[Reprinted from the American Gyn/ecological And Obstetrical Journal 
for January, 1895.] 
THE MORBID CHANGES IN THE PUERPERAL ENDO- 
METRIUM DUE TO LOCAL INFECTION, AND THEIR 
RELATION TO GENERAL SYMPTOMS.* 
W. Reynolds Wilson, M. D 
The modern treatment of early infection in the puerperal state il- 
lustrates the theory of its origin. The point of attack has been proved 
to be the endometrium by the efficacy of treatment when applied to 
the cavity of the uterus in relieving the general symptoms. 
According to the classification of Bumm (i) there exist two pri- 
mary forms of puerperal endometritis : putrid and septic. Inasmuch 
as the developed manifestations of septic forms of endometritis de- 
mand surgical intervention and are more properly considered in the 
surgical discussion of the subject, we shall confine our attention to 
the origin of septic infection in the endometrium and to the local 
morbid changes due to putrid infection. 
Septic endometritis occurs in two forms : First, a localized septic 
process in which a granulating zone, shutting off the necrotic endo- 
metrium and preventing the invasion of germs, is present. The uter- 
ine lymphatics are not actively involved. The placental site, as in 
the putrid form, is most markedly affected. Secondly, a septic endo- 
metritis, accompanied by a general infection. Bumm has studied 
five cases belonging to this class, and has found' in three instances 
that infection has occurred by invasion through the lymphatic system, 
and in two instances along the course of the veins. In the first set 
of cases examination shows the placental site free from micro-organ- 
isms and thrombi; the lymphatics generally exhibit accumulations of 
streptococci and staphylococci which penetrate directly to the perito- 
naeum. In the second set of cases only the smaller lymphatic branches 
surrounding the sinuses are marked by colonies of cocci ; from these 
isolated lymphatic channels the accumulations of cocci penetrate to 
the larger lymphatics underlying the peritoneal covering of the uterus. 
* Read before the Philadelphia Obstetrical Society, December 6, 1894. 2 
W. Reynolds Wilson, M. D. 
The decidua is disorganized and infiltrated with a fibrous exudate 
presenting a diphtheritic appearance. In this class of cases, as well 
as in that just described, the granulation zone is absent. This fact 
has evidently an important bearing upon the function of such a zone 
of demarcation, in combating the progress of micro-organisms into 
the underlying tissues. 
Although putrefactive germs may be present in all forms of septic 
endometritis they do not predominate, consequently foetid lochial dis- 
charge, the sign of necrotic decidual tissue and disorganized thrombi, 
usually do not accompany the piore active septic processes. 
The active cause of puerperal septic infection attacking the en- 
dometrium is the presence of the pyogenic cocci (so called), namely, 
Streptococcus pyogenes aureus, the Staphylococcus pyogenes aureus and 
albus and the Streptococcus erysipelatus. 
These germs attack the endometrium upon the placental site or 
at points of denudation the result of lacerations about the cervical 
canal; abrasions and contusions of the vulva and vagina are less 
likely to communicate the infecting material to the general circula- 
tion on account of the less active lymphatic circulation from these 
parts owing to the comparatively moderate development during preg- 
nancy of the lymphatic vessels accompanying the pudic and uterine 
vessels, in distinction to the active development of those correspond- 
ing to the ovarian vessels running to and from the fundus of the 
uterus. 
The causes which predispose to local infection, inasmuch as they 
act as preparatory influences in their effects upon the endometrium, 
are, first, the earlier local changes due to former endometritis (notably 
the presence of infecting cocci in a dormant state) ; second, the con- 
stitutional character of the gravida, determining the power of resist- 
ance of her tissues to infecting elements ; third, the degree of uterine 
contraction ; fourth, puerperal hsemorrhage ; fifth, the presence of 
gonococci and the resulting local changes due to them. 
As to symptoms we find by examination in localized infection ab- 
dominal tenderness and imperfect involution, the uterine tumor pre- 
senting an abnormally yielding consistence. Internal examination by 
means of the speculum reveals a cervical portion covered with patches 
of discolored deposit (diphtheritic) alternating with areas of necrosis 
and granulation. The vagina is reddened, glazed and sensitive to the 
touch. Among the general symptoms we have those of a mild irrita- 
tive fever often marked by roseolous eruptions over the chest and 
neck, together with the presence of foetid lochia. In the acute form The Morbid Changes in the Puerperal Endometrium. 
3 
of infection with active lymphatic absorption there are present either 
the symptoms dependent upon peritonitis or those due to the active 
absorption of septic germs and their products, including pyaemia 
among these symptoms. 
In discussing the putrid form of endometritis it will be better to 
use the term necrotic endometritis, as the germs of putrefaction are 
only active in an environment of unorganized tissue. We shall also 
speak of saprophytes as mycotic organisms in contradistinction to their 
parasitic classification. 
The general symptoms accompanying necrotic endometritis are 
those which are classed under the head of sapraemia. A careful study 
of the pathology and aetiology of sapraemia will throw important light 
upon the development of these symptoms. In the broadest sense the 
cause of necrotic endometritis is the retention of putrid material 
within the uterus. This may be in the form of decidual debris or of 
putrid foetus ; it may be the result of sloughing following pressure, or 
of the previous condition of the endometrium, as in carcinoma or the 
various forms of non-puerperal endometritis. As to the pathology we 
have to deal with, first, a general necrotic condition of the endome- 
trium, and secondly, a condition of necrosis localized in the placental 
site. The remnants of decidua retained within the uterus, the placen- 
tal ddbris and the thrombi which project from the placental site are 
prone to putrefactive changes in the presence of saprophytes. Histo- 
logically we detect a necrosis of the epithelium and basement mem- 
brane, the necrotic tissue being cut off by an inflammatory zone of 
small-celled infiltration extending into the muscular layer and chok- 
ing of the lymph spaces. In other words this zone of reaction acts as 
a barrier against the products of putrefactive change; as a result of 
this we find that of all forms of puerperal endometritis this form is 
most distinctly localized in its effect. The only point where this 
protection is weakened is at the placental site. Invasion of the 
thrombi occurs here owing to the want of organization of the throm- 
botic tissue. At this point the sinuses become filled with necrotic 
material and the lymphatics surrounding them act as channels for 
the absorption of the bacterial and degenerative products of putrefac- 
tion. In this instance it is incorrect to speak of the process as an 
endometritis, as the muscular layer is involved in the process and the 
condition is better described as a metritis. A less frequent mode of 
invasion of putrid germs producing metritis is that by which the micro- 
organisms are absorbed from necrotic areas in the lower segment of 
the uterus and cervix the result of lacerations during parturition. 4 
IV. Rey?iolds Wilson, M. D. 
Unfortunately the bacteriology of putrid infection has not been 
worked out to the same extent to which the study of septic infection 
has been developed. We are led by recent researches however to in- 
clude many of the so-called non-pyogenic germs, among the pus-pro- 
ducing organisms. For instance within the last few years the specific 
germs, such as, the bacillus typhosis, and the Diplococcus pneumonia, 
as well as the Bacterium coli communis, (2) also the saprophytic germs, 
the Micrococcus tetragenus and the Bacillus pyogenes fcetidus, (3) have 
been classed as pyogenic organisms. We are further confronted by 
the fact that certain chemical substances under peculiar circumstances 
are capable of producing suppurative processes, as proved in the case 
of putrescin and cadaverin. 
Associated with this pathological condition we have the symptoms 
characteristic of two degrees of putrid infection or sapraemia, the mild 
and the grave form. In each case the morbid manifestations outside 
of the local condition are usually those due to a toxaemia, although, 
as noted above, the products of putrid changes may be capable of 
producing suppuration as in septic infection, so that at the present 
point to which recent investigation has led us we are not able to di- 
vide the sapraemic and septic infections distinctly as to their cause. 
The pathological changes, both local and general are certainly dis- 
tinct, but the chemical and bacterial products of sapraemia, on the one 
hand, are capable of producing suppurative changes analogous to 
those found in septic infection, while on the other hand the mild in- 
fections characterized by parametritic infiltrations and local accumu- 
lations of the pyogenic cocci are sometimes due to a mixed infection 
(putrid and septic) in which the irritative disturbance depends as 
much upon the chemical products of putrefaction as upon the pres- 
ence of septic germs. 
The grave septic conditions are often unaccompanied by symp- 
toms of local putrid changes, such as foetid lochia and the discharge 
of necrotic decidua. In this case the lymphatics have actively ab- 
sorbed the septic products and the local reactionary changes (small- 
celled infiltration and the formation of a dense inflammatory zone) 
have been moderate. In fact it appears to be the rule that where we 
take into account the seat of infection and the systemic action the 
result of infection we find the latter more pronounced in cases 
where the local changes have been of a mild nature. It has been 
suggested that the preponderance of the general over the local 
changes depends not so much upon the products of the bacterial 
elements set free at the point of infection, namely the ptomaines, as The Morbid Changes in the Puerperal Endometrium. 
5 
upon the death of the plasma contents of the bacterial cell itself the 
result of the combative qualities of the local cells (4). Abbott how- 
ever states : “We are not as yet in a position to say definitely to 
which of these influences the death of the tissue is due, or, indeed, 
that it is, when occurring spontaneously, the result of the action of the 
one to the exclusion of the other.” He believes that the local necro- 
sis occurring in suppuration is dependent upon both the poisonous 
products of growth of the living bacteria and the poisonous activities 
of the proteid constituents of the dead and disintegrating bacteria. 
In conclusion it is important to note that putrid changes at the 
seat of infection have an important bearing upon the spread of infec- 
tion, rendering the septic germs more active than they would be in 
attacking tissues unaffected by necrotic and putrefactive changes. In 
other words, the saprophytes, with or without causing symptoms of 
intoxication, may render the individual receiving them more suscep- 
tible to infection from other bacteria (5, 6). This fact bears upon the 
cases in which putrid changes in the endometrium accompany the 
grave symptoms of septic infection, such as those due to metrolym- 
phangitis and peritonitis. 
References. 
1. Bumm : Archiv f. Gyn., Bd. xxiii, p. 237. 
2. Abbott : Trans. Path. Soc. Phila., vol. xvi, p. 248. 
3. Janowski : Beitrag. z. Path. Anatom, und z. Allgemein Path., Bd. xv, Heft 1, 
p. 128. 
4. Buchner : Berlin, klin. Wochenschr., 1890, No. 20. 
5. Welsh : Amer. Text Book Theory and Practice of Med., Pepper, vol. ii. 
6. Goldscheider : Charite Annalen, Bd. xviii.