Under this head we include diseases to which the uterus is liable in consequence of the puerperal state, which are essentially (in reference to causation) connected with the latter, and especially with the concurrent detachment of the membranes and the placenta from the inner surface of the uterus, and which, for that reason, must be termed puerperal affections. We pass over the subjects which have already been discussed, and enter at once upon the consideration of these diseases in the following (natural) sequence.

1. On Defective And Irregular Contraction And Involution Of The Uterus After Childbirth

We occasionally find that the uterus presents a condition of universal flabbiness or collapse of its parietes, accompanied by a trifling reduction of size, which must be considered as paralysis from exhaustion, and which results from tedious or instrumental labor, or from parturition, the first stages of which had been much accelerated. In other cases, and they are of frequent occurrence, we find the fundus and the neighboring parts of the corpus uteri to be the seat of excessive contraction and energy, whilst the inferior segment is in a contrasting state of atony and collapse; there are other cases again in which excessive contraction prevails at the middle of the uterus forming a zone round it, or at smaller and less defined portions. These occurrences may be brought about by the most various impediments to parturition, by pressure, contusion of the uterus, apoplexy of the womb (vide page 217), by original irregular innervation of the uterus, etc. As may be supposed, they give rise in the first instance to hemorrhage, and in consequence of this and of the general debility, they impede the further involution of the uterus, and thus protract the disposition to puerperal affections. We must here mention a very singular circumstance, which may, on account of the consequent danger, become important, and may even be misunderstood in post-mortem examinations; it is paralysis of the placental portion of the uterus, occurring at the same time that the surrounding parts go through the ordinary processes of reduction. It induces a very peculiar appearance. The part which gave attachment to the placenta is forced into the cavity of the uterus by the contraction of the surrounding tissue, so as to project in the shape of a conical tumor, and a slight indentation is noticed at the corresponding point of the external uterine surface. The close resemblance of the paralyzed segment of the uterus to a fibrous polypus, may easily induce a mistake in the diagnosis, and nothing but a minute examination of the tissue can solve the question. The affection always causes hemorrhage, which lasts for several weeks after childbirth, and proves fatal by the consequent exhaustion. We have met with it twice, once after abortion, and once after parturition at the full period.1

1 Dr. Betschler, during his visit to Vienna in 1840, communicated a similar case to me as having occurred at Breslau; and there can be little doubt that Dr. Burkhardt (vide Berliner Centralzeitung, x, 19) speaks of this condition, under the title of acute fungus hurinatodes uteri, as of a new and hitherto unknown cause of flooding after childbirth.

Lastly, we observe that the contraction and involution of the uterus is more or less permanently impaired by all the different puerperal inflammatory processes.

2. Puerperal Inflammations

Puerperal inflammations generally, are in most cases of a very complicated nature, and it is of extreme scientific and practical importance that we should obtain a comprehensive sketch of their anatomical bearings, as well as an analysis and correct interpretation of the constituent phenomena. If we consider puerperal inflammation of the uterus by itself, we find that it always appears in the shape of an exudative process, affecting the raw exposed surface of the uterus to which the placenta had been attached; in reference to its original seat,* it must therefore always be considered as endometritis. We shall first have to examine into the characters of this affection, and then proceed to investigate other important puerperal diseases; after which, we shall give a summary and an analysis of changes taking place in organs and tissues that do not belong to the original seat of disease, and conclude with a consideration of the issues and consequences of primary and secondary puerperal affections.