Another very rare form of the disease, which rapidly terminates in death, is that in which suddenly, without appreciable cause, perhaps by infection through surgical manipulations, decomposition of the pus takes place. Cases of this kind never came under our observation. Olshausen, who observed such a course in abscesses of the iliac fossa, thinks that the gases which diffuse from the neighboring rectum cause decomposition in the originally healthy pus. The patients die from exhaustion or rapidly with symptoms of septicemia. In rare instances intraperitoneal and para metric abscesses are caused by actynomykosis as in a case of Billroth's clinic described by Hacker.
Diagneeis of Acute Pelvic Peritenitie.—It is ushered in with the same grave alarming symptoms as general peritonitis. High fever, marked tenderness on pressure over the abdomen, the adjacent sub-peritoneal connective tissue being almost always at the same time involved, early tympanites, which is partial and limited to the lower part of the abdo men, more severe on one or the other side, these symptoms indicate that the peritoneum largely participates in the process. The starting-point of the pain, the spot of greatest tenderness, indicates the locality where the disease is most intense. With these first violent symptoms an exten sive parametritis may simultaneously exist; but high fever tympanites and great tenderness are sure indications of the presence of pelvic peritonitis. Only after a few days, when the pain has subsided, can we by vaginal oxamination—a thorough bi-manual examination may be harmful to the patient—and palpation of the connective tissue in all directions make sure that the pelvic connective tissue is not diseased, and that only the periton eum is affected.
In many cases we must rely on the first symptoms to make a diagnosis, for in a large number of cases no palpable exudations take place.
The presence of fluid exudation can not always in acute cases be diag nosed by changing the position of the patient, since the exudation is small, or if large it is encapsulated. In passing we will mention that in acute general peritonitis these phenomena are also rare, but they frequently accompany chronic cases where larger areas of the peritoneum are in volved, although accompanied by but slight febrile disturbance.
The diagnosis is greatly facilitated by the presence of the palpable changes which generally occur in the course of pelvic peritonitis, enabling us to determine the extent of the process; and, in doubtful cases, where the pelvic connective tissue is also affected, we often are able to decide whether and to what extent the pelvic peritoneum is involved. It is not
always easy or even possible to decide whether a tumor is intra- or extra peritoneal, for if peritoneal exudations are enclosed between adhesions near the uterus, it is quite impossible to distinguish them from extra-peri toneal. Only under quite definite conditions can a positive diagnosis be made. These conditions we will try to describe.
The tympanites in ease of pelvic peritonitis is often limited to a few con volutions of the intestines near the pelvic inlet or iliac fossa. Just at these places we notice later in the disease points of resistance or swellings, which are produced by adhesions formed between convolutions of intes tine, parts of the broad ligament, cr the uterine appendages. In case we can determine the presence of masses near the pelvic inlet, in most cases laterally, it is quite certain that they were caused by pelvic peritonitis. In the beginning tympanites is usually present in some part of the un yielding spot, and this will prevent us from mistaking the exudation for tumors situated high in the broad ligament. Later it is observed that these swellings change their seat with distension of the intestine or bladder, and the area of tympanites also changes, which can readily be ascertained by marking the borders of the swelling daily. Further, we may diagnosticale with certainty as intra-peritoneal, swellings which be come rapidly encapsulated by large masses of exudation behind or at the side of the uterus, protruding far over the pelvic inlet. Where tumors are formed in Douglas's and do not protrude over the pelvic inlet, or when they are situated in the iliac fossa, it is difficult to determine whether they are intra- or extra-peritoneal. The diagnosis may be as sisted by remembering that intra-peritoneal swellings remain soft for a long time, while exudations into the meshes of the sub-peritoneal cellular tissue rapidly harden and may be palpated.
With less certainty can the anatomical seat of resistant spots in the anterior abdominal wall near the pelvic inlet be determined as exudations into the sub-peritoneal cellular tissue, since they present the same phe nomena as those which are intra-peritoneal.