136 DISEASES OF THE UTERUS. 



and, according to my experience, of the nerves along the walls of 

 the pelvis. The presence or absence, and the degree of severity and 

 obstinacy of dysuria and difficult defecation, as well as of the pain 

 extending along the sacral, sciatic, and crural nerves, depend in 

 each case on the seat and amount of the exudation. Where there 

 has been extensive exudation, on examination we may find a tumor 

 of variable size above the pubis. Examination through the vagina 

 or rectum usually shows that the uterus is displaced and firmly 

 wedged in. Intraperitoneal exudations usually fill Douglas's cul- 

 de-sac, and may be readily felt. Subperitoneal infiltrations and 

 abscesses are generally somewhat higher, but they also can mostly 

 be reached by the finger. 



[Unless the two conditions should happen to coexist, the results 

 of physical exploration show differences in many respects which can 

 be made out by bimanual palpation. A peritoneal exudation sinks 

 into Douglas's space, as being the lowest level in the abdominal 

 cavity. The cul-de-sac becomes distended and pushed downward. 

 If the exudation has coagulated, or when a liquid exudation is incap- 

 sulated so that it cannot yield to the finger, we can feel a more or 

 less voluminous tumor, such as a retrouterine hcematocele presents, 

 lying behind the uterus and vagina, displacing the one upward and 

 forward, and bulging the other forward and downward. On the 

 other hand, the extraperitoneal exudation of parametritis is found 

 as a rule toward the side of the womb, sometimes on both sides ; 

 and through the vagina it feels at first like a resisting infiltration, and 

 afterward like a hard, sharply-defined tumor, which seems to spring 

 from the lateral edges of the womb, the boundary-line between the 

 two being sometimes difficult to determine. In exceptional cases 

 as when Douglas's cul-de-sac is closed by adhesions a perimetritic 

 exudation may likewise form in a more lateral region of the pelvic 

 peritoneum, and bulge downward ; and conversely, there have 

 been rare cases of parametritic exudation into the areolar tissue, 

 behind and even in front of the uterus and the upper vaginal region. 

 In such instances, when the intra- and extra-peritoneal exudations 

 exist together, a diagnosis becomes extremely difficult.] The disease 

 may continue for weeks, and greatly exhaust the patient by the 

 accompanying fever. 



[Extraperitoneal abscesses tend by preference to find an outlet 

 at the surface of the body, especially in the groin, or from the iliac 

 fossa, or after passing under Poupart's ligament to appear upon 

 the front surface of the thigh, or else to perforate backward through 

 the ischiatic foramen and muscles of the buttock. On the other 

 hand, intraperitoneal abscesses open more often into the cavities of 



