A Study of the Pathology and 
Treatment of Intra-pelvic 
Inflammations. 
BY 
l. s. McMurtry, m.d., 
DANVILLE, KENTUCKY. 
REPRINT PROM TRANSACTIONS, 
1889. A STUDY 
OF THE 
PATHOLOGY AND TREATMENT 
OF 
INTRA-PELVIC INFLAMMATIONS. 
BY 
l. s. McMurtry, m.d., 
DANVILLE, KY. 
REPRINTED FROM THE TRANSACTIONS OF 
THE AMERICAN ASSOCIATION OF OBSTETRICIANS AND GYNECOLOGISTS, 
SEPTEMBER, 1889. 
PHILADELPHIA : 
WM. J. DORNAN, PRINTER, 
1 8 8 9. A STUDY OF THE PATHOLOGY AND TREATMENT 
OF INTRA-PELVIC INFLAMMATIONS. 
By L. S. McMURTRY, M.D., 
DANVILLE, KY. 
Intra-pelvic inflammations, with their sequelae, comprise the 
most common conditions with which the gynecologist has to deal. 
In the entire compass of medical science and practise no subject has 
been more misunderstood and none more erroneously interpreted. 
Thirty years ago Bernutz and Goupil, after careful clinical and 
post-mortem investigations, clearly described the true pathology of 
pelvic inflammations, but it is only since operative surgery has 
opened up the peritoneal cavity to daily exploration that their 
researches have been appreciated and accepted. Even at this 
advanced period, many of our prominent teachers and authors 
classify intra-pelvic inflammations under two heads-parametritis 
and perimetritis-with treatment adapted accordingly. Modern 
investigation has swept this classification aside, confirmed the truth 
and accuracy of Bernutz's researches, and demonstrated the relation 
of diseased states of the ovaries and Fallopian tubes, together with 
puerperal, specific, and other infections, to pelvic inflammations. 
It is not my purpose to review before this audience the anatomical 
relations and histology of the pelvic organs, a task altogether super- 
flous; nor will I, except in the most casual way, touch upon the 
vast literature of pelvic inflammations. It seems to me most 
profitable at this time to treat the subject from the pathological 
and clinical standpoint. 
M. Bernutz made a most happy comparison between inflammation 
within the pelvis, and the same process within the chest. Skene 
and other modern writers have utilized the same analogy to describe 
and illustrate the pathology of intra-pelvic inflammation. In both 
thoracic and pelvic inflammation we have the croupous and catarrhal 4 
MC MURT RY, 
processes. We have peritonitis and parenchymatous inflammation 
on the one hand, while we find pleuritis and parenchymatous inflam- 
mation on the other. In pelvic inflammations we have recovery by 
resolution just as in pleuro-pneumonia, leaving adhesions and bands 
in the one cavity as in the other. When the inflammatory process 
so interferes with nutrition as to destroy vitality, we have pelvic 
abscess in the one site and pyothorax in the other. We find the 
bacilli of tubercle invading the pelvic serous membrane and con- 
tained organs, just as in the pleura and lungs. A mucous surface 
furnishes access for infection in both cavities. M. Bernutz further 
states that uterine pathology is as certainly subordinate to a thorough 
acquaintance with pelvic peritonitis, as pulmonary diseases have been 
to a complete knowledge of pleuritis made possible by the discovery 
of auscultation. In the light of knowledge recently established this 
last statement shows how thorough and profound were the researches 
of these eminent clinicians and pathologists, MM. Bernutz and 
Goupil. 
Permit me to continue in the lines indicated by Bernutz once 
again. After discussing the theory of pelvic inflammation promul- 
gated by M. Nonat-essentially that of pelvic cellulitis, which until 
recently held full sway in the practise of modern gynecology-he 
says: 
"For some time I had no idea that the view propounded by M. Nonat was 
a mere hypothesis which rested on no post-mortem evidence. And it was 
not till after the unfortunately fatal termination of two cases, that I was able 
to prove incontestably that the peri-uterine tumor, which during life pre- 
sented all the symptoms of the so-called peri-uterine phlegmons, was not 
situated in the cellular tissue at all. In the autopsies in question, the tumor, 
which even after death presented all the usual signs, was seen to be formed 
by the pelvic viscera being matted by peritoneal adhesion These 
researches, then, have led to the conclusion that inflammation of the pelvic 
peritoneum, which is the cause of the visceral adhesion, is a disease which is 
very commonly met with Lastly, I conclude that inflammation 
of the pelvic serous membrane is symptomatic, and that it is generally symp- 
tomatic of inflammation of the ovaries or Fallopian tubes. Thus, great interest 
attaches to the study of this affection, and it is very important to understand 
thoroughly the symptoms, in order to describe satisfactorily the uterine, and 
more especially the tubo-ovarian, diseases which occasion it It 
follows from all this that unless we get fatal cases to enable us to determine 
anatomically where the pelvic inflammation began, we cannot state positively 
whether it came from inflammation of the ovary or of the Fallopian tube ; 
nor whether it was caused by the puerperal state, by blenorrhagia, scrofula, INTRA-PELVIC INFLAMMATIONS. 
5 
or any other malady. Thus we can only lay hold, as it were, of the two ends 
of the pathological problem, the primary disease and the serous inflamma- 
tion-the intermediate gap we can only fill up after death."1 
Herein may be found the very essence of the most advanced 
pathological knowledge of the day concerning intra-pelvic inflamma- 
tions, and it is surpassing strange that the researches of MM. Ber- 
nutz and Goupil lay before the profession for so many years like 
good seed upon sterile ground. It was only when the science and 
art of surgery made great strides forward, as illustrated in the per- 
fected aseptic surgery of the day, that " the intermediate gap " 
which Bernutz could " only fill up after death " was filled up during 
the life of the patient. The researches of Bernutz and Goupil in 
this important field of pathology are complete, and constitute the 
basis of the pelvic surgery of the present time; their work is the 
first and the greatest-a monument to the genius and patient indus- 
try of these faithful followers of science. 
The points relating to the pathology of pelvic inflammations 
which have been established, the correctness of which I am fully 
convinced by my own clinical observations and experience, may be 
grouped in this manner : 
1. Intra-pelvic inflammations cannot be properly classified as 
parametritis and perimetritis, inasmuch as inflammations of serous 
and cellular tissues cannot be separated clinically or histologically. 
2. Peri-uterine phlegmon of Non at (pelvic cellulitis of Emmet) 
is as rare as inflammation of the cellular tissue in other parts of the 
body. 
3. Intra-pelvic inflammation is, as a rule, peritonitis, resulting 
from disease of the ovaries and Fallopian tubes, arising in puerperal 
or gonorrhoeal infection, or the miscellaneous infections carried to 
the endometrium by unclean instruments, tents, or medicinal agents, 
or from traumatism. 
4. Pelvic peritonitis is symptomatic, never idiopathic. 
Pelvic peritonitis presents every grade of severity. In some 
instances there is a mere inflammatory spot, giving rise to but little 
discomfort at the time and passing away without treatment, leaving 
a bare trace behind, often found post-mortem. A higher grade is 
illustrated by those instances wherein the peritoneum exhibits sub- 
1 Clinical Memoirs on the Diseases of Women. New Sydenham Society, London, 
1867. Vol. ii. p. 5. 6 
MC MURTHY, 
serous congestion, transudation of serum, and exudation of plastic 
material. In a more severe grade there is immense transudation of 
serum, which accumulates in the pouch of Douglas, corresponding to 
pleurisy with effusion. In a very high grade the entire pelvic 
peritoneum is involved, the several stages of the process-congestion 
and exudation-are followed by suppuration, an affection of fearful 
proportions, and, unless treated surgically, going often to a fatal 
issue. The sequelae of pelvic peritonitis depend upon the vitality of 
the individual, the grade of the inflammatory process, and the area 
involved. Where the surface is limited, or may be quite extensive, 
recovery may take place by resolution and leave only slight adhe- 
sions behind. When the inflammation is higher and the exudate 
more extensive, layers and bands of false membrane remain, form- 
ing organized adhesions. The products of inflammation may be 
deposited over the uterus, ovaries, and broad ligaments, leaving 
these organs imbedded or entangled in a mass of adhesions. As 
time goes on, the exudate passes through repeated stages of conges- 
tion into organized tissue with constant tendency to contraction. 
Pressure upon the ovaries is followed by inflammation, degenera- 
tion, and atrophy of these organs. The fimbriated extremities of 
the Fallopian tubes are imprisoned and destroyed. At each recur- 
ring menstrual flux,these bands are made tense by congestion, increased 
in thickness, and more thoroughly organized. In addition to the 
lesions entailed by pressure, the secretions are retained, and ovarian 
abscess and pyosalpinx are common results. When the inflamma- 
tion is very intense, involving sub-serous structures, the vitality of 
tissues is destroyed, and one form of pelvic abscess is the result. 
Although it is not contemplated to discuss the diagnosis and 
symptomatology of intra-pelvic inflammation in this paper, I must 
be permitted to dwell for a moment upon the clinical picture which 
corresponds to the lesions I have just described. A woman suffers 
an attack of gonorrhea, often contracted innocently, and has a 
severe attack of pelvic peritonitis; or she has an abortion, or labor 
at full term, and has the misfortune to become infected and perito- 
nitis results. After a severe and protracted illness, the acute symp- 
toms pass away; in time, she gets up and is congratulated by her 
friends upon her convalescence and recovery from so severe an ill- 
ness. Time wears on with improvement in her general condition, 
but she maintains that she is not well. The menstrual periods are INTRA-PELVIC INFLAMMATIONS. 
7 
seasons of intense pain and distress, and usually opium is adminis- 
tered. By and by, the family physician makes an examination, and 
my observation has been that he usually decides a malposition of 
the uterus to be the principal trouble, and inserts a pessary. The 
trouble persists, and pain is intensified by the pessary, which after 
a varying period has to be abandoned. The woman is an invalid. 
If well-to-do, she spends the greater portion of her time in bed, 
drives out occasionally, and craves morphine, chloral, or other ano- 
dynes. She walks with a peculiar halting gait, has a pinched ex- 
pression, and suffers from reflex nervous disturbances. She is 
treated with the hot vaginal douche, local applications to the cervix 
and vaginal vault, but is improved by none of them. About this 
time, massage, rest in bed, milk diet, with varying and unsatisfac- 
tory results, will be invoked in her behalf, but nothing in the way 
of permanent relief results. She is a helpless invalid, and a great 
sufferer. The ultimate issue of the case may be one of three alter- 
natives : either to hold out until the menopause, when physiological 
repose and atrophy may bring relief; to remain an invalid for years 
with opium and all the accompanying misery, ending probably in 
abscess; or to have the diseased and imprisoned organs with their 
consequent histological changes removed. I submit that the picture 
is a familiar one to those w'ho see much of pelvic disorders. In 
connection with such a pathological state, we must not overlook the 
persistent influence of the menstrual congestion upon the growth 
and density of the organized exudate, to which I have previously 
referred. 
The treatment of intra-pelvic inflammations must depend upon 
the structures involved. The cardinal fact that pelvic peritonitis 
is always symptomatic, always the sequel and result of infection, 
must never be lost sight of in formulating any plan of treatment. 
Catarrhal inflammation of the endometrium may, by the ordinary 
process of continuity of surface, extend to the tubes and ovaries. 
Prolonged congestion with thickening of the mucous lining and 
retained secretions, results in localized peritonitis. Treatment by 
depletion, cleanliness, antisepsis, and drainage may arrest and limit 
the inflammatory process and induce a cure by resolution. The 
peritoneum is an immense lymph-sac, quick to open the avenues of 
microbic invasion. An untidy exploration with the uterine sound 8 
MCMURTRY, 
often conveys the infectious spark which spreads from the endome- 
trium like fire on the prairie. Gonorrhea is a disease leaving in 
woman the formidable sequelae of salpingitis, peritonitis, pyosalpinx, 
ovarian abscess, and often general suppurative peritonitis. Labor 
and abortion are processes especially prone to admit infection, and, 
unless rigid cleanliness is observed, are usually followed by varying 
grades of pelvic inflammation. Rest; the clean, hot douche facili- 
tating drainage; saline cathartics favoring revulsive drainage and 
depletion, are means of treatment which often arrest or limit the 
inflammatory process and lead to cure by resolution. To recount 
the various pathological states of the uterus, ovaries, and Fallopian 
tubes, with which general or localized pelvic peritonitis is associated 
would, of course, greatly exceed the limits of this paper. 
In consequence of the matting together of the pelvic organs by 
adhesive inflammation, the exact seat and starting-point of the 
inflammatory process cannot be decided by the ordinary means of 
pelvic exploration. Fortunately, the indications for operative inter- 
ference are so unmistakable that such exactitude in diagnosis is not 
essential for proper treatment. The localized pain, the fixation of 
movable organs, the exudation, and, when pus has formed, the 
rigors, fever, and emaciation are signs too positive to be overlooked 
by the experienced attendant. When the means that I have indi- 
cated fail to secure resolution, and septic symptoms present them- 
selves, we may know that the only treatment is to open the 
abdomen, evacuate the pus, remove the inflammatory mass (usually 
Fallopian tube and ovary), cleanse the peritoneum, and establish 
drainage. Where the disease has gone on to suppuration, the sur- 
geon has no option. Here the only course worthy of consideration 
is total removal of inflamed, suppurating, and degenerated ovaries 
and tubes, of which pelvic peritonitis is the result. Equally is it 
the surgeon's duty to operate in those cases in which the diseased 
tubes and ovaries-one or both-can be made out by the touch 
upon the side of the uterus, accompanied with pain and 1 he familiar 
functional derangement incident to diseased states of the tubes and 
ovaries. I am presuming of course, upon discriminating knowl- 
edge on the part of the surgeon. To operate early, before adhe- 
sions become organized and the inflammatory area extends, and 
before pus forms and the system is infected, simplifies the operation, INTRA-PELVIC INFLAMMATIONS. 
9 
enhances the patient's chances of recovery, and abbreviates suffering.1 
In illustration I may mention hydrosalpinx and hematosalpinx, 
so prone to purulent change. 
When bands of false membrane have imprisoned the Fallopian 
tubes and ovaries, with the consequent alterations of structure 
already described ; when the tubes are in a state of constantly recur- 
ring inflammation, with functions destroyed and secretions retained ; 
when the ovary has become cirrhotic or with the tube has under- 
gone caseous degeneration ; when the patient is a miserable invalid 
and an opium habituS, then these organs should be removed and 
the patient restored to health, home, and society. In cases of 
limited pelvic inflammation, careful discrimination is necessary in 
deciding upon operative treatment. 
For accurate diagnosis an experienced tactile sense and repeated 
examinations are required. Many cases of intra-pelvic inflamma- 
tion of lesser grade are improved and some few cases cured by the 
hot douche, the application of iodine and glycerine, the supporting 
tampon, and rest; but by far the greatest number, in which the 
inflammatory process has been more active and extensive, are in- 
curable without operative interference. Moreover, women dependent 
upon their own labor for a livelihood, and those of meagre pecuniary 
resources, are unable to indulge in months of palliative treatment 
for temporary relief. To those of us who have dealt with cases of 
long-standing pelvic inflammation at the operating table, and shelled 
out diseased tubes and ovaries from a mass of organized exudate, 
the cures claimed for electricity in such cases are difficult to 
accept. When treated upon sound surgical principles by abdominal 
section the results are good, the cures permanent, and restoration is 
complete. 
1 Operation by abdominal section should invariably be adopted in preference to 
puncture of Douglas's space through the vagina.