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women who have recently been delivered. Again, this dilaORIGINAL LECTURES.
tation of the womb is dangerous in proportion to the advancement of the pregnancy. It is not nearly so danger
ous in a woman who has an abortion as in one who has CLINICAL LECTURE
recently borne a full-grown child.
Now, this dilatation of the womb is familiar to you all ON RETENTION OF BLOOD. and to every practitioner as a common occurrence in post
partum hæmorrhage. Then the womb not only gets full By J. MATTHEWS DUNCAN, M.D., LL D., of blood, but expands, so as to hold a large and, it may be, Physician-Accoucheur and Lecturer on Midwifery at St. Bartholomew's even a fatal quantity of blood. But when you have such Hospital.
puerperal retentions as I am now discussing you may have
a womb expanding, not immediately after delivery, but at a I use the term “retention of blood ” in preference to the
late period after delivery, and before the six weeks of the term “ retention of menses,” because in every case blood is
puerperal state have passed.
Clots often form in the enlarged uterus, and, when this certainly retained, whereas in no case is it absolutely certain
happens, you are generally told that there is a copious that the retained blood is menstrual;—it may be retention of watery discharge; the serum of the blood flows out bloodmenses ; it certainly is retention of blood. The circumstances tinted and in the form of a copious watery discharge, to which show that, in any particular case, it is retention of
which the nurse or the patient herself may direct your menses, and not of mere blood, I do not propose to enter
attention. upon here, because to do so would throw no light upon the
From a uterus containing a clot you may have further
hæmorrhage without displacement of the old clot, the new subject of the present lecture.
hæmorrhage flowing round the clot and passing into the A great and well-known cause of retention of blood in the vagina, and so forth from the woman's body. Not very genital passages of women is atresia. Such retentions get long ago I saw a case of this kind, where the clot was the names of hæmatocolpos when blood is retained in the retained almost certainly from the time of delivery until vagina, hæmatometra when it is retained in the womb, and three weeks after the birth. Then the woman had a flooding, 'hematosalpinx when it is retained in the tube. But it and after the flooding had proceeded alarmingly for some would be a great mistake to suppose that blood is retained time, before my arrival there came away, partly in consein the genital passages of women only when there is atresia. quence of the treatment, a clot of the shape of the distended
Before advancing further, I may just state that there are uterus, and which proved the condition that I am describing many diseases of women in which there is retention of blood. by having on its surface partial decolorisation, a mottled In hæmatocele you have retention of blood within the peri- surface, showing that the clot was an old clot which had toneal cavity; in that disease, indeed, the blood frequently lain in the uterus almost certainly since the time of the regurgitates from the tube or uterus into the peritoneal woman's confinement. cavity, to be retained there. In hæmatoma, or thrombus, When a woman is not perfectly or completely delivered, in the perimetric or perivaginal cellular tissue, you have but has a little bit of placenta or pendulous decidua left retention of blood. Ovarian apoplexy is not a rare disease. attached to or hanging to the womb, then you have arrest of Bleeding into an ovarian cyst is not uncommon; and some- the diminution of the bulk of the womb, and clots are formed times the bleeding is dangerous from its profuseness, some- in it, generally soft clots, rarely becoming old and decolor. times from the ovary bursting.
ised, such as I have mentioned above, but soft clots which These are not such retentions as I propose to speak of are discharged now and again. to-day, and I shall dismiss in a few words retention of Of this condition I have, in a former lecture, given you blood in the Fallopian tube or tubes, for this is a subject of remarkable examples. To-day I shall give you another; and which practically or clinically little is known. I spoke of before I read it I shall say a few words about the polarity of retention of mucus or muco-pus in these tubes in my last the uterus. lecture.
Polarity is a name long ago given to certain functions of I shall also say very few words about retention of blood in the uterus which I shall describe very briefly, because the the vagina. This occasionally happens in ordinary menstrua- case is one which illustrates the subject. The same polarity tion, especially if it is more copious than usual. The blood is illustrated in the function of the bladder, and less dislodges in the vagina, coagulates; and clots are expelled during tinctly in the function of the rectum-that is, in urination menstruation or after it. The clots may be bright and fresh, and defæcation. or partially changed in colour into dull or dirty brown. It What is polarity of the uterus? It implies an opposite is not, indeed, a very rare thing for menstruating women state, as to activity or the reverse, of its two ends; of the who retain blood in this way to have foetid menstrual dis- lower part of the uterus on the one hand, and of the fundus -charges, fluid blood or clots being not only retained in the and upper parts of the uterus on the other-inhibition, as vagina, but decomposing and stinking, and coming away it is nowadays called, at one part, while there is action at with a fotor which is always and justly not only very dis the other. And there may be change from inhibition at one gusting, but also alarming, in consequence of the frequency part to action in the same, and from action at the other part of fætor in very dangerous diseases of women.
to inhibition in the same; that is, the reversal of the condi. With these preliminary remarks I come to the first great tion in each of the two parts. These two conditions are subject of the lecture-retentions of blood after and in co-ordinated to one another both in health and in disease ; connexion with a recently passed pregnancy, before the womb and the study of this polarity explains a good many things has regained its unimpregnated condition; and you know which I wish I had more time to enter upon. that in most women this does not take place until about six Consider pregnancy. In this state the lower segment of weeks have elapsed from the child-birth or abortion.
the uterine body keeps continually contracted until the end; After I have described these puerperal retentions, I shall but the fundus and body of the uterus are in the state describe cases of retention of blood in the virgin womb, or called inhibition ; they are expanding, not expulsively acting. in the organ apart from any connexion with pregnancy. When the time of delivery comes, you have the reversal of
I begin with the retentions in the puerperal state. Such these conditions: the lower segment of the uterus is in the may take place, first, in a womb which is still large. The state of inhibition, while the fundus and body are expulretention of lochia is an extremely important subject, which sively operating. These are illustrations of polarity in I shall say nothing about here. In addition to retentions health ; and in disorder of labour, also, it is frequently illusof blood in a womb that is still large, you may, secondly, trated. Such a case as this often happens : a woman has a have retentions of blood in a womb which is rapidly slow labour with a healthy cervix, but the cervix is not increased in capacity, as if for the purpose of containing dilating; the lower segment will not open. In some such and retaining the blood.
cases - and it is very difficult to diagnose which are the cases This dilatation of the womb happens with frequency or fitted for the plan of treatment-you let off the waters. Imfacility in proportion to the nearness to the birth, whether mediately, the fundus and body of the uterus, being partially of a child at full term or of an abortion. In all cases evacuated, and consequently much contracted, begin to work of retention of blood in the womb it is possible that the vigorously; and in co-ordination with that working by uterine womb may expand, but it is especially liable to occur in pains the neck of the womb is inhibited and opens almost
VOL. I. 1880. No. 1540.