The most frequent seats of these exudations are the sides of the uterus, which give attachment to the broad ligaments; the infiltration is triangu lar, half as large as the fist, having its base at the uterus and its apex be tween the layers of the broad ligament. This variety is frequently observed in connection with laceration of the cervix, or operations on the uterus in non-pregnant women. Through the relaxed abdominal and vaginal walls during the puerperium, the exudation may be felt by careful con joined examination to the sides of the usually sub-involuted and more or less fixed uterus, extending in the direction of the broad ligaments. If the process is only on one side, the uterus is pushed to the opposite side. This variety usually runs a favorable course.
Another variety is a tumor from one to two fists in size, irregular in shape, situated in one or both lateral ligaments, smaller in size at the side of the uterus, and also diminishing towards the pelvic brim. The tumor is more readily felt through the abdominal walls than the vagina. The uterus is pushed to one side, and fixed to a greater degree than in the pre ceding variety The next frequent form is where the exudation extends from the uterus and broad ligaments to the iliac fossa, and can be perceived by inspection. It is to be mentioned that the exudation may be very slight in the broad ligament, is on the road towards absorption, when the tumor in the iliac fossa is still quite large. This is important as it shows the connection of abscesses, formed late in the disease, with the uterus, although remote from and apparently independent of it.
Further, we meet with an unyielding irregular mass surrounding the cervix, and extending towards the sides of the pelvis anteriorly along the round ligament to the anterior pelvic and abdominal wall. Thereby the uterus is displaced to the opposite side and rendered immovable.
The portion of the uterus, then, which is situated in the parametrium, is surrounded by masses of exudation, and the greater part of the pelvis seems as though it were completely filled with these hard masses. The uterus, which is wedged in on all sides, seems to be situated deeper, the anterior and posterior fornices of the vagina seem to be obliterated, and are often pushed downwards by the masses of exudation. The exudation often forms a hard ridge nearly in or below the middle of the pelvis, which may be felt through the vagina. The findings through the abdominal walls differ according to whether the exudation extends high up towards the broad ligament, the iliac fossa, anterior abdominal wall, or if it is limited to the cervix uteri. In the first case we find the tumors already described, in the latter the result of the examination through the abdo men is negative. In both cases the exudation is found to extend to the point of attachment of the round ligament to the inguinal canal, and we find above Poupart's ligament an unyielding site curved upwards, which by bi-manual examination is found to be a prolongation of the deeper situated masses Of rarer occurrence is the extension of the exudation from Poupart's ligament to the sub-peritoneal cellular tissue of the anterior abdominal wall, but occasionally flat masses, sometimes as large as the hand, are found in this region. Just as rare is it to find the surroundings of the
uterus entirely free, and an exudation on the sides of the pelvic wall ex tending through the broad ligaments towards, but not to the uterus. Ex tension of the exudation downwards from the cervix uteri, and its limita tion to the same, is also rare; but sometimes we find, more often along the posterior than the anterior wall, exudations extending to the orifice of the vagina.
The very large hard masses remaining unchanged for months or years are found in a minority of cases, either following childbirth, or operative interference with the uterus or vagina. After the fever and pain subside, the mass of exudation may retain its irregular shape or assumes a more rounded form through partial absorption. These masses, according to their seat and size, may cause slight pain only, aggravated at times espe cially during menstruation, or they may become a source of constant suffering to the patient without confining her to bed. The following cases may be instanced: A woman, who for five years had a large mass at the anterior and lateral pelvic wall extending to the enlarged uterus, and between it and the bladder, came to the clinic, and without special treat ment the tumor disappeared in the course of two years. In a few other cases, where, on account of the long unchanged standing of masses of ex udation, neoplasms were suspected, we at last saw the swellings diminish in size and almost entirely disappear. The most prolonged case that we saw lasted for twelve years In cases where smaller or larger pus centres are formed in parametric exudations, this usually occurs early in the disease, rarely later. The formation of pus may be suspected when long-continued fever is present, at first slight, becoming more severe later, or when chills and rigors occur. Post-mortem findings, and the course which many cases run, indicate that pus centres may form during life, and be absorbed without evacuating into neighboring organs. The finding of pus centres which have appar ently existed for a long time, and the retrogressive changes which the same have undergone—further, the recurrence of chills and fever without an extension of the exudation—will make it evident that from time to time pus has entered the circulation. This is proved by another fact to be mentioned later.