Such is the ordinary clinical picture of the progress of puerperal metri tis, when it is present in its most striking form. In certain cases, how ever, the progress of the accompanying pelvic peritonitis is still more in sidious. The general phenomena are scarcely pronounced, the febrile reaction insignificant, the abdominal tenderness not marked, the tume faction and bogginess scarcely apparent, and it is only the touch which will reveal the existence of the process. Cure, in these instances, is the rule. Unfortunately, by the side of this relatively benign form, there are two others far more grave, for they are rarely recovered from, and these are the suppurative and the gangrenous forms of metritis.
In case of suppurative metritis, whether the process invades only the tissue of the uterus itself, which is exceptional, or the veins or lymphatics, which is the rule, the general phenomena are much more severe; if the pain is not more intense, the fever is and the pulse often exceeds 120 pulsations, the chills are more violent and more frequently repeated with notable irregularity. The temperature rises to 103° and even 106°, the facies alters, the patients are in a state of more or less pronounced stupor and prostration, the tongue is dry, sometimes there is vomiting of bile, but, curiously enough, the process does not tend so much to extend be yond the uterus. The abdomen is less sensitive, the same hard tumor is not found in the hypogastric or iliac regions, the uterus itself is less pain ful on pressure, but the general condition is far more serious, and in a few days, the general phenomena become more intense. The fever goes on
increasing, and then appear delirium, coma, frequent, painful respiration. Foetid diarrhoea succeeds to constipation, followed by involuntary dejec tions and death, which is the rule in these instances. The lochia are ordi narily suppressed, and where they persist a trifle the odor is more intense.
In gangrenous metritis the striking characteristic is fcetor of the lochia, so intense that it simply poisons the entire ward, and the color is black ish, the contents being often gangrenous shreds. Gangrene is rarely limited to the uterus alone, but spreads to the vagina and the vulva. Prostration is extreme, the facies greatly altered, the pulse small, worth less, very frequent. There is a general tendency to refrigeration. The face is pale, dusky in spots, the lips are blue, the eyes dimmed, the patients are in a constant state of semi-delirium, the abdomen is more or less tympanitic, and not very sensitive, and the patients again usually die. We would add, further, that gangrenous metritis, usually the result of trauma during operations, breaks out more quickly than simple or sup purative metritis, usually on the day following delivery, increasing pro gressively and ending in death within four to five days.