A Case of Combined Pelvic Hæmatoma and Pelvic Abscess fileA CASE OF COMBINED PELVIC HEMATOMA AND...

A CASE OF COMBINED PELVIC HEMATOMA AND PELVIC ABSCESS.

By DAYID B. SMITH, M.D., Officiating Obstetric-Phisician, Medical College IIos-

tital, Calcutta; and Lecturer on Midwifery.

Me. PniisiDENT,*?I desire to engage the attention of the

Society this evening, for a short time, with a few remarks on two diseases which are, in certain respects, allied each to the

other, and both of which are of extreme Surgical interest. Instead of writing in an essayistic manner on the subject, I

propose to take, as the text of my observations, a single case

from practice, which is illustrative of both the conditions I

have alluded to.

My case is one of pelvic abscess, co-exi&tent with that affec- tion which has been culled by French writers retro-uterine

hematocele, and by certain high English authorities pelvic hematoma. The patient was a native female, a Bengalee, of the Ahoorie caste, age 2G, by name Bhahbo. She was ad-

mitted into the Midwifery ward of the College Hospital on the 6th November, 1865 ; and I may here anticipate the description of the case, by mentioning that she was discharged, cured, on

the 21st December, i. e., one month and fifteen days from the

date of her admission. The patient was transferred from the first physician's ward, and it was at the request of Dr. Francis

* Originally read at the Bengal Branch, British Medical Association.

that I first saw her. She was then in great distress, with a hot skin and rapid pulse. On external abdominal examination, a

large tumour was discovered, extending as high as the gravid uterus at the end of the sixth month. It was painful on pressure, firm and dull on percussion. No actual fluctuation could be made out anteriorly. She stated that she had one child, 11 years ago, which died four years later ; about that time, too, she lost, her husband ; she first menstruated at 13 years of age, and since then, as a rule, she has always been regular. She had, however, suffered a good deal from fever about five years ago, from which time she had never been altogether strong. Nine

days before her admission into hospital her catamenia came on with great pain, in the region of the uterus, and the dis-

charge continued for seven days. Before it ceased, she noticed a swelling forming in the left iliac region, which, within a week, extended to the size of the tumour above described. At first sight on casual inspection one might have supposed that the woman was six months gone in pregnancy, but a care- ful analysis of lier condition soon dispelled such an idea. The

stethoscope was employed, but no bruit, uterine or placental, could be heard. On vaginal examination, a swelling was

detected posteriorly. The uterus was immensely pushed up, so as to be quite beyond the reach of the finger. After consi- derable difficulty a uterine sound was passed into it, and the uterus itself was found unimpregnated and, though displaced, of natural size. On instituting an examination, by what Dr. Tilt calls " double touch," i. e., with a finger in the rectum and the thumb of the same hand in the vagina, a considerable

swelling was detected. I ought to have mentioned that for about a week the patient had been suffering daiiy from fever, preceded by rigors; the paroxysm commencing regularly at 10 a. m. She had much pain all about the pelvis, the loins, and down the thigh. She was altogether in a very anxious state indeed. On the following day, after she had been somewhat soothed by continuous fomentation, by tepid vaginal injections, and by the administration of morphia, she was again examined as before. I then diagnosed the case as one of pelvic abscess, the result of pelvic cellulitis. Fluctuation was to be felt between the vagina and rectum. At that part I made an incision through the posterior wall of the vagina with a small tenotomy knife. Through the opening thus made there escaped no pits, but about six onnccs of a pinkish fluid, evidently serum and blood. It was limpid and clear, and there were no coagula. The result of this operation was that the great bulk of the tumour remained as before, although it was slightly collapsed over the left iliac fossa. The fore-finger, when passed through the inci- sion, entered a tolerable sized chamber or loculament thoroughly emptied of its contents. The patient suffered a good deal of pain after the operation, which extended to the right iliac region. The skin was warm and dry; the pulse 120, small, and weak. The stomach irritable. Little or no dis-

charge came from the opening after the first operation. On the following day she was no better. Another examination was made ; and on account of the urgency of her symptoms, another incision was made considerably deeper in the pelvis than the first, and in fact through the fascia or membrane which bounded the chamber or loculament before described. The result of this incision was the evacuation of about

eight ounces of bloorl and serum as before ; still no pvs escaped. The tumour now somewhat collapsed over the right iliac fossa, but still the bulk of the tumour remained almost as large as ever, extending from the pubis to the umbilicus. The finger now passed into a second chamber, which had also been quite emptied of its contents, but the roof of which could not be reached. After the second operation, she suffered much pain over the right iliac region. A blister was applied over the part, the morphia was continued every four hours, and she had full diet.

On the following day she had no fever j the blister had great- ly relieved the local pain. The pulse came down to 108, but it was still 6mall and weak. She was troubled with great irri-

tability of stomach, which was partially relieved by efferves- cing draughts, chloroform taken internally, ice &c. After this she improved ; the bowels were kept open by tepid enemata ; the skin became more cool, but the pulse remained at about 100; the tongue was red and dry in the centre, and she was restless. The tumour remained still the same. There was a very slight sanious discharge from the vagina through the

opening that had been made. The tumour was continuously poulticed, and lint was kept in the wound. She had good diet, two measures of port, and five grains of quinine three times a day,

June 1, 1866.] CASE OF HEMATOMA AND PELVIC ABSCESS.?BY DR. D. B. SMITH. 151

So matters continued for four or five days, when the fever began to return and the pulse again rose to 108. On the 16tii November, i. e., seven days after the last opening was made, the patient, wliilt at stool, passed a large clot of blood from the vagina and about one ounce of pus from the rectum. She was then in an

alarming state, with great heat of skin, rigors, and pulse at 120. I again carefully examined her, and after a good deal of difficulty succeeded in passing the right fore-finger through the two open- ings already made, and even beyond them. On pushing the

finger as deep as possible, I succeeded in doing what I had failed in doing before, viz., feeling a further projection of the tumour downwards. When I felt this I was much gratified, because I was quite at a loss in what direction I should next

explore for the tumour, which still remained encysted and very nearly as large as ever. From the very first, since the patient's admission, I had declared my conviction that there was a pelvic abscess somewhere. I had arrived at this conclusion from a careful consideration of all the circumstances of the case, from the woman's hectic condition, and from a general impres- sion, the grounds for which I could scarcely define iu my own mind. Hitherto my diagnosis had proved to be inaccurate, in- asmuch as nothing but a pelvic hajmatoma had been discovered. The moment I felt a new fluctuating projection, I determined

to thrust the point of a narrow-bladed knife into it ; and whilst I was preparing to do this, and feeling where it could best be done, the membranous wall in contact with the tip of my finger gave way, and, much to my satisfaction, more than a pint of pus of a very foetid odour escaped. I ought here to

mention that it could not be ascertained where the open- ing into the rectum was situated, through which an ounce of pus had escaped. Immediately after tho evacuation of this large quantity of pus, the tumour almost entirely subsided. The patient became very weak, but she was kept up with brandy and nourishment. On the following morning a most satisfactory change had occurred in her condition. She had slept well; the skin was cool ; the tongue not so dry as before, and the pulse 84 and regular. From this date she continued to improve. The tumour became more and more reduced in size, \mtil it altogether disappeared. The discharge gradually diminished in quantity ; and, with the exception of two or three attacks of fever and a threatening of dysentery, which, however, yielded to treatment, she progressed in a most satisfactory manner. Tonics, stimulants, and plenty of nourish- ment were administered, and on the 21st of December the wound in the vagina might be said to be closed. The tumour had disappeared, the discharge had all but ceased, she had

gained strength, was free of all pain, and she was permitted, at her own request, to leave the hospital (cured) on the 21st of December.

Remaeks.

It appears to me most important that all such cases as the above should be carefully recorded. Twenty years a20, even in Europe, pelvic hematocele was almost completely ignored. It is true the ancients have left indications of their knowledge of such a disease, but it is only since Bernutz, Nelaton, Voisin, Recamier, and Velpeau in France; Tilt, West, Grail y Hewitt, Dolierty and Churchill in England ; Simpson and Matthews Duncan in Scotland ; and M'Clintock in Ireland, have carefully recorded their clinical observations of the disease, that real

practical interest has attached to it. Bernutz was the first modern writer on the subject in France ; he described the affec- tion under a variety of names; and Tilt, in 1853, in his work on the Diseases of Women," devoted his last chapter to the consideration of " the pathology and treatment of sanguineous pelvic tumours."

I will not occupy the time of the Society by speaking in general terms of this complaint, but I will make such remarks on the case at issue as will be sufficient to indicate the opinions I hold with regard to the proper practice iu such cases. In

the first place, then, it ought to be remembered that pelvic abscess in the puerperal or non-puerperal female is most gener- ally the result of pelvic cellulitis ; so that thoroughly to under- stand the former condition, we ought to have a perfect appre- ciation of the pathology of what is sometimes called oedema

of the cellular tissue : indeed, pelvic cellulitis and pelvic abscess are, in the majority of cases, but different stages of one lesion.

I will only here remark that it appears to me most extraordi-

nary that so very little should have been written in India

about this pelvic cellulitis. It is true practitioners in India

know what it is, and ever and anon they discuss the subject with each other, as indeed they are obliged to do from the

frequency of the disease in practice. We have also from time to time notes on the subject read at our Medical Societies ; but, as far as I am aware, no systematic memoir or paper has ever been published on the subject in India. This is truly extra- ordinary when we think how commonly it engages our attention

by the bedside. Within the last year, in this hospital, and out of it, I myself must have seen at least fifty cases, either simple, or complicated by the subsequent formation of abscess. The little firm almond-shaped swelling in the vicinity of one broad ligament or the other, most generally on the left side, or the firm little tumour felt through one or other of the

vaginal walls, at once attracts attention to a condition of parts which it seems very extraordinary that our forefathers did not ac- curately describe. But I must leave this subject for the present and return to the casein hand. The first thing, perhaps, to be said of it is that it might possibly have been mistaken for a case of extra-uterine gestation. The symptoms, however, set in rapidly ; there was no enlargement of the breasts, no darken- ing of the areolae, and no foetal heart could be heard ; the uterus was little, if at all, enlarged ; there had been no labour

pains; the tumour was not one-sided, but extended from the hypogastric region to the umbilicus. The tumour could

scarcely be mistaken for ail ovarian cyst or fibroid tumour, although it may here be noted that so eminent a surgeon as Malgaigne once mistook a pelvic hematocele for a fibrous tumour of the uterus. He determined to enucleate it; and with this object he divided the neck of the womb. Two pounds of coagulated blood escaped, and the patient died from excessive haemorrhage. The cause of pelvic liaematocele is very obscure, and it still

involves a debated point. The French school for the most part believe it to be always intra-peritoneal, and the result of the rupture of ovarian vessels, whilst the possibility of the exist- ence of the extra-peritoneal variety is more commonly allowed by English writers, and this either from hemorrhage at the menstrual period, from violent efforts shortly after menstruation or delivery, or from a varicose development of the sub-peri- toneal veins. Bernutz went the length of saying that an extra- peritoneal haemorrhage was not a genuine hematocele, but simply a thrombus. In my opinion, it is to be regretted that he endeavoured to institute any such distinction, and the voice of subsequent observers, particularly in England, is decidedly against such a nosology. I believe the present case to have been one of extra-peritoneal hematocele ; this partly because the swelling extended betvvcen the rectum and the vagina, almost to the outlet of the latter, and again because I feel tolerably confi- dent that I did not, in making my first incision, divide the peri- toneum. I might here remark that the fluid which escaped was almost exactly like that described by Dr. Matthews Duncan in certain cases which he has recorded in the Edinburgh Medical Journal for November 1862. It was a syrup-like blood. Whe- ther in this case the pelvic abscess was intra or extra-peritoneal, it is much more difficult to say ; I am inclined to think it was the latter, although the existence of a large quantity of fluid in the posterior peritoneal " cul de sac," commonly called

Douglas' fossa, would help to simplify the explanation of the extremely retroverted condition of the uterus which we had in

this case. Whether this abscess was the result of secondary inflammation, lighted up by the presence of the blood effusion, or whether the hematocele itself suppurated, as it is sometimes

known to do, it is extremely hard to determine ; indeed, these

two points appear to me the most difficult in connection with this case, viz.?1st, whether it was possible that the hematocele was extra-peritoneal, and the abscess intra-peritoneal ; and 2nd, what was the exact relation of the one lesion to the other in its

nature and order of production. I lean to the idea that both were extra-peritoneal, and that the abscess was encysted in fal>o membranes, whilst the hsomatoma was diffused in the cellular

texture behind and on both sides of the womb. To such tumours

as surround the uterus, Bernutz has applied the term" peri-uterine hematocele." With regard to diagnosis in this case, I was correct, inasmuch as there was a pelvic abscess, the presence of which I

suspected throughout ; I failed, however, to diagnose hematoma. In favour of its existence was the suddenness of its occurrence, the co-existence of menstruation, &c.; against it was the presence of fever, the painfulness of the tumour, the hectic condition of

the patient. I may hero mention that when the syrup-like blood escaped, I did not detect its having the peculiar odour

of faded and slightly decomposing flowers, as described by Dr. Matthews Duncan in his paper already alluded to.

I feel strongly inclined to differ from Bernutz in the stress which he lays on peritonitis as the cause and explanation of

THE INDIAN MEDICAL GAZETTE. [June 1, 1866.

"] elvic cellulitis. I am convinced that wc very often meet with the latter condition, without any sign of the former. He even

goes so far as to deny the possibility of pelvic cellulitis (in "any position, except between the folds of the broad ligament), but as a result of peritonitis. This has always seemed to

me to imply an error in clinical observation. I agree with

West when he writes, " it is quite an exceptional occurrence

for severe puerperal peritonitis to precede the inflammation of the uterine cellular tissue" (p. 425). As regards the fre- quency of cellulitis leading on to suppuration, Monsieur

Gallard, in an essay published ten years ago, "Du Phlegmon Peri-uterine," believes it to be very rare, except in puerperal cases ; such does not coincide with my experience. At present I have two cases of the kind in my ward, and I have recollec- tion of a vast number of others; although I am prepared to

allow that suppuration is more common and more fatal in

puerperal than in non-puerperal cases. In this country, where wc do not, as a rule, see such non-puerperal cases in their

early stages, it is very common indeed to find that they have run on to formation of abscess. I have no recollection of any single case of this kind, within my own experience, proving fatal, although I remember a good many sad and fatal puer-

peral cases, the result of tedious or instrumental delivery. M'Clintock mentions that out of 70 cases of puerperal pelvic cellulitis, only two proved fatal. I am sorry to say my experience is much more unfavorable than this. A very interesting account of a case of pelvic hematocele

is to be found in the third volume of the "Obstetrical Transac- tions" by l)r. Henry Madge; it proved fatal and was compli- cated with phlegmasia dolens. I have never met with a

case of this sort. The case I have described is interesting as disproving the opinion of Bernutz, that hematocele is only met with in connection with pregnancy or the puerperal state. It is also unusual to find so large an abscess formed in so

short a time. Lastly, a few words about the treatment employ- ed. If there is any reasonable hope for the occurrence of resolution of an abscess or a htematoma, I should most

certainly never think of using a knife or a trocar. But in

cases where resolution is unlikely to occur, where the con-

stitutional symptoms are urgent, as in this case they were, and where there is any indication of pointing at any part of the tumour, particularly if this occurs between the rectum and

vagina, I should never hesitate to do again what I did in this case, and what I have done in a good many others, viz., to make an artificial opening where it seems most advisable to do so. I am well aware that many excellent authors have written strongly against the practice of anticipating nature by making incisions or by giving exit to blood, to serum, or

to pus by artificial means. I bave much respect for such

opinions ; at the same time I cannot but think it a bad rule for universal guidance, to maintain the necessity for absolute non- interference in all cases. I can by no means agree with Becquerel when he says,

" the abscess is never to be opened, even though its apparent pointing in one situation should seem to invite interfer- ence." Matthews Duncan, Professor Braun, and Professor Simpson all think well of the practice of making the necessary openings in suitable cases. The latter authority cites a. most instructive case in point. He saw a patient with Dr. Ziegler, in whom pelvic abscess threatened to burst spontaneously ; they thought that it would find an exit For itself either into the rectum or into the vagina. Within 24 hours the abscess did burst, but

. it was into the peritoneum ; the patient died in consequence. A

timely opening would in all probability have saved her life. I will not now extend my remarks, but I shall rest satisfied if I have met the wishes of the members of the Society, by bring- ing before them the subject of pelvic htematoccle, "than which," it has been said by a late President of the Obstetrical Society, "there is none of greater interest and novelty within the range of Uterine Pathology."