ENDOCOLPITIS AND ENDOMETRITIS.—In the superficial, catarrhal form of inflammation the mucous membrane of the vagina is swollen and hyperæmic, the papillæ are enlarged, and the discharge is profuse; in the vaginal portion of the cervix the labia uterina are oedematous and covered with granulations which bleed at the slightest touch; in the cavity of the body there are increased transudation of serum and abundant pus-formation. The deep structures of the uterus are usually not affected. Sometimes the inflammation extends to the tubes—salpingitis—or, passing outward through the fimbriated extremities, it may spread over the adjacent peritoneum.
The small wounds at the vaginal orifice are at times converted into ulcers with tumefied borders. These so-called puerperal ulcers are covered with a greenish-yellow layer. They are associated usually with oedematous swelling of the labia. Under favorable sanitary conditions the deposit, which consists in the main of pus-cells, clears away and the surface heals by granulation. The ulcerative form of inflammation is very rare outside of crowded hospitals.
Diphtheritic ulcers are situated with greatest frequency in the neighborhood of the posterior commissure or around the vaginal orifice. In rarer instances they are found upon the anterior wall and in the fornix of the vagina, in the cervix, and upon the site of the placenta. The borders are red and jagged; the base is covered with a yellowish-gray, shreddy membrane; the secretion is purulent, alkaline, and fetid; and the adjacent tissues are oedematous. From the vulva they may extend to the perineum or pursue a serpiginous course down the thighs. In the uterus and about the cervix they vary as regards size, and are either of a rounded shape or form narrow bands. The intervening portions of tissue which have not undergone destructive changes swell and stand out in strong relief. Where the entire inner surface has become necrosed, it is often covered with a smeary, chocolate-brown mass which, when washed away with a stream of water, leaves exposed either the deepest layer of the mucous membrane or the underlying muscular structures.
The difference between the superficial ulcerations of the genital canal and the diphtheritic form involving destruction of the deeper tissues is due to the presence in the latter of minute organisms termed micrococci, the relations of which to puerperal infection will be considered in a subsequent division.
METRITIS AND PARAMETRITIS.—In ulcerative endometritis, and even in the extreme catarrhal form, the parenchyma of the uterus likewise becomes involved. The changes which are designated under the term metritis consist in the first place of oedematous infiltration of the tissues. As a consequence, the organ contracts imperfectly and becomes soft and flabby, so that sometimes, upon post-mortem examination, it bears the imprint of the intestines.
In diphtheritic endometritis the gangrenous process may attack the muscular tissue, and give rise to losses of muscular substance—a condition known as necrotic endometritis or putrescence of the uterus.
Inflammatory changes are rarely lacking in the intermuscular connective tissue, which exhibits in places serous or gelatinous infiltration, with afterward pus formation, and with here and there small abscesses. The sero-purulent infiltration of the connective tissue is specially marked beneath the peritoneal covering of the uterus either behind or along the sides at the attachment of the broad ligaments. In the same situations the lymphatics, which normally are barely perceptible to the naked eye, are sometimes enlarged to the size of a quill, and are characterized by varicose dilatations occurring singly or presenting a beaded arrangement. In the substance of the uterus the dilated vessels are liable to be mistaken for small abscesses. The pus-like substance contained in the lymphatics is composed of pus-cells and of micrococci. From the cellular tissue surrounding the vagina, or that beneath the peritoneal covering of the uterus, the inflammation may spread by contiguity of tissue between the folds of the broad ligament, and thence pass upward to the iliac fossæ. Usually the process is unilateral. After the inflammation has crossed the linea terminalis it may take a forward direction above the sheath of the ilio-psoas muscle to Poupart's ligament, or it may creep upward, following the course, according to the side affected, of the ascending or descending colon, to the region of the kidney. It is rare for inflammation of the cellular tissue to travel around the bladder to the front. In such cases it pursues its course between the walls of the bladder and the uterus, and along the round ligament to the inguinal canal. In a few cases the cellulitis mounts above Poupart's ligament, between the peritoneum and the abdominal wall.
The course of the inflammation is not simply fortuitous, but follows prearranged pathways in the connective tissue. König7 and Schlesinger8 have shown that when air, water, or liquefied glue is forced into the cellular tissue between the broad ligaments the injected mass has a tendency to invade the iliac fossæ. In Schlesinger's experiments, if the canula of the syringe was inserted into the anterior layer of the broad ligament, the glue spread between the folds to the abdominal end of the Fallopian tube; thence, following the track of the vessels, it passed to the linea terminalis; and finally mounted upward along the colon or swept forward to Poupart's ligament until the advance was stopped at the outer border of the round ligament. If the injection was made to the side of the cervix through the posterior layer at the junction of the cervix and the body, the posterior layer gradually bulged out, the peritoneum was lifted from the side wall of the pelvis, and the glue passed beyond the vessels to reach the iliac fossa. If the injection was made to the side of the cervix through the anterior layer, the glue passed between the bladder and the uterus, and forward along the round ligament to the inguinal canal, while another portion of the fluid passed between the layers of the broad ligament, and reached the peritoneal covering of the side walls behind the round ligament. If the injection was made in the median line in a peritoneal fold of Douglas's cul-de-sac, the fluid travelled forward upon one side along the round ligament and thence to the posterior wall of the bladder.
7 Arch. der Heilkunde, 3 Jahrg., 1862.
8 Gynaekologische Studien, No. 1.