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 rB-/^ 
 
 
 THREK CASES OF PELVIC HilMATOMA. 
 
 BY 
 
 WILLIAM UAKDNER. M.I)., 
 
 Professor of Gynecology in MeGill University ; Gynecologist to tliu Koy.il Victoria 
 Hospital ; Consulting Gynjecologist to the Montreal General Hospital. 
 
 Thk Pathological Repokts hy C. F. Martin, M.D. 
 
 Assistant Physician to the Koyal Victoria Hospital ; Lecturer on I'athology in 
 
 McGill University. 
 
 (Reprinted from the Montrnil Medicil Journal, January, 1897.) 
 
THREE CASES OF PELVIC H^EMATOMA. 
 
 BV 
 
 William Gaiiunkk, M.D., 
 
 Professor of Gymi-cology in McGill University; Gynu'cologist to the Royal Victoria 
 Hospital ; consulting Gynii'cologist to the Montreal General Hospital. 
 
 Thk Pathologioal Rkpokts, hy C. F. Martin, M.I)., 
 
 Assistant Physician to the Royal Victoria Hospital ; Lecturer on Pathology in 
 
 McGill University. 
 
 The association of pelvic hsematocele with cancer and tuberculosis 
 of the genital organs of women must be exceedingly rare. In none 
 of the recent works on gynecology which I have examined is any 
 mention made of it. This statement applies to the classical paper 
 of Whitridge Williams on genital tuberculosis, the chapter on the 
 same subject in the third edition of Pozzi's magnificent work on 
 gynaecology just published (1897), and that of Sir William Prie.stley 
 in Clifford Abltott and Playfair's system of gynaecology (1896). The 
 .same remark applies to cancer of the uterine appentlages as treated 
 in each of the works mentioned. This is certainly remarkable, espe- 
 cially as regards tuberculosis now known to lie so frequent a disease 
 of the tubes and ovaries, and to which so much attention has been 
 devoted by many observers in recent years. That pelvic hseraatocele 
 may be associated with these diseases is proved beyond a doubt ' y 
 the two cases I am about to describe. They are unique in my experi- 
 ence. Their exact relation as regards cause and effect is not .so certain. 
 The necessary nutritive and vascular changes may have preceded or 
 co-existed with the cancer or tuberculosis, but may not have been the 
 result of these marked processes. What we know of these di-seases 
 as they affect other organs or structures of the human body is surely 
 a cause for wontler that effusion of blood is not frequently caused by 
 the much more frequent tuberculosis of the ovaries, and especially the 
 
8 
 
 Fallopian tubes. By most authors and operators pelvic hn^inatocele is 
 in the enorn'ions majority of all cases held to be .lue to ruptured ectopic 
 .restation. The evidence on which this opinion is based does not 
 always bear close scrutiny. The necessary evidence of the presence 
 of a fa-tus or chorionic villi or ..ther decidual elements is not always 
 to be had even when carefully sought for. 
 
 Exira-wterhie Pregnancy. -Mv^. S., aged 95, was seen ,n consulta- 
 tion with her ordinary medical attendant, Dr. W. F. Hamdton. She 
 has been married twelve years and is the mother of six chddren to 
 full term She had a miscarriage in January, 1H9H, for which an 
 anaesthetic was given to remove some portion of the products ot con- 
 ception In May she had regained her health and continued well till 
 Aucrust The last normal menstrual period occurred about the 5th 
 of Au<rust there was no return till the 10th of September. The dis- 
 charge was then scanty and of short duration. From this time on 
 till the time of operation on the 11th of November, there were dis- 
 charc^es of blood at irregular short intervals, there were also paroxysms 
 of pc'lvic pain, but no syncope or collapse. During the last two weeks 
 previous to operation vomiting occurred several times, but at no time 
 was there any elevati<.n of ten.perature. When I first saw her about 
 the middle of (October, the uterus was somewhat enlarged and sott, 
 •uid to its left and adherent to it there lay an elastic fixed mass ; this 
 rather rapidly increased in si.e during the three weeks I occasionally 
 saw her before operation. At the time of operation there was a .hs- 
 tinct abdominal tumour. The patient was admitted to my private 
 hospital on the nth of November. ,.,,,« 
 
 0, ,, ration -T\vi uterus was dilated sufficiently to admit the hnger 
 to the fundus and the cavity found to be empty except for a general 
 linins with decidual membrane : it measured five inches in depth. 
 
 AMomlnal Sectiou.-^o free bloo.l or riuid of any kind in he 
 cavity a livid tumour-like swelling adherent to the whole of the 
 pelvic walls and floor, the adhesions not very dense. During the pro- 
 cess of separation a large quantity of almost black fluid and clotted 
 blood escaped. At the bottom of the pelvis lay the tV.tus and placenta 
 apparently detached, but lying in the sac described ; part of the wall 
 ol the sac was forme.l by the posterior wall of the uterus. After the 
 removal of the f.ttus and placenta the rest of the sac wa.s easi y 
 separated and bn.ught through the abdominal incision when it could 
 be as easily ligated as an ordinary empty ovarian cyst. No bleeding 
 of any coi"isequenc.) followed the separation of the sa«. so that the 
 abdomen could be closed without drainage. Recovery has been abso- 
 lutelv uneventful. 
 
8 
 
 Tlift apt'ciinoiis pn-scntcd, illustrate oik! ol" the most unusual varieties 
 (if ectopic fjo.stution, hikI clearly show from a careful study of the 
 relation of the parts how intimately associated may be the ovary 
 and tuhe in ectopic gestation, the tube being the primary site of the 
 event, while the ovary is to all intents and purposes purely passive. 
 
 The material was sent me by Prof. Wm. (Jardneron Noveniber llth, 
 1806, and on gross examination was seen to consist of four distinct 
 j)()rtiona : 
 
 1 A male fietuf 1*2.2 cm. Icmg with 3 cm. of cord attached. 
 
 2, A placenta 15x0x2 cm. in dimensions with a jiortion of cord U) 
 cm. long adhei'cnt to it. 
 
 •S. A containing .sac of about 12 cm. in greatest diameter. Its wall 
 was of varying thiekne.ss, den.sest at its outer extremity {I.e., the part 
 furthe.st from the uterus) where there was seiMi a flattened out mass 
 of tis.sue of l.l cm. in thickness, and containing a few narrow, elongated 
 spaces tillerl with clear, thin fluid (probably compresseil ovarian cyst). 
 This mass wasintimat(!ly as.sociated with the rest of the wall, gradually 
 becoming thinner at its peripheral portions where it passed imper- 
 ceptibly into the rest of the wall of the sac. Mici'oscopic sections 
 showed abundant evidence of its ovarian nature. 
 
 Elsewhere the sac was thinner ; in some places quite translucent, 
 in others moderately dense and thick. The Fallopian tulte was seen 
 coursing for .several cm. along the superior portion of the sac, and 
 terminating abruptly in the .sai- itself as a sudden dilatation, evidently 
 th<! site of the ectopic gestation. 
 
 The inner lining of the .sac was in some parts smooth and glistening, 
 where presumably the amnion still remained, in other parts it was 
 rough an<l ragged from the presence of placental remains and blood 
 clots, all easily detached. 
 
 Round about the sac there was evidence of some adhesions with 
 chronic intlannnatory fibrosis and local thickenings of the peritoneum, 
 
 Microscopic Sections were made through eight different portions of 
 the sac wall, and through two portions of the ovei-lying Fallopian tube. 
 In the first place, specimens were examined from the outer thi«k 
 mass of tissue suspected to be ovarian, and the condition revealed was 
 as follows : An outer layer of peritoneum with unusual proliferation 
 of the endothelium was seen to cover tissue, undoubtedly ovarian in 
 nature inasmuch as a graafian follicle was found. The t)vary itself was, 
 to a large t'xtent, markedly fibn^il. Advancing further inwards, in 
 the same specimens, towards the inner wall of the sac, one could dis- 
 tinctly see the mucosa of the Fallopian tube with great proliferation 
 
of the epitlu'liuin and nuincrous fiinbrisi' projoctinj; on all sides. 
 Between the tulx! itself and the .s\ii)eriinj)<)sed ovary no peritoneal coat 
 could he found, the prolongt-d stretchinjf, with its accompanying hyper- 
 plasia of connectivti tissue, evidently obliterating all such distinctions. 
 The ovary tlien, as these sections clearly showed, was flattened out 
 upon the sacculated tube, and helped to f»)rni a \)iivt of the; wall of the 
 sac, but its participation was obviously purely passive, and the con- 
 dition cannot, by any means, be regarded as a true ovarian pregnancy. 
 
 Sections from the smoother, tliinned-out portions of the .sac showed 
 no special features of interest. Those specimens, however, which 
 included the placental remains showed the usual appearances of the 
 villi, with the blood sinuses, decidual cells, hemorrhages anil what has 
 been regarded by FTubrecht, Webster and others, as remains of f(vtal 
 epiblast. These cells or collections of cells are massed together, their 
 nuclei .staining ileeply, as in the case of all embryonic tissue, and their 
 protoplasm al^orljing a diffuse eosine stain. They occupy what .seem 
 to be indiffei'ent sites in various jmrtions of the placental tis.sue. 
 
 The case then is of interest as showing how easily one may con- 
 clude the presence of an ovarian pregnancy, a condition which has 
 been time and again deni(;d, and certainly never been absolutely 
 proven. While ectopic gestation is thought by many to occur prima- 
 rily not only in the tubes and the ovary, but also on the abdominal 
 peritoneum, the question .seems recently to have been more fully 
 studied by Webster, who liases his views on a variety of different 
 methods of examination of a large (juantity of material. By means 
 of careful dissection, examination of gross frozen sections and micros- 
 copical specimens, he was enabled to show that many cases previously 
 reganled as abdominal or ovarian wei'e really after all but modifica- 
 tions of the tubal form ; cases that might under ordinary conditions 
 have been descril)ed as truly ovarian in origin were thus shown to be 
 after all merely one or other form of tubal pregnancy, and he is led to 
 considei- that ovarian does not exist. Hence, he classifies all ectopic 
 gestation cases under the three simple headings of ampullar, intersti- 
 tial and infundibular, our own case being included in the last of these 
 three varieties. 
 
 It has been granted by mo.st authorities that the ordinary uterine 
 and tubal mucosa' play, but a very minor role in the occurrence of preg- 
 nancy, and that the .subei)ithelial connective tissue is that upon which 
 the true fertilization occurs; it is for this reason that Orth and many 
 other European authorities still believe in the possible occui-rence of 
 an abdominal pregnancy, arguing that the peritoneum itself contains 
 tissue quite analogous to that beneath the uterine mucous membrane 
 
 II 
 
 h 
 
h 
 
 h 
 
 Were thorc! mitliinp further required to induce this prepfnancy there 
 would lie IK) ri'dsoti for supposinj^ it to occur ahnost anywhere in the 
 peritoneal cavity, hut Wehster has shown that there is good reason 
 for believing that some special cellular action must prohably occur to 
 induce the process of fecundation. He argues that wherever preg- 
 nancy occurs a genetic decidual nuiidirane forms, associate<l prohably 
 in some way with nerve influence, and he further urges that this can 
 take pl"ce cmly along the parts which take their origin from the Mul- 
 lerian tlucts. Hence ovarian anil abdominal pregnancies would be 
 impossible, and no one has yet proved a very early ovarian pregnancy 
 to (ixist. 
 
 That some nervous influence is associated with the condition would 
 aeem to be true from the discovery made l)y him in a case of ectopic 
 gestation where the nonparturient tube had likewise a definite decidua 
 upon its iiuier surface. 
 
 Some months ago I had occa.sion to examine some specimens from 
 a case operated on by Dr. Alloway, in which there had been a double 
 tubal hemorrhagi', arousing the suspicion of a bilateral ectopic gesta- 
 tion. In one of the tubes 1 readily found villi, though in the other 
 there was no evidence of any chorionic tissue. The case, however, is 
 suggestive as possibly being one similar in nature to that described by 
 Dr. Webster. 
 
 In one of the recent numbers of the British Mediad Journal there 
 is a synopsis of an article from Chrobak's clinic in Vienna, referring 
 to a case of ovarian pregnancy, which, however clear, seems to be 
 none other than an ampullar tubal pregnancy if one regards the ori- 
 ginal site of the placenta. The ovary, as in our own case, forms a por- 
 tion of the sac wall, and the ligament of the ovary enters directly into 
 the sac, but nevertheless the placenta itself is described as being fixed 
 to the uterus. 
 
 Pelvic Hiifmatomd Complicating Malignant Disease. — Mrs. J. 
 McC, aged 89 years, entered the Royal Victoria Hospital in July, 
 1896, complaining of pain in the right inguinal region radiating 
 towards the umbilicus. This pain began in January, 1896, was of a 
 dull aching character and remained constant for seven days, during 
 which time the bowels were rather constipated. For the first three 
 days there was constant vomiting, and the abdomen was somewhat 
 distended ; after the pain disappeared there was tenderness in the 
 right inguinal region for a week. Since January, 1896, she has had 
 intermittent attacks of pain in the same region, but no vomiting until 
 June, when she had an attack similar to that in January, accompanied 
 by vomiting and chilliness with constipation. Since then she has had 
 
6 
 
 w»nHtant pain in tho nj^lit in^niiiial rojjioii railiatinjr towards the 
 uiiiliilicus with a sctiHatioii of iliau^jiii^' (lowiiwanl.s of thn navel. 'I'ht' 
 patitsnt haw had thrt'i; chihh'cii ami one niiscania^f, the hist chihl three 
 years ago ; tlu; miscarriage seven years ago. Menstrnation regular, 
 at intervals of three to four weeks, duration three days, (|uantity 
 moderate, no clots. On examination theahdominal wall was lax, with 
 a tolerably thick layer of subcutaneous fat. Stria' fairly well marked, 
 moderate tenderness in the umbilical region. No descent of either 
 kidney. In the hypogastrium immediattOy above the brim and rising 
 ijuite to tlu! level of the uppei- surface of the pulies is a Hrm, rounded, 
 smooth and sensitive tumour, i'er vaginam ; the cervix is cleft bila- 
 terally, granular and everted, the oh is {)atulous and admits the tip of 
 the finger. The cervix is directed to the left side of the pelvis. To 
 the right of the cervix is a moderately Hrm mass partiall}' movalile 
 and continuous with the ma.ss felt in the hypogastriuin. The sound 
 enters three inches and is directed to the right side. There is .scarcely 
 any niobilit}' of the utei-us independent of the mass. 
 
 Operation, July 31st, lH9iJ. —Abdimiival SeHum. — The omentum 
 was adherent to a pelvic mass and to the brim of the pelvi.s. Several 
 coils of intestine were also very tirudy adherent to the mas.s. These 
 were separated by the scalpel leaving portions of the sac wall attached 
 to the gut. The sac lay in the vesieo-uterine pouch adherent, but not 
 very intimately. It was enucleated and tietl ott" with cat-gut; the 
 pedicle being composed of the right ovary and tube. The left tube 
 and ovary were also removed. During enucleation the sac was par- 
 tially ruptured and black fluid l)lood and poi'tions of partly decolor- 
 ised clot escaped, the oozing from the vesico uterine pouch was 
 controlled by pressure and the thermo-cautery. No drainage. Recovery 
 speedy and uneventful. Discharged August 20th, 1890. 
 
 The .specimen from this case was sent to the Laboratory on July 
 31st, 1896, and was found to consist of two distinct portions : (1) a 
 large mass of tissue to which was attached the right ovary and tube, 
 and (2) the left normal tube with a slightly cystic left ovary. 
 
 The large mass measured 14 cm. in greatest diameter, was moder- 
 ately well encapsulated, and the tube which WJis of normal thickness 
 could be seen stretched out upon the surface. On section the mass 
 was seen to consist of shreddy friable material throughout, dark 
 brown-red in colour, evidently containing much blood pigment. The 
 whole friable mass appeared to be loo.sely held together by a moderate 
 amount of fibrous framework. The central |)ortions presented far 
 greater disintegration than did the peripheral. The capsule itself 
 varied in thickness, the average being 4-0 ram. 
 
Microscopic sections wcro prepared from various portions of the 
 mass. Thos(« taken from the capsule and peripheral portions of the 
 tumour, show a fairly dense fibrous tissue containing' altundant hlood 
 pigment in crystals and amorplioiis granules, and a moderatt^ degree 
 of small rcamd celled infiltration. The irmermost portions .showed a 
 small number of epithelial cells arrangeil in an irregular manner amid 
 the tihroiis framework. Sections through the morefrial)le portions of 
 the growth n^vealed a tissue consi.sting almo.st entirely of epithelium 
 and Hlirous tis.sue. The epithelial cells were in parts, arranged as 
 glandular structures such as are seen in a nudtilocular ovarian cyst, 
 l)ut for the most part all trace of glandular arrangement was lost, and 
 the irregular luxuriant growth of epithelial cells amid the -stroma gave 
 all the characteristic features of an adeno-carcimona. 
 
 There was in addition al)undant necrosis and a large amount of 
 luematoidin. The tu>)e was normal. 
 
 Pathological diagnosis. Adeno-carcimona of the right ovary. Cystic 
 left ovary. 
 
 Pelvic Ifo'matoma Associated with Tuberculosis of the Fallopi.m 
 Tube. — Mrs. L. J., age 34 years, came to the out-patient department 
 of the Royal Victoria Hospital on August 14th, Ih d, complaining of 
 profuse discharg(!s ot blood per vaginam, pains in lower portion of 
 abdomen and back, and tend(>rness in the hypogastric and right in- 
 guinal regions. Until the present illne.ss patient has always enjoyed 
 good health. The fanuly history is phthisical. She has had eight 
 children, but no nuscarriage ; labours all normal. Recoveries favour- 
 able. The last child April 11th, 18<>,5. Menstruation was due on the 
 1st of July, but dill not appear till the 4th, continuing till the 14th, 
 when it ceased, and the patient began innnediately to have hypogastric 
 pain which continued till the next menstrual period. Since then she 
 has had attacks of flooding with severe pain in the intervals. On 
 July 30th she passed a large clot from the vagina. 
 
 Exavdnation. — Abdominal wall tolerably fat, flabby and somewhat 
 pendulous, stria) well mark.'d, marked pigmentation from uudjilicus 
 to pubes. Tenderness in hypogastric, right inguinal and iliac regions. 
 No descent of either kidney, no tumour or mass to be felt. 
 
 Per Vaginam.— ^'kenes glands inflamed, a purulent looking dis- 
 charge can be squeezed from their orifices. Vaginal orifice torn and much 
 relaxed, no evidence of disease of vulgo-vaginal glands. Descent of 
 vaginal walls. Cervix bulky, thickened, firm and patulous, a bloody 
 mucous discharge escaping. Uterus retroverted, its mobility dimin- 
 ished. To the right and behind the uterus an elastic, exceedingly 
 
8 
 
 tender, pulsating mass. The patient was admitted to the gynaecolo- 
 gical ward of the Royal Victoria Hospital. 
 
 Operation, August 19th, IHdH.— Dilatation and Curetting..— 
 Result moderate in quantity, endometrium roughisu to the curette. 
 Gauze packing. 
 
 Abdominal Section. — Intestines adherent to a mass in the true 
 pelvis. After separation of some adhesions a cavity containing eight 
 to ten ouncpf of black blood clot was opened and evacuated. In the 
 floor of tin^ pelvis lay the right ovary as large as a medium sized 
 orange, adherent and containing a straw-coloured transparent liquid. 
 The corresponding tube was dilated and contained a blood clot partly 
 decolorised. Chain ligature of cat-gut and removal. The left ovary 
 was also expanded into a cyst at least two inches in diameter. It was 
 removed. The left tube was not removed, it was adherent but not 
 enlarged to any extent. No drainage. Recovery speedy and satis- 
 factory. Discharged September 8th, 1896, apparently in perfect 
 . "th. 
 
 lis specimen which was sent by Prof. Wm. Gardner on August 
 .., 1896, consisted of a large hjematoma — two ovaries and two tubes. 
 
 The one ovary (Rt.) was enlarged to more than twice its normal 
 size, was mainly transformed into a bilocular cyst with generally thin 
 walls and containing clear gelatinous fluid. 
 
 Attached to this ovary was an enormou.sly di.stended and thickened 
 tube evidently closed at both extremities. Its contents were ha-mor- 
 rhagic in nature, its wall for the most part much thickened and dis- 
 torted, the inner lining dotted over with fairly large tubercles and 
 very few ragged portions of tissue. About midway, tbe wall was 
 much thinned, shreddy, and showed a large irregular perforation 
 evidently the original source of the hsematoma of the broad ligament. 
 The other ovary was enlarged to twice its normal size, firm, and with 
 an apparently normal tube. 
 
 The existence of a hsematoma associated with tuberculosis of the 
 Fallopian tube seems to be an event of considerable infrequency inas- 
 much as the literature on the subject seems not to consider its occur- 
 rence at all, and yet in the very nature of tuberculous processes the 
 occurrence of hemorrhage is to l)e looked for rather than otherwise. 
 Just as the exudates of tuberculous peritonis and pleurisy are for the 
 most part hamorrhagic, so, too, one might expect a similar occurrence 
 in the chronic diffuse miliary tuberculosis of the Fallopian tubes.