A day or two after the first attack of fever and pain the exudation into the pelvic cellular tissue can be felt as a bulky swelling by abdomi nal or vaginal examination. These swellings, that can be made out as be longing to the parametrium, by bi-manual examination, are the only characteristic symptoms showing that the disease has its seat in the para metrinm. As a rule the extension of the exudation corresponds to the severity and duration of the fever and pain; but often an extensive infil tration into the connective tissue, takes place after fever and pain have lasted only one to two days. According to the site of the exudation, in the broad ligaments, round ligaments, or close to the cervix, the masses will be felt best through the abdominal wall or by the vagina. For the first few days the cellular tissue has a doughy feel, subsequently becom ing harder.
The pain and functional disturbance depend upon the seat and exten sion of these hard masses. Of the functional disturbances are especially to be mentioned : frequent and painful micturition, retention of urine, tenesmus, irritability of the pelvic muscles, usually of the psoas and iliacus, irritability of and pressure on the nerves, which run from the pelvis to the lower extremities.
The symptoms of the acute form of the disease usually last from six to thirty days. In the most favorable cases the exudation may be absorbed without the formation of the characteristic hard masses. In this way doughy tumors of considerable size may disappear in a very short time. In less favorable cases the mass is absorbed only after it has become hard ened, which of course requires a longer time, and this is not always com pleted.
Parametric affections resulting from operative interference and man ipulation of the uterus, especially of the cervix in non-pregnant women, frequently run the same course.
This disease does not always run the same rapid and favorable course, but the process may have from the beginning a chronic insidious charac ter, or the disease may be prolonged for weeks or months with intermissions, or the hard and bulky masses may remain for months or years in an un changed condition, or smaller or larger pus centres form in the hard masses, or they change into an abscess.
In cases where the process has a chronic insidious character from the beginning, the symptoms are often so slight that they escape the attention of the patient. Frequently the patients come to the clinic from four to twelve weeks, or even longer after abortion or delivery. Usually they
are anemic and complain of protracted convalescence, loss of appetite, sleeplessness, occasional chilly sensations with slight fever and pain in the lower part of the abdomen, pelvis and thigh. On' examination hard mimes of exudation are frequently found around the uterus, usually con joined with extensive laceration of the cervix. On close questioning it is found that during the first few days after delivery, there was slight fever, which was considered to be milk fever, and, as a rule, the patients recol lected having had pain corresponding to the seat of the exudation.
In cases where the disease is prolonged for weeks or months, with oc casional attacks of fever and pain, usually soon after the first symptoms, the result of the inflammatory process manifests itself, and corresponding to the seat of the inflammation, a tumor in the broad ligament on one or both sides, or a hard mass to one or both sides of the supra-vaginal portion of the cervix, is felt through the abdominal wall or vagina. After the first inflammatory attack the fever subsides, the pain ceases and the patient feels well for two to three days. Suddenly fever and pain reappear. The direction of the radiation indicates the course of the extension of the process. On examination it is found that the exudation extends from the broad ligament towards the iliac fossa, or from the cervix uteri laterally to the pelvic wall, and usually also anteriorly along the round ligaments and the abdominal wall. At first both fever and pain remit, but later the pain is constant.
The patients are confined to bed, and according to the extent of the disease the functional disturbances before mentioned appear. Irritation of the nerves causes great pain in and contraction of the hip and knee joints. These phenomena we have seen in patients one and a half to two and a half years after the beginning of the process, which was associated with vesico-vaginal fistula.
After the patient has apparently entirely recovered, all the symptoms may reappear, and even after the exudation has been absorbed on one side it may appear on the other, which phenomena we have seen in several patients where the process lasted for one to two years, without the forma tion of an abscess.
The seat, size and form of collections of exudation in the pelvic cellu lar tissue differ greatly, and we will attempt to give an account of the most frequent varieties.