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 pal turition.
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 bursw, 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.
1 he 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 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 diarrhcea), and of infiltrations into the mucous and sub nmcous 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 brillation 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 conimonly 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 tlistant 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 fbr 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 c)lindrical 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 laminm, or their paler yellow colour, upon the absence of the same, and the consequent greater purity of the (perhaps effused) fibrine. The centre of these coagula may be found softened, and containing the creamy pus-like fluid which results from the molecular disintegration and liquefaction so commonly observed in fibrinous clots. Frequently the clots are of a less consistent texture, being of a dark brown or chocolate colour, or reduced to the con sistence of a soft pulp. The coats of the veins may be thickened and adherent to the contained coagula, or covered by fibrinous laminw or merely blood-stained, or pre senting no deviation from the natural state.