We have here to advert briefly to two symptoms that occur during the course of puerperal peritonitis, and which not unfrequently coexist - they are, vomiting of the biliary matters contained in the duodenum and the stomach, and of the sero-feculent matters that rise from the intestine, and diarrhoea. The former is to be explained by the paralysis of the muscular coat of the intestine, caused by the peritoneal exudative process, and the fixation of the intestine by plastic exudations; it commences at the duodenum and the stomach, the peritoneal covering of which generally remains unattached. The latter is caused by the exudative process, and the consequent irritation of the intestinal muscular coat, which forms a counterpoise to, and even counteracts, the paralysis at some points; it is the more frequent and the more considerable the less marked the paralyzing influence of the peritoneal affection is.

Almost all organs appear in a state of relaxation, which is proportioned to the primary or secondary dyscrasia of the blood, and to the extent in which the blood has become deprived of its fibrine by the fibrinous exudations caused by inflammations of the peritoneum, the pleura, etc. It is owing to a moistening or imbibition of the tissues with the attenuated serum of the blood, which easily exudes through the vascular coats, and is for the same reason coupled with pallor or discoloration, owing to the coloring matter which adheres to the serum. In the abdomen we find that the kidneys and the liver are chiefly distinguished by the softening, pallor, or pale red discoloration, oedema and imbibition, relaxation and friability of their tissues. In the thoracic cavity, the lungs are chiefly affected by these and similar deviations; the muscular portion of the heart, too, is, like the other muscles, and especially those that are involved in the peritoneal inflammatory process, soft, pale, moist, and lacerable. All the serous membranes and the lining membrane of the vessels are infiltrated with serosity, and are more or less reddened, and the serous cavities contain various quantities of a transuded, pale or dark-red serum. The brain alone, as in numerous other allied processes, e. g. in typhus, forms an exception, inasmuch as it appears denser and harder, drier and paler, than usual.

The spleen is very frequently, though not always, tumefied; it is so particularly in secondary disease of the blood, whether or not accompanied by the secondary processes (deposits), that we shall subsequently have to notice.

The lungs are reduced in size, and denser, in consequence of the upward pressure exerted by the contents of the abdomen; their inferior lobes are of a dark purple color, and in a condition of passive hyperemia.

"We now proceed to enumerate the separate morbid processes in the different organs, and to point out their relations to the original puerperal disease.

Our first attention is due to the exudative processes on the various mucous and serous membranes. That affecting the intestinal mucous membrane is of particular importance. The entire tract is generally involved; it is but slightly reddened, and commonly exhibits a thin, watery, serous, or viscid gelatinous, or gelatino-purulent or genuine purulent product; the tissue fuses, and the submucous cellular tissue is more or less infiltrated. In this manner the diarrhoeas of the puerperal state are established. The exudation is rarely of a firm, fibrinous, or croupy nature, but most commonly its serous character predominates, and this is the more the case the larger or more fibrinous the product, resulting from the coexistent attack of peritonitis. In certain cases the process that takes place on the mucous membrane of the colon assumes a dysenteric type, and as in the above-named forms, corresponds to the exudation upon the internal surface of the uterus or to the product of metrophlebitis. Similar processes, though generally accompanied with a coagulable product, are occasionally discovered upon the mucous membrane of the stomach, the oesophagus, and the bladder, and in the lungs in the shape of (partial) aphthous pneumonia; this is chiefly the case when the blood has not been exhausted of its fibrine.

Among the exudative processes that take place on serous membranes, the most frequent, after that occurring on the peritoneum, is pleuritis, which is often coexistent with peritonitis; pericarditis is of less frequent occurrence. We also meet with exudations in the synovial bursae, and especially in that of the knee-joint, the sterno-clavicular and humoral articulations, and, lastly, in the capsule of the humor aqueus. The exudations are generally very copious, fibrinous, and purulent. A thin soft exudation is often found upon the dura mater, accompanied by a slight reddening of the latter.

All these processes may be variously combined, and they are dependent upon the primary or secondary disorganization of the blood, and especially upon that caused by the absorption of pus in metrophlebitis.

Next in order come the processes dependent upon secondary phlebitis of the larger veins, and of the capillary venous systems of various organs and tissues.

The former are generally developed in the vicinity of the original morbid affection, as in the plexus pampiniformis, the trunk of the internal spermatic vein, the internal iliac and crural veins; though they frequently, too, are generated at a distance, as in the cerebral sinuses and the pulmonary artery. These give rise to the so-called metastases or lobular abscesses, which we shall now proceed to examine.

We often find larger or smaller circumscribed spots in the most various organs and tissues; the dark-red points of congestion, or small accumulations of pus or sanies, which we have repeatedly adverted to. They are remarkably frequent and numerous in the organs of sanguification, especially in the lungs and the spleen; they are next seen in the kidneys, and more rarely in the liver; they are occasionally met with in the brain, in the thyroid and parotid glands; in all muscles, particularly in the heart; in fibrous tissues, as in the dura mater and the periosteum. Again, they are very common in the mucous tissue, especially of the bladder and the intestines; they occur throughout the cellular tissue, but they seem to predominate in the cellular tissue of the extremities, of the mediastina, of the neck, the iliac muscles, and the intestines and stomach.

We have already demonstrated that these processes are either genuine exudative processes, or that they consist in a coagulation of the blood within the capillaries (capillary phlebitis). In the latter case the coagu-lum fuses in a manner corresponding to the disease of the blood, and to the deleterious matter absorbed into the blood, and forms a purulent sani-ous fluid or gangrenous pulp (metastasis puerpcralis septica).

They may probably be invariably considered as the result of a secondary infection of the blood, of a poisoning of the blood by the introduction of some product from the original nidus of disease, and particularly of venous pus and sanies in metrophlebitis. They consequently always give rise to purulent and sanious products, and terminate fatally as capillary phlebitis. They enter into various combinations with one another, and with the exudative processes occurring upon serous and mucous membranes. Owing to their position at the surface of the organs, we always find that pleurisy supervenes upon their occurrence in the lungs, and peritonitis upon their deposition in the spleen.

A black softening of the mucous membrane of the fundus ventriculi, or of the oesophagus, or of both at the same time, which is indicated during life by the vomiting of black coffee-grounds-like matter, is of frequent occurrence. It not rarely reaches that degree of intensity, that the fundus of the stomach, and sometimes the diaphragm also, and the oesophagus, with the adjoining cellular tissue and mediastinum, are ruptured, and the fluid that would have been evacuated by the mouth is effused into the abdominal or thoracic (especially the left) cavities.

After difficult labor, the cartilages of the pelvic synchondroses are liable to inflammation, in consequence of the traction exerted upon them, and if the blood has assumed a septic constitution, the inflammation may terminate in gangrenous fusion of the cartilage, the latter being converted into a dirty brown and very much discolored fluid, contained within the investing ligamentous tissue.

The blood contained in the cavities and larger vessels presents various and more or less evident changes. Its fibrine may be converted into consistent, viscid, greenish-white, or yellowish coagula; or after previous extensive discharges of fibrine it may be attenuated, watery, exuding tin ough the coats of the vessels and the adjoining tissues, and presenting but few and trifling, gelatinous, soft coagula. Again, after previous purulent or sanious absorption, it is of a dirty brown-red or chocolate color, viscid, glutinous, depositing dirty white, opaque, fibrinous concretions, which in the heart form numerous ramifications, or presenting dark-red coagula, which are paler at the surface, and fusible. Lastly, if the disease has run a rapid course, the blood is much reduced in quantity, and even without defibrination having taken place, it is attenuated and discolored, and transudes all the tissues. The fibrine is sometimes found deposited on the valves of the heart in the shape of vegetations, without the demonstrable occurrence of previous pericarditis. The severe jaundice affecting women during the puerperal state is always dependent upon pyaemia, and never upon an appreciable derangement of the liver.

The formation of bone occasionally noticed on the external and internal table of the skull after parturition is, as we have already observed, in no connection whatever with the puerperal process.