Should resolution occur and this condition pass into a stage of chronicity, at which time only would it be amenable to intra-pelvic technic, there would be found a conglomerate mass in one or both sides of the pelvis composed of tube, ovary, peritoneum, connective tissue and perhaps coils of intestines and adhesions. The fibrinous exudate of the acute stage has followed its natural course of organization and contracture and is now binding these deformed and distorted tissues together in some abnormal position. If the connective tissues in the uterine ligaments were affected in the acute stage, these, too, have contracted (shortened) and have drawn the uterus into some malposition. In severe cases with extensive involvement the resulting contracture may have almost obliterated the ligaments and connective tissues and left the uterus immovably fixed in some displaced or perhaps normal position. (Figs. 13, 14.)

The disastrous effects of this condition upon the blood vessels which so freely traverse this connective tissue is easily imagined. As connective tissue, following its inflammation, is organized into scar tissue with its inevitable contracture, blood vessels are obliterated and vital functions are correspondingly disordered. The same is true of the lymph channels. They, too, disappear and proper nutrition and drainage become impossible, Even more important is the involvement of the nerve tracts and plexuses. Interwoven as they are through this connective tissue and in turn permeated by it, if by any means they escape destruction in the acute attack, they are subject to continuous pressure and tension and distortion by the unrelenting grip of the contracting tissues. Can a more prolific source of reflexes be imagined?

These adhesions vary all the way from gossamer-like films and spider web threads, easily broken by slight traction, to sheets and cords of organized tissue which it is impossible to rupture without serious damage to the organs to which they are attached.

Should a limiting exudate fail to form either because of the virulence of the infection or the weakness of the natural defenses a diffuse peritonitis with a fatal outcome may result.

The inflammation causing adhesions due to pus germs generally follows labor, abortion or the use of instruments within the uterus. In such cases the inflammation usually passes directly through the uterine wall by the way of the lymphatics to the connective tissue, located principally at the sides and in front of the cervix and at the base of each broad ligament. The involvement may vary from a small localized spot to that of the entire area of connective tissue. As the inflamed area extends the peritoneum superposed becomes affected, adding a peritonitis of proportionate extent.

Following the acute stage there may be abscess formation that demands immediate evacuation or resolution may occur. In the latter case scar tissue, adhesions, develop in the infiltrated areas of the acute stage. Organization and contracture occur in these areas and displacement or immobilization of the uterus results as before mentioned. It is doubtless true that these contractures occurring in the connective tissues are a more prolific cause of displacements than those occurring primarily in the peritoneum.

In the treatment of these cases it is important to determine if possible whether the original acute inflammation was due to infection by the gonococcus or the streptococcus, these being the most frequent infecting agents. As a rule a collection of gonorrhoeal pus becomes sterile or innocuous in a few months while it is doubtful if streptococcus pus ever does. In treatment the danger of arousing a streptococcus inflammation, while remote if care is used, is still present. As a general rule, with exceptions, gonorrhoeal infection travels along the mucous membranes. Some one has said that it is a "surface rider," and its chronic lesions are mostly along the tube and its immediate vicinity. The streptococcus usually travels by way of the lymphatics and its chronic lesions are found mostly in the pelvic connective tissues. In the gonorrhoeal cases there is, at least the clinical history of gonorrhoeal infection or of trouble developing in the pelvis without apparent cause, often soon after marriage. In the strepto coccus cases there is the history of labor, abortion or some operation about the uterus or cervix.

Aside from the purely physical effects of adhesions, Graves has the following to say: "The conditions which produce genital neuroses are more apt to be the minor pelvic affections which, without causing severe symptoms, maintain a nagging discomfort and keep the searchlight of the attention constantly turned upon them. The most common or most important source of such neuroses is that which comes from the adhesions of chronic pelvic inflammation. The discomfort may be caused by peritoneal irritation or by the immobilization of organs which normally enjoy free motion in the pelvis."