Fixation of the cervix, as the result of these inflammatory changes, leads to recurrent inflammatory processes, the secretion being confined and alterations occurring in it. The less movable cervix is exposed to injury during cohabitation, and we may often detect erosions on the sur face of the organ when the tissues are exposed to fr!ction, and thus the chances of infection are increased.
In a number of cases belonging to this class, extensive parametric and also peritoneal residues are found, which usually have their seat around the tubes and ovaries, the latter being connected with each other and with the surroundings of the broad ligaments and the peritoneum of Douglas's by pseudo-membranes.
Fig. 24 represents the uterus of a nnllipara. Besides the described changes in the cervix, this preparation showed extensive residues in the parametrium; the blood-vessels and nerves were in many similar cases imbedded in a thickened tissue; the layers of the broad ligaments were firmly adherent to each other and contracted; both ovaries were displaced by strong false membrane towards Douglas's both tubes some what dropsical and fixed to the anterior layer of the broad ligament. The body of the uterus was quite movable and seemingly not diseased.
These findings are of great importance, for it is not the enlarged uterus, its position and the change of its axis, nor the displaced ovaries, nor the tortuous dilated tubes, which give rise to suffering; but it is the tissue thickenings determinable bi-manually in the surroundings of the uterus which render life a burden to many women.
The mobility of the uterus is more impaired where the pare- and peri metric contractions exist to such an extent, than in the former cases, and by the pathological changes in Douglas's the organ is usually displaced posteriorly or postero-laterally, and anteflexed. In cases where inflammation has taken place simultaneously or later in the body of the uterus and its surroundings retro-lateral version or retroflexion may also be found.
On examination the cervix and ovaries are not tender; pain is only felt when by moving the uterus or ovaries traction is made on the parametric tissue.
In a small number of cases belonging to this class residues of para metritis between the uterus and bladder are found. They may often be
noticed immediately on making a longitudinal section of the genitals; if the genitals are then lifted up on to the body of the uterus, the bladder will normally separate by its own weight from the cervix for about in ches, being normally connected to it only by loose connective tissue. If parametritis has existed between the uterus and the bladder, then the latter separates only slightly or not at all from the cervix, and if an at tempt is made to separate the two organs it is found that they are more intimately connected with one another than normally. In a small num ber of these cases, one or both ureters are found more or less surrounded by thickened tissue and fixed, to which fact W. A. Freund long ago called attention. Nearly as frequently as between the cervix and bladder rem nants are found between the cervix and rectum, and sometimes the body of the uterus is also involved, as is proved post mortem by thickening of the tissues, sections of the body of the uterus being made with greater difficulty, the uterine tissues having lost their elasticity although the organ is not much increased in size.
Fig. 25 illustrates the anterior aspect of a uterus of a young nulli para, and shows, besides the described changes, residues between the uterus and bladder. The ureters are imbedded in a thickened tissue, and the body of the uterus also presents evidence of inflammatory changes. The organ was markedly retro-placed in the cadaver. The tubes and ovaries were so much adherent to their surroundings in Douglas's sac and to the rectum, that they had to be dissected out with tha knife and scissors. The body of the uterus formed a right angle with the cer vix and could not be straightened by considerable force.
The course of the disease in these frequent cases is, according to ob servations during life and post mortem, as follows: first the cervix is af fected by catarrh or gonorrliceal virus, giving rise to inflammation of its wall and surroundings. which terminates in anteflexion. In the altered cervix the secretions stagnate, erosions take place in the canal and around the external os, and from any cause the peritoneum, tubes and ovaries become involved, and at the same time or later the body of the uterus as well.