{231} PHYSICAL SIGNS.--Physical examination may reveal no evidence of exudation or of the presence of an inflammatory condition, and may lead the physician to infer that the attacks are not inflammatory in character, but that they are of a neuralgic nature. As a rule, however, examination will show a thickening or an absence of the usual mobility of the surfaces, and deep pressure may elicit considerable tenderness. On the other hand, the physical signs may be marked, and the surfaces may be felt to be quite thickened and very rigid, so that it will be evident that there is exudation on the surface of the peritoneum. Usually, the vaginal examination reveals a fixation and induration posterior to the uterus. If that organ is retroflexed, it is bound firmly in that position. If the uterus is in its normal position, there will not usually be the same amount of fulness posteriorly. If an ovary and Fallopian tube have been displaced, it will probably be fixed in the post-broad-ligament space or in the cul-de-sac of Douglas. The pelvic roof, so called, may be found as hard and tense as a deal board, as was first described by Doherty. The exudation may be so great as to displace the uterus forward or laterally, and to fix it as though it were surrounded by hardened lymph. This is especially felt in the post-uterine space, gluing the uterus, ovaries, tubes, and broad ligaments together. If there is a small ovarian or fibroid tumor, it may be likewise fixed in this posterior position. A later examination may show a change in this condition. The exudation material may have been reduced by absorption, or there may have been an increase. If the latter, the disease will probably run an acute course and end by resolution or suppuration--more likely the latter--and practically it will then run the course described under the head of Parametritis. DIAGNOSIS.--The diagnosis of perimetritis is made with comparative ease. The subjective symptoms are sometimes obscure, but the physical signs are perfectly plain. When there is exudation posterior to the uterus, especially if it has bound the organ in a retroverted position or incarcerated a foreign body, it is almost absolutely certain that agglutination is due to peritoneal exudation. This exudation is, as a rule, not so extensive as that which occurs in parametritis, and if a tumor is present--which is uncommon--its location is different. Where a tumor is present as the result of pelvic inflammation, I think that it may be safely ascribed to connective-tissue inflammation rather than to peritoneal. On the other hand, where there is simply agglutination, and where the effusion seems thin and spread out, the organs and ligaments rigid and thickened, instead of a somewhat circumscribed tumor, the disease may be ascribed to perimetritis rather than to parametritis. Where the condition just described is found there can be no doubt as to the existence of perimetritis.