In women who have borne children the post-mortem inflammatory changes are more marked still. I have noticed this fact for years, and in nearly two-thirds of cases in this category inflammatory remnants are found. Winkel has laid stress on the same point. During the past two years, in 130 women, I found in seventy-six marked residues in the pars metrinm, pelvic peritoneum, ovaries and tubes. In nearly all of these eases the uterus also showed residues of former inflammation, especially the lacerated or cicatrized cervix; the latter were rarely found without the former.
Most frequently the residues in this class are found on the cervix and its parametral surroundings; these are nearly as frequent as superficial or deep lacerations of the cervix caused by parturition.
It is very rare that the edges of the lacerations become covered with epithelium and healed without giving rise to inflammation in the wall of the cervix and its surroundings. In such fortunate cases the edges of the lacerated cervix may be gaping so that the index can be introduced, but they remain parallel with the axis of the uterus, and even with lacer ations of from to 1 inch no eversion takes place. Such an organ usu ally presents during life a slight anteflexion, with its angle at the upper edge of the laceration, which is nearly always found firmly adherent to the parametrium, but there is no change in size and consistency.
Still more rare is the occurrence, that lacerations heal post-partum as perfectly as if they had been brought together carefully by suture. Out of several hundred cases I found this only twice.
Usually the lacerations of the cervix leave inflammatory remnants in its walls in the parametrium, and peritoneum. We may find the lacers, tion, with edges sharply everted by cicatrices, in the parametrium and in the vagina; the parts between the rents are found in a state of subinvo lution or chronic inflammation, or tumefied from venous obstruction caused by the cicatrices.
The mucous membrane of the everted cervix, and usually as far up wards as the characteristic membrane of the organ exists, has lost its epithelial covering and is diseased. At the upper portion of the rents, usually corresponding to the upper border of the distinct cervical mucous membrane, there is frequently a cicatricial narrowing (Muller's ring).
In a considerable number of cases the edges of the laceration are more or less irregularly anited by cicatricial tissue, and the external os is often narrowed. The tissue of the cervix is subinvoluted, it is firmer and has lost more or less of its elasticity. The muscular structure of the uterus
which radiates into the parametrium is also involved, as is seen to best advantage in the retractores uteri.
The changes in the broad ligaments, the vessels and the nerves, are more marked in this class than in those already described.
During life these uteri have lost more or less of their mobility. The cervix is usually displaced posteriorly or laterally. According to the changes in the tissues surrounding it posteriorly different forms of ante flexion occur; the angle is usually found where the diseased tissue termi nates. This formation of anteflexion can be easily observed during the puerperal state.
The cervix feels more or less hard to the touch, and seemingly more voluminous than the body of the uterus, for reasons which we have al ready laid stress upon A cervix so changed frequently becomes the seat of catarrh, which is the source of recurrent inflammations of the uterus and its surroundings.
In many post-mortem cases the uteri are found enlarged without pre senting any change in their normal consistency either of the cervix or body; the enlargement is either uniform or more marked in the body or in the cervix, the walls of which are usually thinner and longer.
With this condition of the uterus (subinvolution) large residues, es pecially in the peritoneum, are frequently found. Here often the uterus is readily replaceable, but again the organ is retroflexed and fixed. In both instances the cervix and its surroundings are generally normal.
In another class of cases similar changes to those which we have de scribed are found in the uterus and in the parametrium surrounding it, the organ frequently thus being bound closely to the adjacent pelvic organs.
In these cases we can observe well the course of the disease as it ex tends to the retractors uteri. By their firm connection with the sur rounding cicatricial tissue and the peritoneum, anteversion or latero ver sion frequently arises when the axis of the uterus has accidentally re mained straight during the inflammation. But if the contraction is more anteriorly and laterally, or if peritoneal residues play a role in the pos terior and lateral surroundings of the uterus, retroversion takes place; torsion of the uterus or a partial projection of its wall may sometimes oc cur, as is illustrated by Heitzmann. In the formation of anteversion, besides the parametric residues in the posterior surroundings of the cer vix, peritoneal and parametric residues between the uterus and bladder often also play a role.