Puerperal metro-peritonitis is characterized by symptoms which prevent its being confounded with any other puerperal process, although at times it complicates metritis, and while it may have a prodromic period, usu ally its onset is abrupt, sudden, and within the three days following de livery.
The first symptom is a chill, usually a single one, lasting for one half to three quarters of an hour, violent enough to shake the bed on which the woman lies. This chill is accompanied by a sensation of extreme cold, so much so that it is with difficulty the patient can be made to feel warm, and this sensation may persist for a number of hours. The chill is rarely lacking, and is followed by an intense fever.
Coincidently with the chill, or immediately following it, there occurs pain, which is acute, spontaneous, extending over the entire abdomen, although localized in places at the outset. Beginning in the sub-umbi heal region, the maximum point of the pain is in the latero-inferior regions of the uterus, at the site of insertion of the broad ligaments, and thence it spreads rapidly until eventually the entire abdomen is sensitive. This pain is spontaneous; the patients can scarcely bear the weight of the bed-clothing; it is increased by pressure, by movements; it has periods of exacerbation, when the women shriek out from its intensity. At the end of two to three days this pain ordinarily disappears, but we must be careful not to thence draw a favorable prognosis, for this insensibility of the abdomen is on the contrary, in the majority of cases, a sign of aggra vation in the general condition. Under the effect of this pain the facies alters, becomes drawn, pale, and the vital forces diminish.
The abdomen swells, as it becomes painful, from paralysis of the intes tines, and consequent distension with gas. At the outset, indeed, the coils of intestine are outlined under the skin. The percussion note is tympan itic all over the abdomen, when the distension is extreme. In general, pain is in inverse proportion to tympanites; the more the abdomen is dis tended, the less the pain and vice versa; so that when the distension has attained its maximum, the abdomen is absolutely painless.
Concurrently with the chill, pain, and ballooning of the belly, appears fever, and here we must consider separately the pulse rate and the tem perature rise.
The pulse rate in puerperal peritonitis is always very frequent, and this frequency is directly connected with the intensity of the disease. In general, at the beginning, it ranges between 110 and 120 pulsations, although it may rise above 120. It never, however, falls below 100. At first strong, full, resisting, it diminishes later in force as it increases in frequency, until it becomes very small and compressible as the disease approaches its height, and in the period of decline the pulse becomes so small and frequent that we cannot count it. At the same time, the skin
becomes cold and covered with clammy sweat. Ordinarily the pulse is accelerated towards evening, diminishing towards the morning, but always remaining above 100. This is a point on which we lay great stress.
Like the pulse, the temperature presents variations, and like it a high figure is constant. While in simple mstritis it rarely exceeds 103.4° to 104°, it is the rule in peritonitis to see it rise above to 105" and over, and further the rise of temperature is not in proportion to the pulse rate. The elevation is most marked in the evening up to the end of the disease, when the temperature falls notably, at times becoming even sub normal. As Wunderlich says: " Sub-normal temperatures are especially seen in peritonitis, and they should always awaken our suspicions. Death often occurs during this sub-normal stage." Digestive disturbances are constant accompaniments of peritonitis, such as vomiting, diarrhoea alternating with constipation. Vomiting is only exceptionally absent, and appears usually as soon as the disease is well established, but after the occurrence of chill, fever, pain, and tympanites, usually at the expiration of ten to twelve hours. Often preceded by nausea and hiccough, it again frequently d3velopes suddenly. In any event it has characteristic features. Constituted, at the outset, by water and mucosities, it soon becomes bilious and then spinachy. At first with effort, the vomiting gradually merges into pure regurgitation, becomes incessant, and in surprising amount. Vomiting of this nature usually persists throughout the course of the disease, although at times it ceases spontaneously at the end of twenty-four to forty-eight hours. The prog nosis is no more favorable, however, unless the fever and the tympanites diminish concomitantly At the outset, constipation is generally present, but to it succeeds a profuse diarrhoea, on the appearance of which the vomiting frequently ceases. The stools are at first solid, then glairy and involuntary, and finally are composed of bile mingled with bloody mucus. There is always marked ftetor to the stools. At the same time the tongue, which has been moist, thick, white, cleanses and becomes red, pointed, although still moist, only becoming dry at the height of the disease or before death. Then it is dry and blackish; the gums, the teeth, the inside of the lips being covered with blackish material streaked here and there with red. The speech becomes thick and difficult; the thirst excessive, in a word, the typhoid state is very marked. Commonly the patients are slightly jaundiced, particularly when the peritonitis is generalized.