.