Post mortems frequently accidentally reveal the great influence that pseudo-membranes and adhesions formed between the organs, during the course of pelvic peritonitis, have on the health of women. The uterus and its adnexa are found to be so extensively covered with pseudo-mem branes, that it is difficult to separate the individual parts from one an other. Between the layers of the pseudo-membrane are frequently found accumulations of serum, degenerated blood, cretaceous or even osseous masses. glob emphasizes that in cases of perimetritis the adjacent nter ine parenchyma always participates, frequently becoming destroyed by fatty degeneration, and that the new connective tissue forms a tough non-contractile crust-like layer, which takes part in the enlargement of the uterus during pregnancy.
inflammation of the Pelvic Connective Tissue.—For more thorough pathologico-anatomical investigation of this matter, we are indebted to Virchow. W. A. Freund persistently called attention to a form of pars metritis which rapidly leads to a contraction and thinning of the pelvic connective tissue. (Parametritis chronica atrophicans.) He has exhaus tively described the results of his investigation on this subject in his monograph, "Gynecological clinic, Strasburg, 1885," to which we refer the reader. According to Virchow the uterus itself as well as the con nective tissue surrounding it are frequently the seat of puerperal diseases, which are at times independent, but most frequently secondary, in which case this tissue plays the major part in the disease. The process often follows the course of the connective tissue for a great distance, spreading in certain localities, from which it again radiates, thereby assuming a course similar to irregular erysipelas. Its favorite seats on the uterus are the parietal layers; next the process invades the loose connective tis sue around the vagina and cervix, extending from there to the inner por tions of the broad ligaments, the sheaths of the blood-vessels and lym phatics. Virchow also thinks that the disease is generally due to trau matism of the external genitals; " but this is not always the case, and therefore the process resembles the diffuse form of phlegmonous erysipe las, for which reason the name erysipelas malignum vuerperale internum was applied to it by him." In the acute septic cases, very often no other changes are found in the cellular tissue except (edema and dark discoloration of the tissue, but the lymphatics filled with pus and micrococci (metrolymphangitis), and the frequently diseased. veins (metrophlebitis), show the course of ex tension of the infectious process. In sub-acute cases, where exudation
into the meshes of the cellular tissue has taken place, if due to a septic poison, the loose connective tissue may become destroyed to a great ex tent, undergoing purulent and ichorous changes which may involve the whole parametrium. In cases where the poison is less virulent, there must be an extensive exudation of albuminous or fibrinous material in the meshes of the cellular tissue, as shown by the soft swellings, that can be observed shortly after the beginning of the process. (See Fig. 19.) In recent cases the pelvic connective tissue is largely infiltrated with gelatinous material containing numerous small cells. After a short time the soft swellings become hardened, the fluid portion of the exudation having become absorbed. If the disease takes a chronic course, the peri uterine connective tissue is changed into a hard unyielding mass, fixing the uterus on one or all sides, or out of the cellular tissue are formed circum scribed large hard tumors, poorly supplied with blood, often reaching to the inlet of the pelvis, and insinuating themselves between bladder and uterus, rarely between rectum and uterus, or becoming prolonged beyond the limits of the true pelvis, especially in the direction of the reflections of the peritoneum. Frequently the exudation extends in this way from the broad ligament to the iliac fosse, or to the anterior abdominal wall; fur thermore, it may extend through the pelvic inlet to the kidneys. In re cent cases pus centres are frequently found in these hard masses, showing the different stages of retrogressive changes.
From examinations on the living subject and cadaver, it is certain that in most cases inflammations of the parametrium leave cicatrices similar to those left by inflammations of the peritoneum, and which subsequently undergo contraction and hardening. These cicatricial changes varying in amount are readily found with the microscope.
Uteri of virgins where the peritoneum, as the result of catarrhal affections of the cervix is not as movable as normally; uteri, where from laceration of the cervix, or without any appreciable injury to this organ, there is fixation by adhesions, which radiate in the parnmetrium, or where there is displacement in any direction; uteri, where the broad ligaments are not as easily stretched as normally, or where at the same time there are present indurations or marked shrinkage, and whore the nerves and blood-vessels are enclosed in cicatricial tissue, are often accidentally found in the cadaver.