After localization of the process, the phenomena differ according as the inflammatory products are rapidly absorbed; or where they become enclosed by pseudo membranes and form adhesions between the organs, remaining in a more or less liquid or hardened condition for a long time, or sooner or later changing into pus. Iii favorable cases, where the in flammatory products are rapidly absorbed, (the whole process may have lasted only a few days,) no changes can be appreciated, shortly after the termination, by palpation or bi-manual examination; but post-mortem findings teach us that these processes rarely occur without leaving adhe sion& If the process continues for a long time, with pain and fever, pseudo membranes and adhesions are formed to a greater extent. Under such circumstances, tumor-like masses, more or less unyielding, may be felt through the abdominal walls in the course of a few weeks. These phe nomena are produced by fixation of the intestines or agglutination of the same to the lower part of the abdominal wall, or by agglutination of the colon, mesentery, broad ligament, and other pelvic organs. By bi-manual examination it is found that the parametrium is not largely involved in the process, but the changes which can be felt through the abdominal wall, the displacement and fixation of the uterus and its appendages, are evident.
In cases of long duration, occasionally in a short time, the process re salts in an accumulation of exudative material in the spaces formed by the pseudo-membranes and adhesions, resulting in tumors. The most frequent seat of these accumulations is Douglas's cul-de-sac. They are not always situated in the median line, but may be formed at the sides of the uterus, extending through the inlet of the pelvis to one or the other iliac fossa. The formation of such encysted exudations is not of frequent occurrence, and if they are situated near the uterus, it is difficult to decide whether they are intra- or extra-peritoneal; but that such intra•peritoneal accumulations may occur, is well proved by post-mortem findings. The fever and pain sometimes subside after the formation of these masses, but the not well defined soft tumors may be felt unchanged for a long time through the abdominal wall. Sometimes fever is present from the begin ning of the process, and this is due to the formation of pus. In other cases the encysted exudation is changed later into pus, giving rise to fe brile symptoms, and in this way intra-peritoneal abscesses may be formed, which may perforate through the abdominal wall or intestine.
In acute pelvic peritonitis, the uterus and its appendages and the parametrium are usually involved. Inflammations of the uterus lead in rare cases to the formation of abscesses in its walls. The tubes, accord ing to the nature of the infection, may become the seat of hydro- or pyo e.alpinx; the ovaries may undergo inflammatory swelling or suppuration.
Symptoms of Acute Parametritis.—This form of disease, in its early symptoms and etiology, is similar to pelvic peritonitis, with which it usu ally simultaneously occurs. The most acute septic varieties, which often result in rapidly developed purulent and necrotic changes of the cellular tissues, are usually accompanied by intense pelvic peritonitis. These in stances we will not devote much space to, because they usually very soon terminate fatally, without giving rise to palpable changes.
In a large number of cases, which either are caused by a less intense infection, or are of traumatic origin, and run an unfavorable course, owing to the patient's debilitated condition, peculiar phenomena develop, which present a well-defined form of disease. These phenomena are mainly due to changes in the pelvic connective tissue, although it must be admitted that in most cases the other pelvic organs, especially the pelvic perito neum, are also involved.
The disease is ushered in with or without a chill, but always with fever and Spain in the pelvis. Frequently the disease, when occurring after childbirth, is indicated by severe after-pains and febrile excitement. Often too the disease is limited to one side of the pelvis. In the major ity of instances, the left side of the pelvis is rather affected than the right, which is said to be due to the frequency of the first position in head presentations. • Often the pains appear suddenly. Usually they start from the uterus and radiate, according to the spread of the process, in different directions. In many cases the pains are limited to the uterus and its immediate sur roundings. In a large majority of cases the pains extend outwards to one or both sides and are increased by motion. Occasionally they radiate to the lumbar region, and in rare cases there is painful micturition.
The duration of the pain and fever varies from a few hours to a week, or may even last several weeks, with occasional remissions. The intensity of the fever usually corresponds to the intensity of the process. In puer peral cases the fever usually begins during the first four days, more often during the first two or three days, rarely on the fourth or fifth day. The temperature is usually above 102° F., often 104° F., and in rare cases it may reach F. According to R. Olshausen, in 70 per cent. of cases of puerperal parametritis and perimetritis, the febrile symptoms last eight days; in 20 per cent. fourteen days, and only in 10 per cent longer. With rise in temperature, the pulse becomes more frequent, and in some cases becomes accelerated only after the temperature has been elevated for half or a whole day. Usually it reaches from 100 to 120, and often for a short time from 130 to 140, Long-continued pulse rate from 140 to 180 occurs only in very severe septic varieties of the disease.