Again, the lesions may be more accentuated and deeper, and we have no longer a simple endometritis. The mucous membrane, altered, trans formed into a species of reddish slough covering the internal surface of the uterus, presents, here and there, especially at the placental site, gangrenous 'vegetations, diphtheritic patches; whence the names gangre nous, diphtheritic endometritis. In such instances, the parenchyma of the uterus appears to participate in the lesion, and in places seems to have suffered gangrene, but, as Raymond and Spiegelberg have shown, this interpretation is not the correct one. What has been described under the name putrescence of the uterus, is simply phlebitis and lymphangitis of the net-work. (Fig. 187.) The uterine tissue is soft, full of serum, its vessels are empty or nearly so, a few of the larger veins alone contain clots. The muscularis itself is only exceptionally affected. It is in the connective tissue that the inflammatory changes are found. The ab scesses of the uterine tissue, described by certain authors, are simply ectasic veins or lymphatics filled with pus. The affection is a metro-lym phangitis or a metro-phlebitis. When sections of the uterus are made, the sero-purulent infiltration of the connective tissue is found to occupy points of election, so to speak, in particular the borders of the uterus where the broad ligaments are attached, and where the blood and lym phatic vessels enter and emerge. Often, at these points, the peritoneum is lifted up by vessels distended with pus, vessels projecting greatly like a bird's feathei-, and which are due to ectases of these vessels, in particu lar the lymphatics. The pus is most certainly found at the superior angles of the uterus where the tubes insert, and thence these lymphatics, filled with pus, extend into the plexuses of the broad ligaments, and this ex plains the frequency with which peri- and parametritis complicate me• tritis.
In other instances the veins are more particularly affected. There ex ists a metro-phlebitis, and then it is especially at the placental site that the lesions are found. The thrombosed veins are filled with pus, and projecting, simulate abscesses of the uterine tissue, thus misleading the superficial observer.
2. The blood-vessels and the lymphatics are the channels by which the infectious germ are carried; and long before the direct presence of the micrococcus had been determined in them, authorities had laid stress on the capital Hie which these vessels played in the puerperal drama. The two theories of phlebitis and of lymphangitis have for long divided ac coucheurs, and it will suffice to recall the works of Dance, of Bibier, of Hervieux, on phlebitis; those of Tonnel(, Cruveilhier, Championniere, Siredey, Aug(, etc., on lymphangitis. From the writings of the three last, in particular, it is apparent that, although phlebitis does exist, it is infinitely rarer than lymphangitis, and Leopold's researches on the uterine mucosa and the lymphatics of the uterus explain readily the rapidity and intensity of the propagation of the morbid process. The uterus represents indeed a vast lymphatic gland, the mucous membrane being perforated, riddled, by lymph sinuses, whence the lymph vessels arise. The lesions,
finally, are about the same, whether it is the veins or the lymph vessels which are affected: " The first phenomenon which occurs in the veins of the uterus after delivery is coagulation of the blood, thrombosis, which, according to the investigations of Leopold, begins even before the third stage of labor, a thrombosis which normally is limited to the uterine sinuses, but which may extend further, pass out of the uterus to the utero-ovarian plexus, the large venous trunks and even the limbs. If this coagulated blood contains infectious germs, inflammation of the walls of the vein sets in, the throm bus degenerates and the micrococcus appears in the shape of tine grains, like sand, infiltrating the vascular wall, lifting it upward, and sowing little miliary and sub-miliary nodules. (Doleris.) But, according to Doleris, the suppuration, or rather the cause of the suppuration of the clot, is in the blood, and not in the wound. What happens, in fact? Pus is rarely found in the veins of the uterus, but the first traces are met with in the utero-ovarian plexus, in the veins in the neighborhood of the ovary, those which dip into the medullary layer. We may even find a large open trunk, closed by a clot, and spreading out in a putrid cavity, the remnant of the stroma of the ovary. (Fig. 188.) " The centre of the clot is always in a state of suppuration, which makes me think that these successive purulent layers in the coagulum are due to equally successive depositions of micrococci coming from the blood. Their presence in considerable quantity causes inflammation above the stopping-place of the pre-existing phlebitis, and at a variable height. Next, the deposition of fibrin for a time interferes with the development of the micrococcus, seeing that it is shut up, as it were, in the fibrinous masses. Later, the embolus is detached; then follows the infarctus with its varieties, suppurative if the embolus is purely pyogenic, and putrid if the embolus is septic.
" These lesions of the veins may, however, occur after another fashion, secondarily-, so to speak, to a lymphangitis. When the latter exists in the large vessels, the micrococcus within them travels slowly, and, being in contact with the venous trunks, determines periphlebitis and periphle bitic abscesses. The vein, the artery, the lymphatic vessels are then en veloped in a more or less dense mass, in which are found small foci.of suppuration, either around a veinlet or within it. We have thus suc cessively a lymphangitis, periphlebitis, phlebitis, and later pyemia, puru lent infection.
" If the main lesions are rather in the lymphatics, they are caused, similarly, by the penetration of the infectious germ. This invades at the same time the lymphatics of the uterus, and those below the peritoneum. These vessels inflame, and the angioleucitis spreading by continuity of the serous membranes and the cellular tissue, we witness the production of what may be called the secondary lesions, pelvic peritonitis, adenitis, pelvic cellulitis, pleurisy, meningitis, arthritis of the pelvis, and finally every one of the distant metastatic lymphangitides. We may thus follow step by step, so to speak, the progress of the disease.