3. Usually, when pain and fever appear, the patients have a chill, fairly violent, lasting from a few minutes to one quarter of an hour or more, and this is frequently at the beginning of the febrile period. Often, how ever, in multiparie, this chill is lacking. While in them the disease de velopes insidiously, so to speak, while the metritis, the inflammation of the uterus, follows progressively on the after-pains, in primiparm the onset is almost always more sudden, and to the well-being of the day before there succeeds chill, fever, pain, these three phenomena appearing sim ultaneously and more or less acutely.
At the same time the lochia are in part suppressed, diminishing notably, becoming reddish and foetid, occasionally excessively fcetid. If the dis ease breaks out before the establishment of lactation, this does not appear, or only incompletely. Constipation is the rule. Another phenomenon appearing simultaneously is arrest of involution. The uterus, instead of undergoing the retrograde changes which are usual during the early days of the normal puerperium, remains large, heavy, and at the same time is painful. Not uncommonly it increases in size, and on palpation it is found five to six finger breadths above the pubes— sometimes almost reaching the umbilicus, and feeling resistant, instead of having the char acteristic resiliency. On vaginal examination, this canal is hot, painful, and touching the uterus evokes the same painful sensations as external palpation. The uterus is less movable. The pain evoked bi-manually is ordinarily more acute on one side than on the other, and not infre quently within the first few days, there exists bogginess in one or another of the which is an indication of the extension of the inflam matory process to the neighboring parts. There exists in addition to metritis, a pare- and a peri-metritis.
The above state persists for a few days, and then either the disease tends towards cure, or else it is complicated by inflammatory processes in the organs adjoining the uterus. If the case remains uncomplicated, and the metritis tends towards cure, the pain gradually diminishes, the fever persists only towards evening, and is characterized purely by a gen tle elevation of the pulse and of the temperature. The pulse, which in the morning was 100, rises in the evening to 104 or 108, and the temperature, about 101° in the morning, rises to about 103° in the evening. The uterus begins to involute, very slowly however, and at the end of five to six weeks the patients may be pronounced cured. This is the case where the disease has remained local in the uterus.
Far otherwise is it the case usually, however, for then the inflammatory process spreads to the neighboring organs, the annexes of the uterus, the broad ligaments—in a word, we witness the development of peri- and pars metritis, abscesses, etc. Then the scene changes a trifle, according as
the process is localized at one or another point of the pelvis. But that which dominates still, and what indicates propagation, is the reappearance of the three signs, chill, fever, pain. The chill returns with the fever, but the pain is in some respects peculiar, its maximum being no longer just laterally of the uterus, but, according to the case, around this organ, in the iliac fosses, in the hypogastrium, invading the entire abdomen below the umbilicus. At the same time palpation gives very different sensations. While when the uterus alone is affected, this organ only is hard, the rest of the abdomen being soft; when peri- or parametritis, abscess, etc. exist, the entire region invaded by the inflammatory process is tense, owing to the deposition of plastic material, very appreciable to the touch, painful at the outset, and filling one or another of the hypogastric regions accord ing to the site of invasion. At first this plastic mass is readily isolated, but later the uterus is surrounded by it, and in a few days the bi-manual simply reveals density all around the organ. This mass is rarely smooth and uniform, but presents here and there projecting points, harder in places, and exquisitely sensitive on pressure. The vaginal bulge out, the uterus is deviated from the mid-line, and immobilized. Whatever the name given to this process, whether peri- uterine phlegmon, peri- or parametritis, pelvic peritonitis certainly exists, and the disease may follow two different courses. In the one, happily the most common, this indurated mass, after having increased for a few days, begins to resolve very slowly without suppuration, requiring a number of months, the general health improving as the mass disappears entirely. But, on the other hand, this mass, so hard at the outset, softens in places, ends by suppurating, and finally breaks, usually into the vagina or the rectum. The tumor then diminishes rapidly, and often recovery is speedy; usually, however, at the end of a few days, coil' and fever reappear, the temper ature rising to or over, and the tumor increases in size, the abscess having reformed, and thus many times we may witness the partial re filling and evacuation of the tumor, until it empties itself definitely, and recovery ensues. In other instances, again, the fever remains constant, and the patients, worn out by prolonged suppuration, succumb eventu-• ally to hectic fever.