The exact seat of the affection is as little to be determined at the be ginning as in the acute form of the disease. Only after the one or the other inflammatory process has run its course are we able to diagnosticate the tissue involved by the changes which have taken place in it. By ex amination, we recognize by the density of the cervix, its dilatation, its limited range of movability, its change of position and fixation, the dis location of the ovaries or the tubes, that the inflammatory process has affected, in particular, certain of the surroundings of the uterus.
After many apparently normal deliveries, we may be able to diagnos ticate a para-perimetritis. The cervix in these cases is frequently fixed in consequence of lacerations and cicatrizations.
The treatment is the same as in acute inflammations which have be come chronic.
Parametritis S. Schultze has applied this name to a form of the disease where the inflammatory process has extended from the cer vix along the recto-uterine ligaments involving the surrounding connective tissue and peritoneum. He describes it as follows: A very frequent find ing, one which I claim as the most frequent cause of permanent patholog ical anteflexion of the uterus, is the shortening and,hardening of the folds of Douglas. If a finger is passed in the rectum or vagina behind the posterior surface of the uterus, at the point of its flexion, and by bending the finger forwards, we move the organ anteriorly, we become convinced of the great elasticity of the folds of Douglas, which fix the uterus pos teriorly. This elasticity makes it also possible for Douglas's to be stretched during defecation without pain. When the uterus offers
resistance to pressure of a finger passed into the rectum or vagina, the elasticity of the folds of Douglas are impaired, often unequally shortened or thickened, and they are painful at an attempt to stretch them. If the shortening of these folds • is considerable, the uterus with its angle of flexion is placed further backwards and higher in the pelvis, the vaginal portion is markedly in the axis of the vagina, and the os uteri is directed forwards (similar to the position found in case of retroversion, only much higher and farther back in the pelvis). If we succeed by bin-manual pal pation in feeling the corpus uteri we will find it lying parallel to the an terior vaginal wall, the point of flexion forming an acute angle with the cervix. The mobility of the body of the uterus towards the cervix may in this case be undisturbed for a long time, as proved by bi-manual ex amination, when the walls of the abdomen allow of it, but on account of the retroposition of the uterus, the bladder even when externally filled is not able to push back the uterus, its position being one of permanent anteflexion. To recognize this abnormal fixation of the uterus, which causes pathological anteflexion, it is not necessary to examine the folds of Douglas. The high, pOsterior, eventually also lateral position of the vaginal portion, and its marked direction forwards, but mainly the di minished mobility of the uterus from its vaginal portion, and the pain caused by an attempt to move the same, proves the abnormal fixation backwards, and discriminates this most frequent cause of pathological anteflexion from the normal.