This affection, as has already been observed, is invariably an exudative process; but it offers the greatest variety, both in reference to the plasticity of its product and to the condition of the diseased tissue, either in individual cases or in entire epidemics. The series is almost endless, but we may consider genuine uterine croup on the one hand, and the so-called genuine putrescence of the uterus on the other, as its extremes; the very fact of this great multiplicity of forms obliges us to limit our descriptions to the most prominent ones.

In certain cases we find the internal surface of the uterus lined by a yellowish or greenish dense exudation, of greater or less thickness and extent, either in small patches or investing the entire uterus, and either firmly or loosely agglutinated, and occasionally partially or entirely detached from the subjacent tissue, so as to appear corrugated or plicated. The uterine mucous membrane under the lymphatic coating is found reddened, tumefied, and slightly softened; the free parts are discolored, and invested with a dirty reddish or brownish secretion, and with remnants of the deciduous membrane. The exudation generally interpenetrates largely the exposed raw tissue of the placental portion of the uterus, and causes it to assume a peculiar ulcerated appearance. This is uterine croup.

In other cases the exuded matter is a gelatinous, purulent, dirty yellow, loose and easily detached layer, beneath which the internal stratum of uterine tissue appears spongy, infiltrated, soft, and may be easily detached in the shape of a dirty yellowish-red, or partly greenish and brownish pulp. The internal surface of the uterus presents, in addition to the lymphatic exudation, a glutinous secretion of a similar tinge.

Again, the internal surface of the uterus may not present a trace of coagulable lymph, but be invested by a purulent sanious and very discolored exudation, beneath which we find the uterine mucous membrane infiltrated, in more or less extensive or circumscribed patches, with a similar product; and it may either be easily removed in the shape of a thin and much-discolored pulp, or it has already become detached, and is mixed up with the contents of the uterus in the shape of friable discolored flocculi. In the place of the destroyed tissues, we occasionally discover the products of a reactive process, in the shape of a more or less consistent sanio-purulent secondary exudation.

Again, the internal layer of uterine tissue may be covered with a thin opaque or more dense, pale green or brownish, or dark chocolate or coffee-colored product, beneath which it is converted, to a greater or less depth, into a loose, infiltrated, fetid pulp, of a similar tint. This condition, which differs from ordinary sphacelus, has been termed putrescence of the uterus.

All these characters point to an exudative process, the-peculiar nature of which is fixed by the form of its product, and the condition of the substratum, and especially by the state of fusion of the latter. There are numerous states of transition between the forms described, and they not unfrequently become complicated with one another in such a manner that a process of a malignant nature follows one that is accompanied by a secretion of plastic lymph. As primary exudative processes, they are, if possible, to be distinguished from similar secondary processes which may occur in the course of the disease in consequence of a secondary affection of the blood, resulting from inflammation of the veins or lymphatic vessels.

As supplementary to the above, we have to examine those anomalies presented by the uterus, which are either direct reflexes of the processes in question, or which occur as accidental complications.

To the former appertain paralysis of the uterine fibres and impeded involution of the uterus in various degrees. According as the puerperal affection attacks the uterus, sooner or later after parturition or with more or less intensity, the womb is found of greater or less size, more or less relaxed, collapsed, softened; and certain portions that contain a large amount of cellular tissue, such as the lateral edges and the cervix, are infiltrated with a pale yellow, sero-gelatinous, or sero-purulent fluid. The external surface of the fundus and body of the uterus not unfrequently exhibit numerous shallow depressions, that are caused by the pressure of adjoining tympanitic coils of intestine.

Among the accidental complications we reckon sanguineous engorgement (apoplexy) of the neck of the uterus, the superficial or profound lacerations and contusions which occur at this point, and in the vaginal segment; the lacerations being invested with exudation of a more or less plastic character, whereas the contused parts not unfrequently appear in a state of gangrenous solution. We have to mention the sloughs of greater or less dimensions, which occur chiefly at the neck and vaginal portion of the uterus, and also in the vagina and the external genitals, in company with malignant exudative processes. These processes lead to ulceration and gangrenous fusion of the tissues, very often inducing extensive loss of substance in the external sexual organs and the neighboring parts; they render the prognosis of the individual case very unfavorable, both on account of the character of the original affection, as well as of the consecutive destruction which they entail.

Notwithstanding its close relation to the processes of exudation and fusion, which we have hitherto investigated, we think it necessary, on account of the novelty and scientific interest attached to the question, to devote a separate consideration to the dysenteric process occurring in the uterus after childbirth, or puerperal uterine dysentery.

The appearance presented by the inner surface of the uterus varies according to the intensity of the disease. In one case it is uneven, nodulated, and invested by a dirty reddish, or brownish fetid secretion; the projecting parts of the mucous membrane are covered with a grayish-yellow or firm greenish exudation, which here and there presents a fur-furaceous exfoliation, and the subjacent mucous membrane itself is generally converted into a yellow slough; the entire surface may thus in the advanced degrees present an appearance exactly resembling the impetiginous condition of the intestine in dysentery. The tissues of the uterus are infiltrated throughout with serum, and, as in the intestine, we find the projections to be more particularly owing to an accumulation of the serous fluid at certain points. In another and more advanced degree, which always runs a very rapid course, the internal layer of the uterus is found degenerated into a brownish-black, friable, loose or detached mass; the uterine cavity contains a fetid matter resembling coffee-grounds; the uterine tissue is flabby, pale, discolored, and more or less infiltrated with the sanious matter. The process may thus be said to represent essentially, what we must call, if consistent in our terminology, dysenteric putrescency of the uterus.

The uterus in this case is always very large, or, in other words, its involution is eminently retarded.

It is an additional evidence of the nature of this affection that it is often seen combined with true dysentery, or with the dysenteric process on the mucous membrane of the colon. The puerperal diseases occurring during the prevalence of a dysenteric epidemic therefore deserve a more careful examination and appreciation in reference to this point, both at the bedside and in the dead-room.

These processes are scarcely ever isolated, but are almost invariably complicated with others. The degree of connection existing between them and the complications, and between the complications themselves, differs very much; we shall consider these points more fully, as we are about to examine the more important of these processes separately.