REPRINTED FROM 
Annals of Gynaecology and 
September, 1890. 
Peritonitis Due to Rupture of an Ovarian Haematoma; 
Laparotomy; Recovery. 
BY 
Dr. H. J. BOLDT, of New York. Peritonitis Due to Rupture of an Ovarian Haematoma; La- 
parotomy; Recovery. 
DR. H. J. BOLDT, OF NEW YORK.1 
Mrs. Emma Lehman came to my 
clinic January 4th, 1890. She was 31 
years of age, had been married ten 
years, and nine years ago was delivered 
of a 7 months' foetus after a long 
labor. Since that time she had suf- 
fered with abdominal trouble, and 
more recently with intense backache. 
The seat of the most severe pain 
was in the left ovarian region. 
There was also complaint of consti- 
pation and very severe dysmenor- 
rhoea. Examination of the patient 
gave the following result: Perinaeum 
intact; vagina capacious; laceration of 
the cervix ; anteflexion of the uterus, 
right ovary and tube in normal posi- 
tion, but somewhat indurated and sen- 
sitive to touch; left ovary and tube 
decidedly enlarged, and so painful to 
the touch that a careful bi-manual 
examination was impossible without 
anaesthesia. 
On January the 8th I was informed 
that on the previous day the patient 
was suddenly seized with violent pain 
in the left ovarian region, and quickly 
lost consciousness. The pain was 
subsequently diffused over the entire 
abdomen, and there were frequent 
spells of vomiting. When received 
into the hospital, it was found that 
the patient was suffering from peri- 
tonitis ; her temperature varied be- 
tween 39.20 and 39-8° C. in the axilla; 
and her pulse varied between 120 and 
1 Read before the International Medical Congress 
in Berlin, and translated from the German by A. F. C. RUPTURE OF AN OVARIAN HAEMATOMA 
130 per minute, and was quite feeble. 
No definite condition could be made 
out by vaginal examination, with the 
exception of an obscure fullness in 
Douglas' cul-de-sac. The pain was 
believed to be due to a moderate dis- 
charge of pus from the enlarged left 
tube. The treatment consisted in 
the application of an ice bag to the 
abdomen and the administration of a 
saline cathartic, with morphine for 
the relief of the pain. No improve- 
ment followed. The belly continued 
to be tympanitic, the pulse frequent 
(140) and weak, and the axillary tem- 
perature 39.6°. A surgical operation 
seemed imperative, and was performed 
January 10th. As the belly was 
opened a considerable quantity of 
bloody serum gushed out. From 
Douglas' space about 200 grams of 
blood and coagula were removed. 
The adnexa on the left side were ad- 
herent ; on the right side their re- 
moval was not indicated. The abdo- 
minal cavity was then irrigated with 
a large quantity of hot water, the 
loops of intestine being disturbed as 
little as possible. The abdominal 
cavity was not sponged out. The 
wound was then closed. No narco- 
tics were used in the after treatment. 
The temperature and pulse immedi- 
ately fell, and both became normal 
after the first twenty-four hours. Con- 
valescence was uninterrupted. The 
excised left ovary presented a re- 
markable appearance to the naked 
eye. (See Fig 1.) 
On the superior surface of the 
slightly enlarged organ, the contour 
of which was very irregular, was 
a dark-brown swelling as large as a 
cherry. For about a third of its cir- 
cumference it was firmly embedded in 
the ovary, the remaining two-thirds be- 
ing free in the abdominal cavity. Over 
the surface of this swelling was a col- 
lection of small ball-like structures. 
At the uppermost part of the periph- 
ery of the swelling was a rent six 
millimetres long and one and a half 
broad, with irregular borders partly 
filled with blood and clot. The con- 
sistency of the swelling was about 
like that of the normal ovary. The 
naked-eye appearances showed the 
presence of a spontaneously ruptured 
haematoma, the origin of which was a 
matter for investigation, and a ques- 
tion which could only be solved with 
the aid of the microscope. 
Fig. i. 
Ruptured Haematoma of the Left Ovary. Natural size. 
E, Ovary; H, Haematoma with a rent; T, Tube. 
To make the result of the micro- 
scopic investigation intelligible, the 
following historical data must be pre- 
mised : After four years' study of 
ovaries, obtained from about forty lap- 
arotomies, Dr. M. Jones, of Brooklyn, 
was enabled to conclude that haema- 
tomata of the ovary wc±e composed 
of endothelial formations in which 
there has been an extensive metamor- 
phosis of cavernous blood vessels with 
a simultaneous discharge of blood. 
These conclusions, which followed 
studies in the laboratory of Dr. C. 
Heitzmann, of New York, were pub- 
lished in the New York MedicalJour- 
nal in September, 1889. 
2 H. J. BOLDT. 
Further investigations have shown 
that the endotheliomata proceed from 
the so-called structureless wall, of 
Graafian follicles ruptured during 
menstruation. The follicular wall is 
gradually extended in consequence of 
a plastic or formative inflammatory pro- 
cess, in connection with which, how- 
ever, it retains its healthy appearance. 
In many cases almost the entire ovary, 
cortex as well as medulla, is converted 
The walls of the gyromata are con- 
verted into a medullary condition, and 
then the rarer endotheliomata devel- 
op, these without exception being 
caused by new formations of blood- 
vessels and red blood corpuscles, and 
subsequently being changed into an- 
giomata and haematomata. 
My own case is a typical one of 
endothelioma with evolution into an- 
gioma and haematoma. All that the 
FIG. 2. 
Endothelioma of the Ovary Transforming into Angioma and Haematoma. X 50. 
K, connective tissue capsules; V, newly-formed vein ; A, artery in cross section; E, E, Endothelioma; H, Pro- 
cesses of angioma leading to a central haematoma. 
into this abnormal condition. On ac- 
count of the manifold inequalities in 
the outline of these formations, the 
name gyroma was given to them. 
Since the result of these investiga- 
tions referred to has only recently 
been published, I must limit my re- 
marks on the subject to what has al- 
ready been said. I venture to add 
that gyromata are not infrequent as to 
their occurrence, I possessing quite a 
number of them in my collection. 
microscope has revealed to me in my 
case confirms the statements of 
Jones. The interest in the case is 
increased by the fact that the haema- 
toma had burst, and had led to a 
condition in the peritoneal cavity 
which jeopardized life. 
A cross section through the haema- 
toma in my case showed a dark, red- 
dish brown centre with numerous 
projecting processes toward a clear 
cortical layer which averaged one 
3 RUPTURE OF AN OVARIAN HAEMATOMA, 
millimeter in diameter; it became 
thinner at the seat of rupture, and in 
places was entirely wanting. Verti- 
cal sections when examined with a 
low power of the microscope, gave 
the following result. (See Fig. 2.) 
The surface of the tumor consists 
of a capsule resembling connective 
tissue, with delicate papillary eleva- 
tions diffused over it, and at the 
place of rupture appeared to be very 
thin. In the substance of the cap- 
sule there were numerous elongated 
|extravasations of blood, evidently 
caused by the pressure of the blood 
within the haematoma. The endo- 
thelial formation began deeply below 
the capsule, and formed the entire 
cortical layer of the haematoma. The 
processes of endothelia ran parallel 
with the surface near the capsule, 
while toward the centre of the haema- 
toma they showed a radiating ar- 
rangement, the elements being for 
the most part cubical in shape but in 
some parts tending to a linear forma- 
tion. Within the endothelioma there 
were large arteries and veins, the lat- 
ter being filled with blood. Numer- 
ous bloodvessels, some of them in 
process of development, ran through 
the endothelial tissue, especially in 
the radiating processes, where there 
was also a notable new/formation of 
red blood corpuscles. All the angio- 
matous processes ran toward the cen- 
tral haematoma, which was composed 
of blood which was apparently newly 
formed. In many places the blood 
layer was limited toward the endo- 
thelioma by small bundles of connec- 
tive tissue. In the entire endothelial 
cortex there was a new formation of 
Moodvessels and red blood corpuscles. 
Let us next study these processes 
of endothelium which are in the pro- 
cess of development into angioma, 
without marked formation of blood. 
(Sse Fig. 3.) 
We observe endothelium which is 
of considerable size partly cubical 
and partly columnar, provided in 
almost all cases with round or ob- 
long nuclei, in which are frequently 
demonstrable irregular karyokinetic 
figures. The protoplasm of the en- 
dothelial elements is finely granular. 
The boundary between individual 
elements is supplied by particles of 
cement substance in which are thorn- 
like (stachelfbrmige) formations of 
varying size and demonstrability. 
In the most evident development of 
these thorns they take the appear- 
ance of a series of brilliant columnar- 
shaped particles. 
The new formation of bloodvessels 
follows from the vacuolation of indi- 
vidual endothelia, in which the pro- 
toplasm becomes pale, and undergoes 
a kind of dropsical process. All the 
spaces which are developed in this 
way contain variable quantities of 
granular matter, the residue of the 
pre-existent protoplasm. The spaces 
are directly limited by the unchanged 
endothelia in such a way that be- 
tween two vessel-spaces there is al- 
ways an unchanged endothelial cell. 
Hand in hand with the vascular new 
formation, there is a new formation of 
red blood corpuscles from enlarged 
granules of the living matter in the 
protoplasm. From the disorganized 
karyokinetic matter of the nuclei, 
and from the particles of the en- 
larged thorn-like bodies referred to 
in the cement substance between con- 
tiguous endothelia, the same process 
occurs. There is no doubt that the 
4 H. J. BOLDT. 
endothelia are the original elements 
from which are developed, by a drop- 
sical process of the protoplasm, sub- 
sequent endothelia, bloodvessels, and 
by the growth of the living material 
of the protoplasm, red blood corpus- 
cles. As early as 1872 it was shown 
by C. Heitzmann that there may be a 
new formation of bloodvessels and red 
corpuscles in the same way as I have 
described in this paper. It was then 
tions. In my preparations, the grad- 
ual development of the haematoblasts 
into red corpuscles may be followed 
with great precision. 
I have already shown that angioma- 
tous processes pass within the endo- 
thelioma toward the central haema- 
toma. In these processes, the devel- 
opment of the cavernous angioma 
may now be intelligibly studied. (See 
Fig- 4-) 
Fig. 3. 
Endothelioma showing Vessel Formation Without Decided Blood Formation. 
E, cubical endothelia; E1, elongated endothelia; V,1 transition endothelium with an hsematoblast; V, transi- 
tion endothelium with remains of nuclei; V2, transition endothelium associated with a bloodvessel; K, Haema- 
toblasts-formation in the cement substance. 
that he gave to the masses of living 
matter which in consequence of ab- 
sorption of haemoglobin have a dis- 
tinctly yellow color and very bright 
appearance, the name of haemato- 
blasts. This term was used by 
Hayem in 1876 to designate the ele- 
mental forms of red blood corpuscles 
suspended in the blood. Both in- 
vestigators have apparently chosen 
identical terms for the same forma- 
We recognize as relics of endo- 
thelia solid trabeculae distinguished 
by a yellowish-red color, which sur- 
round large blood spaces with fre- 
quent anastomoses. The limitation 
of the blood spaces is determined in 
many cases by vessel-endothelia, 
which in cross section show the well- 
known spindle shape, and are to be 
differentiated from the large endo- 
thelial processes. The endothelial pro- 
5 RUPTURE OF AN OVARIAN HAEMATOMA 
cesses are coarsely granular and may 
be demonstrated with some difficulty 
within their nucleus-like formations 
and within the cement substance 
formations. It is clear that the liv- 
ing matter of the protoplasm of most 
of the endothelia in these processes 
is developed into haematoblasts. Not 
only does the living matter of the pro- 
toplasm participate in the haematoblast 
formation, but also that of the nuclei, 
raneous developments. The latter 
are associated with large numbers of 
granules which are apparently the 
relics of the pre-existing protoplasm. 
If the entire protoplasm of the endo- 
thclia has been devoted to the new 
formation of blood corpuscles and 
bloodvessels, then the outlying en- 
dothelial processes will be entirely 
wanting, and we shall have before us 
nothing but a collection of red cor- 
Fig. 4. 
An Angioma and Haematoma developed from an Endothelioma. X 800. 
E, E, Endothelioma filled with haematoblasts; G, G, cavernous vascular spaces; H, haematoma; B, connec- 
tive tissue processes. 
as well as that portion of the thorn- 
like bodies (stacheln) passing through 
the cement substance. This is the 
reason why neither nuclei nor cement 
substance appear to be especially dif- 
fused. From the haematoblasts of 
different sizes at length arise the red 
corpuscles simultaneously with the 
swelling up and disintegration of the 
protoplasm. Bloodvessels and blood 
corpuscles are therefore contempo- 
puscles; in other words, a haematoma 
without granular relics of the pre-ex- 
isting protoplasm. Then we have an 
accumulation of blood before us, as 
to the origin of which the study of 
the surrounding endothelial formation 
leads to indubitable conclusions. In 
order to appreciate the fact that a 
haemorrhage so extensive as the one 
in the case under consideration may 
take place from the rupture of a hae- 
6 H. J. BOBDT. 
matoma, we must realize that the 
newly-formed cavernous vessel-spaces 
are associated with the dilated veins 
of the ovary. That such a communi- 
cation actually exists I was not able 
to demonstrate in my case; but I 
know from the study of preparations 
from other endotheliomata that the 
veins in their vicinity are much en- 
larged, and are filled with blood, 
while the arteries have become quite 
impervious on account of endarteritis 
obliterans or have suffered much con- 
traction of their lumen. In conclu- 
sion, I would remark that the few 
cases described as endotheliomata by 
Dr. J. Pomorski, in the Zeitschrift fur 
G eburtshiilfe und Gyndkologie, 1890, 
Band XVIII, Heft I., are in reality 
large tumors of the ovary. 
The endotheliomata which, accord- 
ing to Dr. Mary Dixon Jones, are con 
verted into angiomata and haemato- 
mata, on the other hand, are not tu- 
mors, hut products of a formative 
inflammation which does not lead to 
a notable enlargement of the ovary. 
Haematomata are either embedded in 
the ovarian stoma or develop more or 
less at the surface. They can always 
be sharply distinguished from the 
ovarian tissue, and are usually united 
with the same only by delicate con- 
nective tissue. A condition of this 
kind may not infrequently be surmised 
from existing symptoms and as the 
result of a bimanual examination, 
although it would be very injudicious 
to suppose that one could make, with 
certainty, a diagnosis from clinical 
data.