THREE CASES OF PELVIC HEMATOMA. 
BY 
WILLIAM GARDNER, M.D., 
Professor of Gynaecology in McGill University ; Gynaecologist to the Royal Victoria 
Hospital ; Consulting Gynaecologist to the Montreal General Hospital. 
The Pathological Reports by C. F. Martin, M.D. 
Assistant Physician to the Royal Victoria Hospital ; Lecturer on Pathology in 
McGill University. 
{Reprinted from the Montreal Medical Journal, January, 1897.) THREE CASES OF PELVIC HEMATOMA. 
William Gardner, M.D., 
BY 
Professor of Gynaecology in McGill University ; Gynaecologist to the Royal Victoria 
Hospital; consulting Gynaecologist to the Montreal General Hospital. 
The Pathological Reports, by C. F. Martin, M.H., 
Assistant Physician to the Royal Victoria Hospital ; Lecturer on Pathology in 
McGill University. 
The association of pelvic hseraatocele with cancer and tuberculosis 
of the genital organs of women must be exceedingly rare. In none 
of the recent works on gynaecology 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 Priestley 
in Clifford Abbott and Playfair’s system of gynaecology (1896). The 
same remark applies to cancer of the uterine appendages as treated 
in each of the works mentioned. This is certainly remarkable, espe- 
cially as regards tuberculosis now known to be 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 haematocele 
may be associated with these diseases is proved beyond a doubt by 
the two cases lam 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 diseases 
as they affect other organs or structures of the human body is surely 
a cause for wonder that effusion of blood is not frequently caused by 
the much more frequent tuberculosis of the and especially the Fallopian tubes. By most authors and operators pelvic hsematocele is 
in the enormous majority of all cases held to be due to ruptured ectopic 
gestation. The evidence on which this opinion is based does not 
always bear close scrutiny. The necessary evidence of the presence 
of a foetus or chorionic villi or other decidual elements is not always 
to be had even when carefully sought for. 
Extra-uterine Pregnancy.—Mrs. S., aged 35, was seen in consulta- 
tion with her ordinary medical attendant, Dr. W. F. Hamilton. She 
has been married twelve years and is the mother of six children to 
full term. She had a miscarriage in January, 1896, for which an 
anaesthetic was given to remove some portion of the products of con- 
ception. In May she had regained her health and continued well till 
August. The last normal menstrual period occurred about the sth 
of August, 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- 
charges of blood at irregular short intervals, there were also paroxysms 
of pelvic 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 elevation of temperature. When I first saw her about 
the middle of October, the uterus was somewhat enlarged and soft, 
and to its left and adherent to it there lay an elastic fixed mass; this 
rather rapidly increased in size during the three weeks I occasionally 
saw her before operation. At the time of operation there was a dis- 
tinct abdominal tumour. The patient was admitted to my private 
hospital on the 11th of November. 
Operation.—The uterus was dilated sufficiently to admit the finger 
to the fundus and the cavity found to be empty except for a general 
lining with decidual membrane; it measured five inches in depth. 
Abdominal Section.—No free blood or fluid of any kind in the 
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 foetus and placenta, 
apparently detached, but lying in the sac described; part of the wall 
of the sac was formed by the posterior wall of the uterus. After the 
removal of the foetus and placenta the rest of the sac was easily 
separated and brought through the abdominal incision, when it could 
be as easily ligated as an ordinary empty ovarian cyst. No bleeding 
of any consequence followed the separation of the sac, so that the 
abdomen could be closed without drainage. Recovery has been abso- 
lutely uneventful. 3 
The specimens presented, illustrate one of the most unusual varieties 
of ectopic gestation, and clearly show from a careful study of the 
relation of the parts how intimately associated may be the ovary 
and tube 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. Win. Gardner on November 11th, 
1896, and on gross examination was seen to consist of four distinct 
portions : 
1 A male foetus 12.2 cm. long with 3 cm. of cord attached. 
2. A placenta 15x6 x 2 cm. in dimensions with a portion of cord 10 
cm. long adherent to it. 
3. A containing sac of about 12 cm. in greatest diameter. Its wall 
was of varying thickness, densest at its outer extremity (i.e., the part 
furthest from the uterus) where there was seen a flattened out mass 
of tissue of 1| cm. in thickness, and containing a few narrow, elongated 
spaces filled with clear, thin fluid (probably compressed ovarian cyst). 
This mass was intimately associated 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. Microscopic 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 tube was seen 
coursing for several cm. along the superior portion of the sac, and 
terminating abruptly in the sac itself as a sudden dilatation, evidently 
the 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 and 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 inflammatory 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 overlying Fallopian tube. 
In the first place, specimens were examined from the outer thick 
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 ovary itself was, 
to a large extent, markedly fibroid. 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 4 
of the epithelium and numerous fimbriae projecting on all sides. 
Between the tube itself and the superimposed ovary no peritoneal coat 
could be found, the prolonged stretching, with its accompanying hyper- 
plasia of connective tissue, evidently obliterating all such distinctions. 
The ovary then, as these sections clearly showed, was flattened out 
upon the sacculated tube, and helped to form a part 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, thinned-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 and what has 
1 7 O 
been regarded by Hubrecht, Webster and others, as remains of foetal 
epiblast. These cells or collections of cells are massed together, their 
nuclei staining deeply, as in the case of all embryonic tissue, and their 
protoplasm absorbing a diffuse eosine stain. They occupy what seem 
to be indifferent sites in various portions of the placental tissue. 
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 denied, 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 bases his views on a variety of different 
methods of examination of a large quantity 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 
regarded as abdominal or ovarian were really after all but modifica- 
tions of the tubal form ; cases that might under ordinary conditions 
have been described 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 
consider 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 most authorities that the ordinary uterine 
and tubal mucosae play, but a very minor role in the occurrence of preg- 
nancy, and that the subepithelial 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 occurrence of 
an abdominal pregnancy, arguing that the peritoneum itself contains 
tissue quite analogous to that beneath the uterine mucous membrane 5 
Were there nothing further required to induce this pregnancy there 
would be no reason for supposing it to occur almost anywhere in the 
peritoneal cavity, but Webster has shown that there is good reason 
for believing that some special cellular action must probably occur to 
induce the process of fecundation. He argues that wherever preg- 
nancy occurs a genetic decidual membrane forms, associated probably 
in some way with nerve influence, and he further urges that this can 
take place only along the parts which take their origin from the Mul- 
lerian ducts. Hence ovarian and abdominal pregnancies would be 
impossible, and no one has yet proved a very early ovarian pregnancy 
to exist. 
That some nervous influence is associated with the condition would 
seem to be true from the discovery made by him in a case of ectopic 
gestation where the nonparturient tube had likewise a definite decidua 
upon its inner surface. 
Some months ago I had occasion to examine some specimens from 
a case operated on by Dr. Alio way, in which there had been a double 
tubal hemorrhage, arousing the suspicion of a bilateral ectopic gesta- 
tion. In one of the tubes I 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 Medical Journal there 
is a synopsis of an article from Chrobak’s clinic in Vienna, referring 
to a case of ovarian pregnancy, Avhich, 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 Hoematoma Complicating Malignant Disease.—Mrs. J. 
McC., aged 39 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 
constant pain in the right inguinal region radiating towards the 
umbilicus with a sensation of dragging downwards of the navel. The 
patient has had three children and one miscarriage, the last child three 
years ago; the miscarriage seven years ago. Menstruation regular, 
at intervals of three to four weeks, duration three days, quantity 
moderate, no clots. On examination the abdominal wall was lax, with 
a tolerably thick layer of snbcutaneous fat. Strise fairly well marked, 
moderate tenderness in the umbilical region. No descent of either 
kidney. In the hypogastrium immediately above the brim and rising 
quite to the level of the upper surface of the pubes is a firm, rounded, 
smooth and sensitive tumour. Per vaginam ; the cervix is cleft bila- 
terally. granular and everted, the os is patulous 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 firm mass partially movable 
and continuous with the mass felt in the hypogastrium. The sound 
enters three inches and is directed to the right side. There is scarcely 
any mobilitjr of the uterus independent of the mass. 
Operation, July 31st, 1896.—Abdominal Section.—The omentum 
was adherent to a pelvic mass and to the brim of the pelvis. Several 
coils of intestine were also very firmly adherent to the mass. These 
were separated by the scalpel leaving portions of the sac wall attached 
to the gut. The sac lay in the vesico-uterine pouch adherent, but not 
very intimately. It was enucleated and tied off 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 blood and portions of partly decolor- 
ised clot escaped, the oozing from the vesico uterine poucli was 
controlled by pressure and the thermo-cautery. No drainage. Recovery 
speedy and uneventful. Discharged August 26th, 1896. 
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 was 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 loosely held together by a moderate 
amount of fibrous framework. The central portions presented far 
greater disintegration than did the peripheral. The capsule itself 
varied in thickness, the average being 4-6 mm. 7 
Microscopic sections were prepared from various portions of the 
mass. Those taken from the capsule and peripheral portions of the 
tumour, show a fairly dense fibrous tissue containing abundant blood 
pigment in crystals and amorphous granules, and a moderate degree 
of small round celled infiltration. The innermost portions showed a 
small number of epithelial cells arranged in an irregular manner amid 
the fibrous framework. Sections through the more friable portions of 
the growth revealed a tissue consisting almost entirely of epithelium 
and fibrous tissue. The epithelial cells were in parts arranged as 
glandular structures such as are seen in a multilocular ovarian cyst, 
but 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-carcirnona. 
There was in addition abundant necrosis and a large amount of 
hsematoidin. The tube was normal. 
Pathological diagnosis. Adeno-carcimona of the right ovary. Cystic 
left ovary. 
Pelvic Hcematoma Associated with Tuberculosis of the Fallopion 
Tube.—Mrs. L. J., age 34 years, came to the out-patient department 
of the Royal Victoria Hospital on August 14th, 1896, complaining of 
profuse discharges of blood per vaginam, pains in lower portion of 
abdomen and back, and tenderness in the hypogastric and right in- 
guinal regions. Until the present illness patient has always enjoyed 
good health. The family history is phthisical. She has had eight 
children, but no miscarriage ; labours all normal. Recoveries favour- 
able. The last child April 11th, 1895. Menstruation was due on the 
Ist of July, but did not appear till the 4th, continuing till the 14th, 
when it ceased, and the patient began immediately 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. 
Examination.—-Abdominal wall tolerably fat, flabby and somewhat 
pendulous, striae well marked, marked pigmentation from umbilicus 
to pubes. Tenderness in hypogastric, right inguinal and iliac regions. 
No descent of either kidney, no tumour or mass to be felt. 
Per Vaginam.—Skene’s 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, 1896.—Dilatation and Curetting..— 
Result moderate in quantity, endometrium roughish to the curette. 
Gauze packing. 
Abdominal Section.—lntestines adherent to a mass in the true 
pelvis. After separation of some adhesions a cavity containing eight 
to ten ounces of black blood clot was opened and evacuated. In the 
floor of the 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 Bth, 1896, apparently in perfect 
health. 
This specimen which was sent by Prof. Wm. Gardner on August 
19th, 1896, consisted of a large haematoraa—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 enormously distended and thickened 
tube evidently closed at both extremities. Its contents were haemor- 
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, the 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 be looked for rather than otherwise. 
Just as the exudates of tuberculous peritonis and pleurisy are for the 
most part haemorrhagic, so, too, one might expect a similar occurrence 
in the chronic diffuse miliary tuberculosis of the Fallopian tubes.