SYMPTOMATOLOGY.--Pain is probably the first symptom to attract the attention of the patient, and if the attack is sudden or acute the pain is usually attended by a chill of more or less severity. The pain may be so sharp and lancinating as to cause the patient to cry out in agony, or it may be of a throbbing, aching character. If the former, it indicates either intense congestion of the vessels and tissues involved, or that the peritoneum is largely implicated, probably both. Where the pain is of this character the attack is usually of shorter duration, since it is soon followed by the second stage, exudation, when the symptom is at once modified, becoming less acute and resembling now the pain attending an attack of less severity. Of course the location of the pain corresponds to the seat of the inflammatory process. If it is in one or the other broad ligament, the pain is greater in the right or left iliac regions, most {214} frequently in the left. Pain is often experienced in the hypogastric and sacral regions in the beginning of, or preceding, an attack of parametritis, and it is due to congestion of the endometrium and uterus, from which the disease is spreading to the looser cellular-tissue spaces in the ligaments. If, however, sacral pain persists throughout the course of the disease, or exists in that region chiefly, it indicates that the inflammation has become general or has invaded the utero-sacral ligaments. But it would not be correct to estimate the extent of the disease by the amount of pain complained of, for that symptom depends so largely upon the temperament of the patient and her station in life that it is not trustworthy. Some women suffer so much that they become inured to it or acquire the habit of suffering in silence; others, from temperament, do not actually experience pain; whilst others, again, from a love of hardihood, do not complain, although they may be enduring constant and severe pain. To one of these classes those cases must belong which are said to pass through an attack of parametritis without suffering. That cases do rarely present themselves, on account of mild but persistent symptoms, which are found on examination to contain a large pelvic exudation, I can attest; but I have so constantly found on careful questioning that the usual symptoms of pelvic inflammation were present at some time during the course of the existing illness that I cannot agree with the statement made by some authors that this disease may develop "without causing any particular disturbance" (Emmet). As a rule, the bladder and rectum are reflexly affected, the former sometimes becoming very irritable, so that there often exists a constant desire to micturate. Constipation is the rule, though I have known a severe diarrhoea to accompany the disease, the result, I thought, of reflex irritation. The stomach also is often sympathetically affected, nausea, and sometimes vomiting of an aggravated form, being present.