704 



UTERUS AND ITS APPENDAGES. 



topical condition, which may be viewed as the 

 local expression of the former. In a large 

 number of instances, however, the affection 

 of distant parts may be considered as the re- 

 sult of a secondary blood infection, i. c. of a 

 poisoning of the blood by the introduction of 

 some products from the original nidus of dis- 

 ease, and particularly of venous pus and sanies 

 in metrophlebitis.* 



The occurrences which immediately ensue 

 upon the act of parturition, offer a ready ex- 

 planation of the mode in which these and 

 other extraneous matters may gain access to 

 the general circulating fluid. For by the se- 

 paration and removal of the placenta, together 

 with a large portion of the decidua, the con- 

 tents of the uterine cavity, consisting of va- 

 rious puerperal products now exposed to the 

 direct influence of the atmosphere, are brought 

 into immediate relation with the patent ori- 

 fice of the uterine veins terminating upon the 

 placental space. Through these a copious 

 reception of the exudated products of inflam- 

 mation or of septic matters resulting from 

 decomposition within the uterus, or of in- 

 fecting matter derived from sources still more 

 external, may readily take place, and so pro- 

 duce either the primary or secondary dys- 

 crases of the blood just noticed. 



It is also to be observed that independent 

 of external sources of a blood dyscrasis, 

 the latter may be occasioned by an accumula- 

 tion of effete material, resulting from the 

 arrest of those eliminative processes which 

 constitute so large and important a part of 

 the act of involution, and are always more or 

 less impeded during puerperal inflammation ; 

 or commonly by a reflux of pus and sanies 

 formed in the larger venous channels in the 

 case of metrophlebitis already mentioned ; 

 while some of the worst forms of sepsis of the 

 blood are those which result from deep pros- 

 tration of the nervous system, occasioned by 

 exhausting forms of parturition. 



The more important associated morbid pro- 

 cesses occurring in connection with puerperal 

 inflammation of the uterus, which it may be 

 necessary here to notice, consist in exuda- 

 tions into the larger serous sacs and synovial 

 bursae, upon the mucous membranes, and in 

 the parenchyma of various parts and organs ; 

 and of deposits within the larger vessels, 

 chiefly the veins leading from the uterus, or 

 in the capillaries of organs often far removed 

 from the original seat of inflammation. 



The effusions upon the peritoneum and 

 pleura, and less frequently upon the pericar- 

 dium, consist of fibrinous and croupous ex- 

 udations, combined often with copious effu- 

 sions of serous, purulent, or sero-purulent 

 fluids, the latter being, perhaps, often the 

 result of a breaking down or liquefaction of 

 the croupous fibrine, and its conversion into a 

 pus-like fluid. Similar collections are found 

 in the synovial membranes of the larger joints, 

 especially of the knee, shoulder, and hip. 

 While upon the mucous surfaces, particularly 



* Rokitansky, op. cit. vol. ii. 



of the intestines, which are later affected than 

 the serous structures, a less sthenic form of 

 exudation is usually found, the effusion con- 

 sisting here of serous, gelatinous, or purulent 

 exudations (the former contributing largely 

 to the production of puerperal diarrhoea), and 

 of infiltrations into the mucous and sub- 

 mucous areolar tissues. 



These various exudative processes, whose 

 preference for particular tissues is probably in 

 part determined by textural peculiarities, 

 must be considered as efforts to eliminate the 

 dyscrasial materials from the general blood 

 mass, and they will continue until the ex- 

 haustion of the crasis is complete. 



The qualitative variations observable in the 

 products bear exact relation to the nature of 

 the previous infection, and of the dyscrasis 

 arising out of it. The character and mode 

 also of the first effusions may materially affect 

 those which occur at a later period ; for 

 when the plastic products have been very 

 abundantly and rapidly formed, and the defi- 

 brination of the blood consequently very con- 

 siderable, the extensive discharge of the fibri- 

 nous element leaves the blood so attenuated, 

 that the serous portion may then speedily 

 transude through the walls of the capillary 

 vessels, and in this way are produced those 

 enormous collections of serous or sero-puru- 

 lent fluids which sometimes rapidly form in 

 the advanced stages of puerperal inflamma- 

 tions, occasionally with but slight evidences 

 during life of their occurrence. 



Of equal or greater interest are those 

 associated pathological phenomena which are 

 connected with secondary phlebitis, having its 

 seat either in the larger veins, or in the 

 capillary system of vessels. The veins nearest 

 to the uterus are commonly first involved ; 

 and from this point the inflammatory action 

 may spread either by direct or interrupted 

 continuity to more distant vessels, following, 

 however, the reverse order of the circulation ; 

 or it affects vessels remote from the original 

 seat of inflammation, as in the capillary con- 

 gestions, and inflammations of distant parts 

 producing the lobular infarctions, and in more 

 advanced inflammatory stages, the so-called 

 metastatic abscesses and sloughs of various 

 organs and tissues. The obstruction to the 

 circulation arising in these cases from coagu- 

 lation of fibrine within the vessels, and viewed 

 by some pathologists as the cause, and' by 

 others as an effect only of inflammation, may 

 be perhaps regarded as a provision for limiting 

 the spread of the infecting fluids, and pre- 

 venting, to a certain extent, their introduction 

 into the general circulation. 



In the larger vessels, especially in the veins 

 nearest the point of primary infection, the 

 fibrine is found under various conditions of 

 coagulation, forming long cylindrical plugs, 

 as in crural phlebitis, or shorter clots, whose 

 red coloration depends upon the degree in 

 which the blood corpuscles may have been 

 incorporated in its several laminae, or their 

 paler yellow colour, upon the absence of the 

 same, and the consequent greater purity of 



