Part 153

It is by no means easy to decide as to the precise nature of local inflammations following lacerations of the cervix and the bruising or crushing of the soft parts in long or instrumental labors. The marvellous absence of heat, pain, redness, and swelling in wounds treated in strict accordance with the principles of Lister, the very slight reaction when the atmosphere is pure, and the severity of these symptoms in overcrowded hospitals, tend indeed to strengthen the belief that even the simplest inflammations proceeding from wounds owe their origin in great part to septic germs. But, on the other hand, in hospital practice it is not uncommon to observe puerperal inflammations and febrile conditions which possess this distinctive peculiarity--that they in no wise visibly affect the health of puerperal patients in their vicinity. The symptoms of blood-poisoning too are either absent or present to a subordinate extent. Probably the difficulty is best solved by assuming with Genzmer and Volkmann that there is such a thing as an aseptic surgical fever due to the absorption of the products of physiological tissue-changes at the seat of injury. In surgical cases, even where the precautions of Listerism have been faultlessly observed, febrile movements of considerable intensity, but of no prognostic signification, are of frequent occurrence. While in puerperal women we can never exclude the possibility of the septic infection of puerperal wounds, it is in accordance with clinical experience to assume that a high fever belonging to the aseptic class may coincide with a septic process of insignificant proportions.

GENERAL SYMPTOMS.--As in other infectious diseases, there is, from the time of the entry of the poison into the system up to the outbreak of fever, a distinct period of incubation. The first febrile symptoms usually occur within three days of the birth of the child. An attack coming on a few hours after childbirth is indicative of infection during or previous to labor. The third day is the one upon which ordinarily the beginning of the fever is to be anticipated. After the fifth day an attack is rare, and at the end of a week patients may be regarded as having reached the point of safety. Apparent exceptions to this rule are probably referable to cases of mild parametritis, in which the initial {1005} fever and the pain were insufficient to attract attention to the existence of local inflammation.

The symptoms of puerperal fever vary with the character of the local affections and with the extent to which the general system participates in the disturbed action. The different groups of puerperal processes possess the following pathognomonic symptoms--viz. increased temperature, enlargement of the spleen, disturbed involution, and sensitiveness of the uterus upon pressure (Braun).

In most cases the fever is ushered in by chilly sensations or by a well-defined chill. This symptom, however, does not possess much prognostic importance. A chill is significant of a sudden change between the temperature of the skin and that of the surrounding medium. It may, therefore, be absent in pernicious forms of fever, provided only that the temperature changes are inaugurated slowly, whereas it may follow a trifling increase of the body-heat if, as sometimes happens in sleep, the moist skin is exposed to cool currents of air. Repeated chills indicate phlebitis and pyæmia.

In order to grasp the many symptoms of puerperal fever, it is necessary to keep separately in mind the clinical features of each of the local processes, although in fact the latter rarely occur singly, but to a greater or less extent in combination with others.

The symptoms of ENDOMETRITIS AND ENDOCOLPITIS.--The uncomplicated catarrhal inflammation of the uterus and vagina is the most frequent and the mildest of the diseases of childbed. In endometritis the uterus is large, flabby, and sensitive upon pressure; the after-pains are often unusually severe, involution is retarded, and the lochia become fetid, remain sanguinolent for a longer period than usual, and at the outset may be temporarily suspended. Sometimes the large intestine is distended with flatus. In endocolpitis the vaginal discharge is thin and purulent, the patient experiences pain and burning in the acts of defecation and urination, and, where the wounds of the vulva and vagina assume an ulcerative character, there is often found at the same time inflammatory oedema of the labia.

The fever in these cases is ushered in frequently, but not always, by chilly feelings, and the temperature reaches its height usually upon the evening of the third or fourth day, is remittent, almost intermittent in character, and rarely exceeds 102° to 103° F. In mild forms the occurrence of the fever is often overlooked or is referred to disturbance produced by the secretion of the milk. In severer attacks the febrile symptoms may continue from three to seven days. At the end of a week the swelling of the labia subsides, the discharge becomes thick, and ulcers, if present, begin to assume a healthy granulating appearance.

In diphtheritic ulcerations, and in endometritis due to decomposing remains of the ovum, the load condition is often complicated by the invasion of the neighboring tissues.

The symptoms of PARAMETRITIS and PERIMETRITIS (Pelvic peritonitis).--The symptoms of these two affections, as would be naturally {1006} expected from the proximity of the peritoneum to the pelvic connective tissue, for the most part overlap. It must be very rare for one form to occur entirely independent of the other. For this reason it will be found convenient to consider first the symptoms common to both morbid processes, and subsequently to direct attention to what are believed to be points of distinction between them.

During the period of incubation there are usually no prodromic symptoms. Elevations of temperature in the course of the first twelve hours following labor are equally frequent under perfectly normal conditions. Suspicious symptoms are disturbed sleep, excessively painful after-pains, and a pulse of 80 to 90.

The beginning of the fever occurs in 90 per cent. within the first four days of childbed; most frequently upon the second or third day, and taking place upon the fourth day in scarcely 12 to 15 per cent. of the cases. If five days have elapsed without fever, the period of danger, with very rare exceptions, may be regarded as having passed.

At the outset the fever, especially in perimetritis, is ushered in by chilly sensations or by an intense chill. The temperature rises rapidly, though the highest point is usually not reached before the second, and in rare cases not before the third, day. In most cases the heat in the axilla exceeds 103°, and may even mount up to 105°. The decline occurs gradually, the fever ending in 70 per cent. in the course of a week, in 20 per cent. in two weeks, and only in 10 per cent. extending beyond that period. Protracted cases indicate abscess formation.

The fever does not, however, always pursue a regular course. In place of progressively declining until the termination is reached, the high temperature of the second day may be attained upon one or more occasions. The morning remissions are at first slight, but become marked as the disease approaches its close. In cases of long duration the morning hours are often free from fever, a circumstance calculated to mislead a physician who sees his patient but once a day. A pulse of 80 to 90 beats, a disturbed sleep, lack of appetite, and sensitiveness to pressure upon the sides of the uterus are, however, symptoms which should serve as a warning of some disturbing cause, and should lead the physician to renew his visit in the latter part of the day.

If, from a mistaken notion that the morbid process has come to an end, the patient is allowed prematurely to resume her household duties, the pains across the abdomen and along the hip and thigh return, and an examination reveals the existence of exudation in the pelvic cavity or upon an iliac fossa.

Errors of this kind are most frequent in cases of parametritis associated with slight peritoneal inflammation, as the local pain is then insignificant, and the initial chill, happening on the third or fourth day, is apt to be ascribed to engorgement of the breasts.

Relapses after the complete disappearance of febrile disturbance occur in 15 to 20 per cent. They are usually shorter, but sometimes more obstinate, than the original attack. As a rare exception may be mentioned cases with evening remissions and morning exacerbations.

In circumscribed pelvic inflammations the pulse rarely exceeds 120 beats to the minute. A pulse of 140, of more than half a day's duration, betokens severe septic complications, and is therefore of evil omen. In {1007} some cases the slow pulse observed after labor makes its influence felt in the first day or two of the fever, so that the curious phenomenon may be witnessed of a temperature of 104° coinciding for a time with a pulse ranging between 50 and 70 beats to the minute.

As regards other symptoms, headache and sleeplessness are rarely absent. Profuse sweating follows the first febrile attack, and frequently recurs during the course of the disease.

Pain is present at the onset in the majority of cases, and is then usually most violent. The spontaneous pain, which is due to the affection of the peritoneum, subsides in great part in the course of one or two days, but the sides of the uterus remain sensitive to pressure. In the rare cases of pure parametritis, however, this symptom may be absent altogether. The pain, like that from the inflammation of serous membranes, is of a lancinating character. Sometimes it is associated only with the contractions of the uterus. After-pains occurring under unusual circumstances, as in primiparæ or after the third day, are to be regarded with suspicion.

Vomiting occurs occasionally, but is comparatively rare unless the peritonitis becomes diffused and spreads to the region of the stomach. The appetite is lost, and only returns, as a rule, with the departure of the fever. The tongue is coated and moist, and constipation is common. In other cases there is diarrhoea with rumbling in the bowels, but without pain or tenesmus. The urinary secretion is rarely interfered with, and when this is the case it indicates the extension of the inflammation to the peritoneum covering the bladder.

Most cases of perimetritis and parametritis terminate in five or ten days, the fever and other symptoms gradually subsiding. When, as may happen in exceptional instances, the temperature falls suddenly from a high degree to one below the normal level, the body grows icy cold, the pulse becomes small and irregular, and symptoms of collapse develop. But in twelve to twenty-four hours the symptoms of collapse subside, and the disease reaches its end with a disappearance of the alarming manifestations.

If the fever subsides within a week exudation is somewhat rare. Its continuance beyond that date should lead to a careful exploration of the pelvic organs. The exudation is usually demonstrable in the course of the second week or at the beginning of the third week. It is recognized, according to its location, by external or by internal examination, or, where the deposit is considerable, by both methods. In most cases the deposit is extra-peritoneal, and is situated between the folds of the broad ligament, above and to the sides of the vaginal cul-de-sac. It has generally a rounded form, though with less convexity than fibrous and ovarian tumors. Sometimes, however, the tumor is flat below, like a board. It seldom exceeds in size that of a large apple. In fresh exudations the sensation produced is often that of a hard tumor surrounded by a softer layer, due to continued succulence of the soft parts. In a few weeks they may reach or exceed the hardness of a fibroid tumor. The older the tumor, unless suppuration sets in, the less sensitive it becomes. Often the exudation extends to the pelvic walls. The uterus, as a rule, is fixed, and in cases of large tumors becomes pushed toward the opposite side, while as a consequence of later shrinkage the fundus may be drawn permanently toward the affected side.

{1008} The cul-de-sac of the vagina is rendered broader and flatter by the pressure of the deposit, or, when the tumor is deep enough, the vaginal surface may be rendered convex. Behind the uterus the exudation is as it were flattened antero-posteriorly, and in some cases it may be felt in the form of rigid bands between the posterior ligaments which enclose the cul-de-sac of Douglas. The ante-uterine tumors have a spherical shape and depress the vagina anteriorly.

Tumors situated in the iliac fossa have a more or less convex form, and may be of such considerable size that the swelling may be recognized by the eye through the abdominal walls. As the exudation between the broad ligaments may in these cases have been slight from the beginning, or may have subsequently disappeared by absorption, the iliac tumors have often apparently a spontaneous origin.

Sometimes the uterus is surrounded by exudation, and the entire pelvis appears as though it were a mould filled with a solid mass. The fornix is then often pressed downward, and irregular rounded masses are to be felt through the vaginal walls.

The recognition of parametritic tumors through the abdominal coverings is possible when they are situated above Poupart's ligament, in the upper portion of the broad ligaments, and in the iliac fossæ.

The pain and the functional disturbances in the pelvic organs depend upon the size and situation of these inflammatory deposits. Of the functional troubles may be mentioned frequent and painful micturition, obstinate constipation and difficult defecation, contractures of the ilio-psoas muscles when the exudation is seated beneath the sheath or between the muscle and the pelvic bones, disturbances of motility in the abductor muscles, paresis of the lower extremities, and radiating pains in the upper portion of the thigh and in the renal and lumbar regions, produced by pressure upon the obturator, the crural, the cutaneous, and the sciatic nerves.

So long as fever is present the exudation rarely diminishes. If absorption takes place in one point, growth almost certainly follows in some other direction. When, however, the apyretic period is reached, the exudation, as a rule, disappears rapidly, so that often in the course of six weeks no trace of its existence remains. In a smaller number the solid mass may persist for months or even years.