Haemorrhage is a normal occurrence in menstruation and parturition, but it may assume pathological characters when in excess or when the blood is unduly retained.

(A) Menorrhagia

Menorrhagia is excessive haemorrhage at a menstrual period. It is induced by various constitutional conditions, but also by local lesions of the uterus, more especially tumours. Tumours of the uterus also frequently induce haemorrhages apart from the menstrual periods.

(B) Dysmenorrhea Membranacea

Dysmenorrhea Membranacea is a condition in which membranous structures are evacuated by the uterus along with the blood in menstruation. These sometimes form a complete cast of the interior of the uterus, but more usually they are in smaller pieces. The membrane is variously composed in different cases. Sometimes it is no more than condensed blood-clot or fibrinc, perhaps in some cases left over from a previous menstruation. In other cases, however, it is composed of the mucous membrane of the uterus. It is chiefly the superficial layers consisting of epithelium which are exfoliated, but the uterine glands may be present in the membrane, and even the submucous tissue.

This condition is usually regarded as due to an inflammation of the uterine mucous membrane, to which the name endometritis exfoliativa has been given, but this view is not universally accepted. There is no doubt some inflammation, as the membrane contains round cells.

(C) Hematoma Of The Uterus

Hematoma Of The Uterus is of some importance, as it may resemble a tumour. It consists of a polypoid mass of blood-clot attached to the internal surface of the uterus and hanging into its cavity, or even projecting into the vagina. It is sometimes called the Fibrinous uterine polypus. Consisting of blood-clot it has originated in haemorrhage, but there must be some cause for the adhesion of the clot to the uterine wall. This is mostly afforded by the placenta which has been retained after delivery or abortion. The whole placenta may be retained as in Fig. 449, or it may be only a portion. On the other hand, the rough surface after removal of the placenta may induce the coagulation of blood, which if retained may grow by fresh coagulation. As the haematoma originates in haemorrhage it is usually associated with the latter throughout its course. The blood mostly escapes into the vagina, but some of it may coagulate and increase the size of the polypus.

(D) Pelvic Hematocele

This name expresses an accumulation of blood in the neighbourhood of the uterus. Two forms have been described according as the blood is in the peritoneal cavity or beneath the peritoneum. A convenient nomenclature is to call the intra-peritoneal form Pelvic hematocele and the extra-peritoneal form Pelvic hematoma. Intra-peritoneal hematocele is much more serious than the other. It arises as a result of any haemorrhage inside the peritoneum, such as rupture of an ectopic pregnancy, rupture of an aneurysm, regurgitation of the blood during menstruation when there is obstruction to the regular outflow, rupture of enlarged veins, and of the vessels in adhesions around the uterus.

Polypoid hsematoma of uterus after an abortion in the second month.

Fig. 449. - Polypoid hsematoma of uterus after an abortion in the second month; a, projecting part of maternal placenta and wall of uterus; b, remains of foetal placenta; c, stratified coagula around the foetal placenta. Natural size. (Virchow).

The blood, whatever its source, accumulates chiefly behind the uterus in Douglas's pouch. Acting here as a foreign body it sets up a chronic inflammation with the usual results of new-formation of connective tissue which surrounds and causes partial absorption of the blood. There may be thus considerable perimetritis brought about. In some cases suppuration ensues, and an abscess is formed, chiefly when a foetus is present from rupture in ectopic pregnancy.

Extra-peritoneal haematocele or haematoma also originates from rupture of the cyst in ectopic pregnancy, but it occurs also not infrequently as a kind of vicarious menstruation, and may arise in other ways. The blood mostly accumulates in the broad ligament, which it may distend into a bulky tumour. It may also pass around the uterus and rectum, sometimes obstructing the latter. The accumulated blood usually undergoes absorption, but it may leave thickenings and adhesions behind.

Literature

Bebnutz, Clin, memoirs on dis. of women (Syd. Soc. transl.), 1866; Gubserow, in Volkmann's Sammlung, No. 81; Friedlander, Phys.-anat. Unter-such. viber dem Uterus, 1870; Leopold, Die Uterusschleimhaut wiihrend Menstruation, etc., 1878; Banul, in Billroth's Handb. d. Frauenkrankh., v.; Lawson Tait, Ectopic pregnancy and pelvic haematocele, 1888.