Diagnosis of Acute initial symptoms are as a rule not as violent and alarming in inflammations involving chiefly the para-nterine cellular tissue, as those of pelvic peritonitis. Fever and pain may be as intense as in pelvic peritonitis, but tenderness and tympanites are absent in the beginning of the disease. Severe pain on pressure is produced only when the uterus is moved or its sides touched. There are cases, particularly those where the exudation rapidly extends towards the inguinal region or the iliac foam, in which tenderness is present early in the disease, similar to pelvic peritonitis.
The starting-point of the pain and its distribution, the locality of greatest tenderness, indicate the seat of the process, its intensity and ex tent.
With such initial symptoms usually the pelvic cellular tissue is chiefly involved, but the diagnosis is made certain only by the presence of the inflammatory products. As the swellings do not always reach to the ab dominal wall, palpation is more reliable than percussion to determine their presence.
If a day or two after an attack of fever and the appearance of the de scribed initial symptoms, the uterus is found enlarged transversely in the region where the broad ligaments leave it, parametritis certainly exists, and it is hardly necessary to prove it by bi-manual examination. If after fever has lasted for several days points of resistance are found over Pou part's ligament corresponding to the previous seat of pain and tenderness, or if swellings have formed above or extend to the centre of Poupart's ligament, or internally to the anterior superior spine of the ilium, the convex border of which is readily felt or even seen, or if by firm pressure of the abdominal wall tumors corresponding to the broad ligaments are found, then it is also certain that the process involves the parametrium. If still doubtful the diagnosis may be confirmed by vaginal examination, which in most cases will reveal the presence of large masses at the sides of the uterus, extending anteriorly or laterally to the pelvic wall, or filling one side of the pelvic cavity, showing clearly that the swellings felt through the abdominal wall are masses of exudation extending below the perito neum.
If under these conditions the vagina is movable in every direction, and the lower part of the uterus is free, we must take in consideration that there are exceptional cases where the exudation begins high in the broad ligament, extending towards the iliac foam and the lumbar region, but in such cases the diagnosis is uncertain, for it is impossible to determine whether a tumor, which developes high in the broad ligaments, and ex tends in different directions, is intra- or extra-peritoneal.
In some cases the exudation may not be felt at all through the abdomi nal walls, for in many instances the inflammatory process is limited to the deeper regions of the pelvis, and the diagnosis can only be made by vagi nal examination.
If with more or less severe inflammatory symptoms, masses form in the neighborhood of the cervix, or extend to the deeper portions of the pelvis, being doughy and soft at the beginning, but rapidly becoming harder, or if large well-defined swellings form in the true pelvis in front or behind tho uterus, the process can be none other than phlegmonous inflammation of the cellular tissue.
The diagnosis of suppuration and the formation of abscesses in the pelvis is usually not difficult. It is to be remembered, however, that abscess caused by caries of the spinal column or pelvis may also involve the parametrium. If with continued or interrupted fever we find fluctua ting points in the masses of exudation, or if with the same phenomena the swelling rapidly increases and becomes soft, the diagnosis is certain; but in many cases, where the swellings are large, it is difficult or even impossible to decide whether the process is intra- or extra-peritoneal. The decision is indeed of little practical importance, as intra peritoneal abscesses become shut off from the abdominal cavity.
Fig. 21, from a post-martem by Prof. Blob, illustrates how extensive this process may become. The patient, act. thirty-seven years, dated her disease back nine months, and died from cancer of the uterus, during the course of which a large pelvic abscess formed.
The tumor extended upwards as far as the right kidney, involving the renal artery and vein, and downwards to the ischium, denuding the sacrum, and perforating the acetabnlum, so that the head of the femur projected into the abscess cavity; the neighboring parts were covered with cheesy, friable, light-brown and easily removable vegetations.