THE UTERUS. ITS ADNEXA. AND NEIGHBORING ORGANS.
Inflammatory processes may affect each of the organs in the pelvis separately, or else spread from one to another. Thus the uterus alone may be affected, and we have a metritis with its varieties: endometritis, when the mucous membrane is alone diseased, and this may be or gangrenous, diphtheritic, or ulcerative; or else the metritis itself may be accompanied by inflammation of the serous covering of the uterus, and there may also exist peri- and parametritis, abscess, ofiphoritis, salpingi tis, etc. Each of these affections are characterized by peculiar symptoms, it is true, but they are generally insufficient to allow of precise clinical differential diagnosis. These affections, indeed, are masked under the symptoms emanating from the accompanying pelvic peritonitis. Metri tis is the initial phenomenon, and the other lesions are the result of ex tension.
We must here draw a sharp distinction between primiparre and multi. pane. While it is not rare in the latter to witness these inflammatory pro. ceases succeed the after-pains, which occur as a rule in them, and which are then peculiarly intense and persistent, the same does not hold true of the former, where the disease usually developer abruptly without pre monition. In primipane, indeed, after-pains are exceptional, and the disease breaks out while the woman is in nearly perfect health. In the multipara, on the contrary, after-pains are nearly the rule, but while these gradually diminish, to disappear entirely at the end of about thirty six hours, or else only to reappear when the child nurses, when they are about to be followed by inflammatory symptoms, they not rarely resist all treatment, and persist with a notable intensity and frequency, until the in flammatory process sets in. Usually, in these instances, there is a sensa tion of weight in the abdomen, which persists between the after-pains, and is accompanied by a hardness of the uterus, which is in marked con trast with the softness it customarily presents during the first few days of the puerperium.
It is rarely before the third or fourth day, sometimes, however, as early as the second, that the initial symptoms appear. Up to this time the
general and local state is satisfactory, there is no fever, when, of a sudden, appear simultaneously, as it were, three symptoms, two of which are ab solutely constant, and the third nearly the rule. These three symptoms are: 1. Pain; 2. fever; 3. chill.
1. Pain.—At times insidious, dull, continuous, and again sudden, very acute, pain is characterized by the fact that it is always spontaneous and always increased by pressure. Further, there is always one spot where on pressure it has a maximum intensity. Although, indeed, the entire uterus is sensitive to pressure, it is in particular in the lateral regions that pain is most intense, and in those instances where it is least marked spon taneously, and where it shows itself simply by a sensation of weight, and tension in the loins and abdomen, it suffices to press with the finger to the right or left of the uterus in order to excite the pain more acutely.
Usually this tenderness on pressure is on both sides, but it is not rare for it to be unilateral and more pronounced on one side than on the other. The uterus, checked in involution, is harder, tenser, more resisting. At times, indeed, it seems to be more voluminous. If the abdomen is pal pated beyond the region of the uterus, it is painless—in a word, the pain is localized over the uterus, the abdomen is either not tympanitic, or else only to a degree, in the hypogastrium. The striking point then is that the pain is localized purely over the uterus.
2. Coincidently with the pain, there is rise of temperature, which, while moderate in general, is very marked. The pulse is rapid, although usually not above 100 to 110; ordinarily, indeed, it remains at 88 to 104. The temperature rises from 101° to 103°, rarely reaching 104°. The skin is hot, bathed in perspiration, but the facies is calm, not altered, and the general state is fairly satisfactory. The patients, nevertheless, corn plain of a feeling of malaise in addition to the pain.