[Reprinted from the American Gynaecological and Obstetrical Journal 
for March, 1895.] 
SOME PRACTICAL POINTS ON THE DIAGNOSIS AND 
TREATMENT OF PELVIC HEMATOCELE 
WITH REPORT OF A CASE.* 
By W. E. Colgrove, M. D., Horseheads, New York. 
The causes which lead to the production of pelvic hsematocele are 
well known to be rupture of any of the pelvic blood-vessels, sudden 
cessation of the menses, rupture of tubal or other forms of extra-uter- 
ine pregnancy, rupture of aneurisms of blood-vessels of the broad 
ligaments, reflux of blood from the uterus or Fallopian tubes or any 
general haemorrhagic diathesis of the patient or in some instances 
well-defined cases of purpura or transudation from the smaller blood- 
vessels in or around the pelvic cavity, so that in this brief paper I 
need not take up the time in discussing them, also that there are two 
general varieties, the intraperitoneal and the subperitoneal of which 
the intraperitoneal is by far the more dangerous. I beg, however, to 
differ with Thomas that the subperitoneal variety is not dangerous, 
in my judgment any amount of blood accumulated in the pelvic cavity 
is to be regarded with suspicion. 
With a brief report of a case I will try to bring out as well as time 
will permit some of the more important points in the diagnosis and 
treatment. I was called to see Mrs. S. aged thirty-five years on Au- 
gust 15th ; found her to be a plethoric woman of rather nervous tem- 
perament. She had been driving three or four days before and 
jumped from her carriage to the sidewalk. She felt a sudden pain in 
the pelvic region with faintness and some degree of shock, was as- 
sisted into a neighboring drugstore and after a short time resumed 
her journey home. A physician was called who pronounced it an 
acute retroflexion of the uterus and vainly attempted its reduction, 
the effort being attended with great pain and faintness and some vom- 
iting. On the next day another attempt was made to replace the sup- 
posedly retroflexed organ without success, on the fourth day I saw 
* Read before the New York State Medical Society, February 5, 1895. 
Copyright, 1895, by J. D. Emmet and A. H. Bickmaster. 2 
W. E. Col grove, M. D. 
her, and after learning the history of the case made an examination 
per vaginam. The os uteri was of normal size and shape and not in 
the position usually assumed by the os of a retroflexed uterus. On 
passing the finger into the posterior cul-de-sac of Douglas a round 
hard tumor not unlike the occiput of a foetus was felt. No fluctua- 
tion could be detected, the mass was apparently fixed and immovable, 
very tender to the touch, a flexible uterine sound was introduced and 
the curve of the uterine canal found to be nearly normal. Examina- 
tion per rectum was attempted but as it was impacted with faecal mat- 
ter an enema was given and the bowel cleared. The finger revealed 
the tumor, hard, round, posterior to the uterus completely obstructing 
the bowel. '1'here had been no symptoms of extra-uterine pregnancy 
and as the temperature had risen to 102° and symptoms of general 
peritonitis could be detected, I diagnosed pelvic haematocele of sub- 
peritoneal variety which had existed so long that absorption of the 
blood serum had taken place, and we now had to deal only with the 
firm blood clot already partly decomposed which had dissected up 
the peritonaeum, which membrane now formed the roof or upper wall 
of the tumor. Calling in an assistant who kindly gave an anaesthetic 
and with the aid of a large sized duck-bill speculum holding the roof 
of the vaginal wall well up I made an incision an inch and a half in 
length in the post-cervical region and with a dull curette and a small 
placental forceps succeeded in clearing the cavity of the mass of 
blood clots which gave rise to quite a perceptible odor. The cavity 
was now thoroughly irrigated with solution of bichloride (1 to 4,000), 
a drainage-tube introduced, and the wound closed with interrupted 
suture of large size catgut, the vagina carefully and loosely packed 
with iodoform gauze which was changed twice the first day and 
once a day thereafter. The temperature fell to ioo° in six hours and 
to normal in twenty-four hours, the drainage-tube was removed on 
the second day and perfect recovery took place in ten days. 
I would especially call your attention to the character of the tumor, 
usually they are fluctuating, this one was hard and fibrous in char- 
acter, the diagnosis should be made carefully. To diagnose a retro- 
flexed uterus in a case like the one given is humiliating in the extreme. 
Diagnosis by exclusion is a very good way to arrive at a correct con- 
clusion. The uterine sound should in my judgment always be used 
before making pressure necessary to reduce a misplaced uterus ex- 
cepting in cases where pregnancy is certain or suspected. If the 
bowels are obstructed the rectal tube attached to the fountain syringe 
should be passed above the obstruction if possible and the contents Diagnosis and Treatment of Pelvic Hcematocele. 
3 
drained away in a semi-fluid state thereby reducing the pressure and 
aiding in relieving the danger of rupture into the abdominal or peri- 
toneal cavity. The existence of aneurysms and diseased blood-vessels 
should be carefully inquired into, also as to whether the menses occur 
regularly and without unnatural disturbances likely to occur in acutely 
misplaced uteri. The questions of extra-uterine pregnancy should 
receive careful attention. 
Surgical interference is in my opinion authorized and necessary 
when the amount of blood being poured out demands ligation of 
blood-vessels ruptured or when the blood clot becomes practically a 
foreign body and threatened septicaemia appears thereby proving that 
Nature is unable to absorb the product of the haemorrhage. Pressure 
should never be made in any case against a tumor in the cul-de-sac of 
Douglas to replace a retroflexed uterus until all doubt of its being an 
abscess or haematocele have been removed and never as an aid to 
diagnosis with any degree of force. 
The tumor always becomes harder and more tense on the third or 
fourth day. The malady may be almost certainly recognized by its 
sudden onset whereas ovarian cyst, perimetritis with abscess fibroids 
and extra-uterine pregnancy, etc., are of slower origin. 
The small aspirating needle is of value in the early stages but will 
fail to give positive signs after the serum has been absorbed. I do 
not regard the vaginal incision as dangerous and much prefer it to 
abdominal section, although in some cases the latter will be found 
necessary if ligation is to be resorted to. In a majority of cases the 
blood clot causes but a small amount of trouble and is removed by 
absorption. 
Should the patient be seen early hypodermic injections of ergot 
and caffeine may be given with success. The patient should be kept 
flat on the back with head but slightly raised. The predisposition to 
haematocele is most marked during the period of ovarian excitement 
and menstrual occurrence. 
Compresses and bandages applied to the abdomen are of service 
both in allaying the haemorrhage and causing absorption after the 
bleeding has ceased.