The adnexa once diseased, any cause which increases the blood-pres sure in the pelvic vessels may cause rupture and a more or leas extensive hemorrhage. We shall therefore find the immediate cause of retro uterine hematocele specially active at the time of the regular menstrual congestion of the pelvic organs. In most of Voisin's cases the rupture occurred during and especially toward the end of menstruation Almost always these changes of the adnexa are conjoined with inflam matory processes, though these latter may not be very pronounced. If the pathological change is far advanced—if, for instance, a follicle has de veloped in a large, loose-tissued, and vascular ovary—the vascular conges tion at the time in question may be alone sufficient to cause it to rupture, and a considerable hemorrhage may occur from its blood-vessel walls. The same thing may occur from increased vascular pressure at other times. The conditions are the same as in apoplexy; the changes in the cerebral vessels have been long present when a hearty meal or mental excitement determines a rupture. But as in the brain sound vessels may occa sionally rupture, so may healthy adnexa sometimes give rise to hemato cele. The injuries which cause the accident either with healthy or dis eased organs are the proximate causes of the affection.
The most frequent of these causes is intercourse during menstruation. Often women suffering from hematocele will tell us of their own accord that sexual congress had been indulged in during or immediately after the menstrual epoch. In ten cases that Voisin observed, this was stated to be the case in seven; and the first attack of pain usually occurred dur ing the sexual act itself. Excessive intercourse itself may cause a hemor rhage. Puech mentions a prostitute twenty-five years old, who caused the formation of a hematocele in herself by the excessive practice of her profession, and died of it; and Scanzoni and others have observed the affection in public women.
But other causes may also increase menstrual congestion. Patients will often tell us that they danced the whole night through while flowing, or that they did much scrubbing or other heavy work Next to sexual intercourse the most important immediate cause of the affection seems to be sudden cooling, especially of the' lower extremities, and long-continued sitting. If a menstruating woman stands for a long time in cold water, the amount of blood in the extremities will be dimin ished, and the amount in the pelvis increased; and this will also occur if the sitting position is maintained for too long a time. That these causes are really efficacious is vouched for by the fact that so large a proportion of these cases occur in working women. Thus Weber of St. Petersburg ob served twenty-three cases of retro-uterine hematocele in women belonging to the hard-working classes. Sempstresses, according to Voisin, are very
subject to it. Women of the richer classes are more carefully tended during the puerperal period, and therefore less frequently suffer from the remote causes of hematocele; they are less exposed to the immediate causes, and if their organs are diseased, they are more likely to reach the climacterium without the formation of hematocele Anomalies of the blood and of the vascular wall, may also be the cause of hemorrhage into the peritoneal cavity. There are a number of cases of women who have died of the acute exanthemata, in whom con siderable quantities of blood were found in the cul-de-sac. Ferber mentions purpura, icterus gravidarum, scarlatina, variola and measles, and Scan zoni adds typhus, as being among these conditions. Trousseau long ago differentiated hemorrhages due to these blood conditions from those due to other causes, calling them " cachectic hematoceles." We have seen develop in a strong woman thirty years old, who was suffering from morbus maculosus Werlhofii, first a hemorrhage in the vitreous humor of the right eye, and six weeks later, at a menstrual epoch, a fist-sized hematocele.
Flexions of the uterus are mentioned by Trousseau and others as occasional causes of hematocele.
As regards the frequency of the malady there is the greatest difference of opinion. Hugenberger says that he only saw hematocele twice in 3801 cases, and v. Scanzoni in his practice of twenty-eight years only saw eight undoubted cases. On the other hand Seyfert (Prague) found the affec tion 66 times in 1272 cases (5 per cent.); and Olshausen in two years saw it 34 times in 1145 patients, and in two other years 29 times in 769 sick persons (4 per cent.) Lohlein believes that there hardly occur 4 cases of hematocele among 1000 women affected with disease of the sexual organs. We have been able to certainly demonstrate four pronounced cases of hema tocele among 5000'women examined at the polyclinic in the last five years, but this excludes a good many cases in which it was probably present.
Mode of Origin of Retro-uterine Hematocele. —Opinions differ upon this subject. Until lately the view was generally held that hematocele was formed in the way that Nelaton had described. Nelaton claimed that the effused blood collected in the retro-uterine excavation, as the deepest part of the pelvis, and that an inflammatory process was set up in the surrounding walls of the pelvis and the neighboring organs, which soon led to encapsulation of the mass. Thus a tumor was formed limited in front by the broad ligaments, behind by the rectum and the perito neum, below by the utero-rectal cul-de-sac, and above by the coils of ag glutinated intestine.