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Maps, plates, charts, etc., may be filmed at different reduction ratios. Those too large to be entirely included in one exposure are filmed beginning in the upper left hand corner, left to right and top to bottom, aa many frames as required. The following diagrams illustrate the method: Lee cartes, planches, tableaux, «tc., peuvent Atre filmte A des taux de reduction diff^ents. Lorsque Ie document est trop grand pour Atre reproduit en un seul clichA, 11 est fiimA A partir de I'angle supArieur gauciic. de gauche A droite, et de haut en baa. en prenant Ie nombre d'imeges nAcessaire. Las diagrammes suivants illustrent la mithode. 1 2 3 1 2 3 4 5 6 r^ ^/^./a H. ;.. POWi^LL, 1876. -* 2"^Tr y iUBPRINT FROM "VtHB CANADIAN PRACTITIOXER," TORONTO, JULY, 1887. PELVJC HEMATOCELE BY R. W. POWELL, M.D., OTTAWA, ONT. • ■ (Head be/ore the Ontario Medical Association, June, 1887.) .^ I liiliiiiliilMHiiHiiMi PELVIC H.EMATOCELE. I WOULD ask your attention a few moments to a case I propose to relate that recently came under my observation, causing me much anxiety for my patient's welfare, and much satisfaction and surprise in its happy and unlooked-for ter- mination. I have termed the case one of pelvic hsematocele, as I believe that term, in its wider signification, covers all those cases of blood effusion into the pelvic cavity which are bound down either by adhesions, or by the regular tissues of this region, and are thereby converted into the so-called blood tumors, and this whether the effusion be intraperitoneal, retro-, anti-, or peri-uterine, which 1 bolieve is the most common variety, and due to several causes, or extra-peritonea), into the cellular tissue of the pelvis, which is less frequent. I would probably be more correct, and in greater accord with modern nomenclature, were I to term my case a pelvic ha&matoma, and no doubt this would indicate to the large majority of my hearers the pathological condition present. I have made a tolerably careful search through the literature at my command, but 2 have not met with a case similar to the one I propose to relate, though cases of the same nature are referred to by Dr. West, M. Voisin and Bemutz, and also one by Oazeaux, and I regret not having access to the latter's cases, because in Dr. Playfair's work on the " Science and Practice of Midwifery," an aggravated case of Oazeaux is there referred to, though the details are not given. The best description of the condition as it applies to my case that I have read, I may mention, is in the work just referred to — Playfair's "Science and Practice of Midwifery." On March 2nd, this year, I was hastily summoned to Mrs. P , said to be in labor. On my arrival I found that she had been taken in labor at full term at noon, that it had progressed very rapidly with strong expulsive pains, and that the child, a well- de /eloped female, had been ushered into the world quite unexpectedly by a strong expulsive effort before the mother was in proper position on the bed, she not anticipating the birth so rapidly. It was born, therefore, before I entered the house. The mother was a strong healthy woman, an artizan's wife, aged 25, and she had enjoyed excellent health throughout gestation. I recognized her as having attended her in her first labor in September 1884, when, on reference to my note-book, I find she was delivered of a healthy female child at full term, the labor being in all respects normal, and she 8 Tuade at that time a rapid and complete convalescer ce. She informed me that since September 1884 she has had two miscarriages. I may say that on this present occasion my friend Dr. McDougall had been engaged to attend, and it was in his absence that I was summoned so hastily. I satisfied myself that there was no haemorrhage, and moderate pres- sure on the fundus, which was well contracted, soon expelled the placenta. The third stage was quite normal, as was also the placenta itself, and no hseraorrhage followed ; indeed, she lost less blood than usual on such occasions. I left her after careful bandaging, and she ex- pressed herself as quite comfortable and in no pain. This was at 2.30 p.m. I sent a message to Dr. McDougall to see his patient on his re- turn home. Within an hour a message reached me that Mrs. P was in great pain. I sent her a morphia powder to soothe her if pain con- tinued. At 5 p.m. I was sent for hurriedly, the message stating that she was still suffering severely. On my arrival I found that Dr. McDougall had been there, and had given her a morphia powder, and that she had also taken my half grain, but had experienced no relief. I was struck by her appearance, which was that of acute suffering and of fear. She was blanched , her features pinched, and she complained of an agonizing pain, not in the lower abdominal region as I had supposed, but in the lowest I segment of the rectum, and as she expressed it, she wanted to {ass something and could not, though she was straining quite vigorously. I at once instituted an examination, and to my horror, on passing my finger into the vagina at once encountered a firui, elastic, tense tumor filling the pelvis almost completely. The vagina was flattened towards the p ibes, and I could not reach the os ut ri. On rectal examination the same tumor was felt through its walls, tl e rectum being also fl ittened, not directly back- wards, but rather towards the right side of the pelvis, and the sensation to the finger was the same as per vaginam, viz.: firm, tense and elastic. The hand placed on the abdomen, the fundus was felt pushed high above the pubes, and to gain slight comfort the bandage had been unpinned by the nurse half-way up. The bowels had been well cleared the morning of the labor by castor oil, and she had passed water freely be- fore the onset of labor, and during the paius as well. I felt I had to deal with a pelvic hsemi- tocele, and its situation, to my mind, forbade the intraperitoneal variety. I was not alarmed as to the haemorrhage itself, because I knew that in all likelihood it would be controlled by the pressure exerted through the pelvic viscera and cellular tissue, and, besides, her appearance rather suggested a condition of fear and nervous shock than the blanching due to excessive loss of blood. Her lips were not completely anaemic, bnd her pulse was fairly good. The flattening of the vagina was such that I feared, perhaps, the lochia would be obstructed. Pain, then, was the chief symptom I had to deal with, and, as I say, it was referred entirely to the lower rectal region and about the coccyx. Dr. McD. not being expected home for 6 or 7 hours, I administered a full hypodermic dose of morphia and atropia into the coccygeal region, which soon gave complete relief, the pain not returning till about 5 or 6 a.m. the day following. About 9 a.m., 3rd March, Dr. McD. and I visited her. The symptoms had not changed. The intense pain had returned in the rectum with the de.^ire to evacuate something ; her appearance, however, had greatly improved since the pre- ceding day. The lochia had been normal in quantity and quality. She had not passed water, so we catheterized her and again gave a hypodermic in the coccygeal region. The local pelvic condition was unaltered, but as far as I could judge the haemorrhage had not in- creased, as the parts all bore about the same relative position as the afternoon before, and the tumor gave the same sensat'on to the touch. Dr. McD. agreed with the diagnosis, and the woman being fairly comfortable when the pain was in abeyance, and the lochia being properly established we determined to let well alone, giving a very guarded prognosis. That even- ing she was seen also by Dr. H. P. Wright, who agreed wi' ti the diagnosis and course we proposed to pursue. Another hypodermic was then given. On the morning of the 5th, at the ubual visit, there was a subsidence of the symptoms, the woman expressed herself as feeling comfortable, was in no pain and had lost all sense of dis- tress. She said that very early in the morning she felt as if something had given way, to her great relief, and on examination it was found that nature had done what art feared to inter- fere with, and that the cellular tissue about the ischiorectal fossa had given way and the blood had forced its way down be.ieath the perineal fascia and had extravasated between the layers of cellular tissue and fascia under the skin of the inside of the left thigh and over the buttock to the outside of the hip, and no doubt also between the layers of gluteal muscles, as the left buttock felt firm and resisting in the region of the large ecchymosis. On vaginal examination there could still be felt a soft boggy swelling, quite unlike the former firm, elastic, tense one, and it was no doubt the melancholy, or rather happy, remains of the pelvic hsematoma. No untoward symptoms occurred to mar the con- valescence which was rapid and in all respects normal, and the patient was out of bed in a fortnight. The remains of the tumor were gradually and rapidly absorbed, and on the 3nd of May I had the privilege of examining her and found no trace whatever of her former tumor. She was strong and well and her appearance did not belie her, and she was pre- paring to leave town for the Eastern Townships to earn a holiday. Remarks. — Now, in considering this case, to me a most interesting one, I believe it is almost unique, though the condition, as I remarked before, is referred to casually by several authors. It is so by Meadows in his work on Midwifery, yet writing in the Lancet of Nov. 15ih, 1873, ho says he never yet met with a case of pelvic hsematocele or thrombus where the blood was effused* in the cellular tissue of the pelvis outside the peritoneum ; and again he says, " In a certain number of cases, but they are in my experience very rare, the hsemorrhage occurs in connection with pregnancy, or rather with delivery, either at term or more commonly prematurely, especially during the earlier months." This must, of course, refer to the usual intraperitoneal variety when taken in connection with his former statement. I mentioned before some authors who r»-fer to somewhat similar cases, but I have not access to the details. While speaking of the causes, Thomas says that they are predisposing, because it is rare to meet with the disease in a woman who has previously been in perfect health. In the case under discussion no bad condition of health was observable, though pregnancy was here the predisposing cause. Speaking of 8 the exciting causes, Thomas coincides with the other authors who have dealt with this subject, and the only one that would seem to cover our present case is given by him as " violent efforts." The most recent article is that bv Law&on Tait, and he may be quoted freely as probably the highest authority on this sub- ject, and certainly the one whose writings are the most lucid and most free from confusion and mystery. The article I refer to is the Ingleby Lecture of last September, given in full in the Lancet of October 30th, 1886. Speaking of extra-peritoneal hseraatocele, he says there are only two causes known to him — one very common, viz., a sudden arrest of a metrostaxis, and this may be that observed after abdominal operations, or ordinary menstruation ; and the other very rare, viz., rupture of a tubal pregnancy about the 12th week. In these cases the hsematocele takes place into the broad ligament. As to the cause of the haemorrhage in the case we are considering, of course it is obscure, and fortunately a post-mortem ex- amination did not step in in this case to throw light on th:< question, but it was in all pro- bability due to rupture of one of the veins of the plexus about the cervix and upper part of the vagina. It is easy to understand that during pregnancy these veins are apt to become gorged and even varicose, just in the same way as occurs in the labia and th*gh an! even the % 1 \ iM l iteiW.'l li.. f !ie It, ir it v y )- e d 1 leg, and in this present case I incline to the opinion that the cause of the ruptured vein was the almost precipitate labor, for such it was at its terminp^^'^^n, and the violent expulsive eflfort of the woman just as the head reached the perineum caused the vein to tear. It certainly did not take place prior to delivery, because such a tumor would have prevented anything like a rapid ending to a labor, and besides, when I delivered the placenta I would most certainly have been struck with such an abnormal con- dition even if the patient had not complained of j)ain, or of anything unusual in her sensations, and no such hsematocele could occur without attracting her attention as to something un- usual having happened. As a matter of fact, no word of complaint came from her up to the time I left the house, which was about half an hour after the delivery. DISCUSSION. A spirited discussion followed, and the various points of the paper were taken up. Dr. Rosebrugh mentioned a case under his care, but its characters were rather those of intra- peritoneal hematocele, the effusion being into Douglas' cul-de sac. Some of the other members having spoken on the subject, Dr. V. H. Moore, of Btockville, related an interesting case in his practice which appeared quite similar to Dr. Powell's case. It came on almost immediately 10' after labor in the cellular tissue post vaginam. Great pain ':vas complained of, and the patient was in a dangerous state, so in consultation with Dr. Pickup it was decided to aspirate through the vaginal wall. This was done, the tumor emptied in that way, and the woman made a good recovery. Dr. Powell replied to the various speakers, defending his position and his arguments keenly. He congratulated Dr. Moore on his successful issue, but took exception to his bold and heroic surgery in this particular case, holding that in such cases we were not justified in interfering unless there were decided indications, as, for example, chills, rise of temperature, or any symptoms pointing to suppuration in the blood tumor, or that it was the cause of septiccemic symptoms, inasmuch as if left to nature the blood would surely be absorbed. He thought it especially hazardous to puncture through the vaginal wall after a recent delivery, and would have preferred the rectum, if anywhere, but he must say that when it was once decided to interfere actively, the use of the aspirator by Dr. Moore left little ground for objection.