A system of practical medicine. By American authors. Vol. 1

by Unknown

In suppuration of parametritic exudations the pus commonly forms in small scattered collections, and rarely gives rise to large abscesses.

Although parametritis and perimetritis are usually found associated together, there are always cases in which the one form of inflammation so far predominates over the other as to justify an attempt to establish a clinical distinction between them.

In the beginning of the attack, sharp pain, high fever, and tympanitic distension of the lower abdomen are symptomatic of inflammation in the pelvic peritoneum. Whether the cellular tissue is simultaneously implicated can only be determined by a digital examination after the abdominal sensitiveness has subsided. The absence of the objective signs of cellulitis would then contribute to prove that the case had been one in which the peritoneum had been in the main affected. On the other hand, moderate fever, pain elicited only on pressure, and tympanitic distension confined to the colon, coinciding with exudation between the folds of the broad ligament, would be indicative of a nearly pure cellulitis.

A palpable exudation is by no means the necessary product of peritoneal inflammation. Indeed, in many cases, the distinctive symptoms of the latter may be present for from four to eight days, and may then subside without leaving a trace of its existence at the pelvic brim.

The demonstration of a fluid effusion by noting the change of level upon shifting the position of the patient is rarely possible, either because the quantity is too small or because it quickly becomes confined by pseudo-membranous adhesions between the intestines.

Bandl⁴⁹ mentions as a sign of local peritonitis, sometimes noticeable, a number of resistant points or tumors near the pelvic brim or above one of the iliac fossæ, due to a matting together of the intestines or to their adhesion to the uterine appendages. They are distinguished from solid tumors by their emitting a tympanitic sound upon percussion and by their changing position in consequence of an accumulation of urine in the bladder or of feces or gases in the bowels. Again, all tumors may be reckoned as intra-peritoneal which very rapidly form behind or to the side of the uterus from enclosed exudation-products, and which at the same time rise far above the level of the pelvic brim. If, however, they start from the cul-de-sac of Douglas, and do not much exceed the linea terminalis, or if they occupy an iliac fossa, it becomes very difficult to decide whether they are of intra- or extra-peritoneal origin. The peritoneal exudation, however, long remains soft and fluctuating. It arises, as a rule, behind the uterus, and does not exhibit a tendency to spread to the sides or to the anterior or posterior pelvic walls.

⁴⁹ Handbuch der Frauenkrankheiten, red. Von Billroth, 5te Abschnitt, p. —.

Still more difficult is it to decide as to the seat of exudations met with beneath the abdominal walls. When diffused and continuous with a pelvic deposit the diagnosis is uncertain. It is only safe to assume the peritoneal origin of extravasations of a rounded form, of a fluctuating consistence, and when they are situated high up and are disconnected from exudation at the pelvic brim. An opening of the abscess through the navel would indicate a peritoneal source, while the discharge through the abdominal parietes would point to a seat in the connective tissue.

After the perforation of an abscess the fever and pain subside; the wound, if external, either closes in the course of one or two weeks, or fistulas form which become the source of protracted suppuration.

In psoas abscesses the exudation extends beneath the sheath of the muscle or between the iliacus and the bone. In puerperal patients they proceed from an inflammation originating in the broad ligament. They are situated too deep to be easily palpated. The pains they occasion are referred rather to the hip or knee than to the abdomen. The contracture of the psoas muscle furnishes a diagnostic sign which distinguishes this form from the superficial abscesses of the iliac fossæ. The pus eventually is discharged beneath Poupart's ligament, in the lower portion of the inguinal fossa, at some point upon the crest of the ilium, or exceptionally along the thigh. Often the discharge is maintained for months.