ORIGINAL LECTURES.

CLINICAL LECTURE

ON RETENTION OF BLOOD.

By J. MATTHEWS DUNCAN, M.D., LL D., Physician-Accoucheur and Lecturer on Midwifery at St. Bartholomew's Hospital.

I USE the term "retention of blood" in preference to the term "retention of menses," because in every case blood is certainly retained, whereas in no case is it absolutely certain that the retained blood is menstrual;-it may be retention of menses; it certainly is retention of blood. The circumstances which show that, in any particular case, it is retention of menses, and not of mere blood, I do not propose to enter upon here, because to do so would throw no light upon the subject of the present lecture.

A great and well-known cause of retention of blood in the genital passages of women is atresia. Such retentions get the names of hæmatocolpos when blood is retained in the vagina, hæmatometra when it is retained in the womb, and hæmatosalpinx when it is retained in the tube. But it would be a great mistake to suppose that blood is retained in the genital passages of women only when there is atresia.

Before advancing further, I may just state that there are many diseases of women in which there is retention of blood. In hæmatocele you have retention of blood within the peritoneal cavity; in that disease, indeed, the blood frequently regurgitates from the tube or uterus into the peritoneal cavity, to be retained there. In hæmatoma, or thrombus, in the perimetric or perivaginal cellular tissue, you have retention of blood. Ovarian apoplexy is not a rare disease. Bleeding into an ovarian cyst is not uncommon; and sometimes the bleeding is dangerous from its profuseness, sometimes from the ovary bursting.

These are not such retentions as I propose to speak of to-day, and I shall dismiss in a few words retention of blood in the Fallopian tube or tubes, for this is a subject of which practically or clinically little is known. I spoke of retention of mucus or muco-pus in these tubes in my last lecture.

I shall also say very few words about retention of blood in the vagina. This occasionally happens in ordinary menstruation, especially if it is more copious than usual. The blood lodges in the vagina, coagulates; and clots are expelled during menstruation or after it. The clots may be bright and fresh, or partially changed in colour into dull or dirty brown. It is not, indeed, a very rare thing for menstruating women who retain blood in this way to have foetid menstrual discharges, fluid blood or clots being not only retained in the vagina, but decomposing and stinking, and coming away with a fœtor which is always and justly not only very disgusting, but also alarming, in consequence of the frequency of fœtor in very dangerous diseases of women.

With these preliminary remarks I come to the first great subject of the lecture-retentions of blood after and in connexion with a recently passed pregnancy, before the womb has regained its unimpregnated condition; and you know that in most women this does not take place until about six weeks have elapsed from the child-birth or abortion.

After I have described these puerperal retentions, I shall -describe cases of retention of blood in the virgin womb, or in the organ apart from any connexion with pregnancy.

I begin with the retentions in the puerperal state. Such may take place, first, in a womb which is still large. The retention of lochia is an extremely important subject, which I shall say nothing about here. In addition to retentions of blood in a womb that is still large, you may, secondly, have retentions of blood in a womb which is rapidly increased in capacity, as if for the purpose of containing and retaining the blood.

This dilatation of the womb happens with frequency or facility in proportion to the nearness to the birth, whether of a child at full term or of an abortion. In all cases of retention of blood in the womb it is possible that the womb may expand, but it is especially liable to occur in VOL. I. 1880. No. 1540.

women who have recently been delivered. Again, this dilatation of the womb is dangerous in proportion to the advancement of the pregnancy. It is not nearly so dangerous in a woman who has an abortion as in one who has recently borne a full-grown child.

Now, this dilatation of the womb is familiar to you all and to every practitioner as a common occurrence in postpartum hæmorrhage. Then the womb not only gets full of blood, but expands, so as to hold a large and, it may be, even a fatal quantity of blood. But when you have such puerperal retentions as I am now discussing you may have a womb expanding, not immediately after delivery, but at a late period after delivery, and before the six weeks of the puerperal state have passed.

Clots often form in the enlarged uterus, and, when this happens, you are generally told that there is a copious watery discharge; the serum of the blood flows out bloodtinted and in the form of a copious watery discharge, to which the nurse or the patient herself may direct your attention.

From a uterus containing a clot you may have further hæmorrhage without displacement of the old clot, the new hæmorrhage flowing round the clot and passing into the vagina, and so forth from the woman's body. Not very long ago I saw a case of this kind, where the clot was retained almost certainly from the time of delivery until three weeks after the birth. Then the woman had a flooding, and after the flooding had proceeded alarmingly for some time, before my arrival there came away, partly in consequence of the treatment, a clot of the shape of the distended uterus, and which proved the condition that I am describing by having on its surface partial decolorisation, a mottled surface, showing that the clot was an old clot which had lain in the uterus almost certainly since the time of the woman's confinement.

When a woman is not perfectly or completely delivered, but has a little bit of placenta or pendulous decidua left attached to or hanging to the womb, then you have arrest of the diminution of the bulk of the womb, and clots are formed in it, generally soft clots, rarely becoming old and decolorised, such as I have mentioned above, but soft clots which are discharged now and again.

Of this condition I have, in a former lecture, given you remarkable examples. To-day I shall give you another; and before I read it I shall say a few words about the polarity of the uterus.

Polarity is a name long ago given to certain functions of the uterus which I shall describe very briefly, because the case is one which illustrates the subject. The same polarity is illustrated in the function of the bladder, and less distinctly in the function of the rectum-that is, in urination and defæcation.

What is polarity of the uterus? It implies an opposite state, as to activity or the reverse, of its two ends; of the lower part of the uterus on the one hand, and of the fundus and upper parts of the uterus on the other-inhibition, as it is nowadays called, at one part, while there is action at the other. And there may be change from inhibition at one part to action in the same, and from action at the other part to inhibition in the same; that is, the reversal of the condition in each of the two parts. These two conditions are co-ordinated to one another both in health and in disease; and the study of this polarity explains a good many things which I wish I had more time to enter upon.

Consider pregnancy. In this state the lower segment of the uterine body keeps continually contracted until the end; but the fundus and body of the uterus are in the state called inhibition; they are expanding, not expulsively acting. When the time of delivery comes, you have the reversal of these conditions: the lower segment of the uterus is in the state of inhibition, while the fundus and body are expulsively operating. These are illustrations of polarity in health; and in disorder of labour, also, it is frequently illustrated. Such a case as this often happens: a woman has a slow labour with a healthy cervix, but the cervix is not dilating; the lower segment will not open. In some such cases-and it is very difficult to diagnose which are the cases fitted for the plan of treatment-you let off the waters. Immediately, the fundus and body of the uterus, being partially evacuated, and consequently much contracted, begin to work vigorously; and in co-ordination with that working by uterine pains the neck of the womb is inhibited and opens almost