The Cure of Septic Pelvic Diseases 
in Women. 
BY 
Fernand Henrotin, M. D., 
CHICAGO, ILL. 
REPRINTED FROM THE 
American Gynaecological and Obstetrical Journal 
for June, 1896. [Reprinted from the American Gynecological and Obstetrical Journal 
for June, 1896.] 
THE CURE OF SEPTIC PELVIC DISEASES IN 
WOMEN.* 
Fernand Henrotin, M. D., Chicago, 111. 
A very large part of that which is practicable in the attainment of 
the purpose suggested by the above title having emanated from the 
sayings and doings of the gynaecologists of New York, it may seem 
presumptuous to address this Society upon such a subject. But there 
is still so much to be desired in the results usually obtained by the 
profession at large that your essayer appears before you with the 
greetings of the West, urging that you persevere in the work in which 
you have so long and so patiently labored, and presents this paper 
rather as an exhortation than with the belief that his humble effort 
can add to your knowledge. Dazzled by the brilliancy of the symp- 
tomatic cures obtained by the modern aseptic abdominal amputating 
radical methods, it seems evident to the rational, well-balanced ob- 
server that gvngecology has breathlessly rushed into treacherous 
depths, and that the magnificent records obtained by our experts 
have proved alluring temptations to the inexperienced and ambitious. 
Moreover, the every-day insights gained by modern methods of for- 
merly unknown pathological conditions have solved many intricate 
problems and opened up possibilities of treatment of which we were 
ignorant. Every skilled gynaecologist of to-day, who was already in 
active work twenty-five years ago, can not fail to recognize the truth- 
fulness of these remarks if he refreshes his memory and recalls the 
utter helplessness that followed his discovery at that time that his 
patient’s uterus was fixed by adhesions. Certainly his agony was 
mitigated by his grand faith in the latest pattern of hot-water douche 
* Read, by invitation, before the New York Obstetrical Society, March 17, 1896. 
Copyright, 1896, by J. D. Emmet, M. D. Fernand Ffenrotin, M. JD. 
and the artful manner in which necessity has taught him to dodge the 
question of prognosis ; but truthfulness insists upon the acknowledg- 
ment of the fact that at that date what was known of the means of 
cure and the character of morbid processes in pelvic septic diseases 
of women was most shadowy and uncertain. In the highest ethical 
sense, the term cure as applied to a local affection means the removal 
of the disease without the removal of the organ or organs affected by 
it, or at least without destroying or altering the particular physio- 
logical function which is characteristic of that particular organ. To 
amputate a limb for a tuberculous disease, for example, is not a cure 
in the highest sense of the word, because it destroys or impairs the 
physiological function of walking, and in the same sense of the word 
to remove a pelvic disease by removing the ovaries is not a cure. 
At least that is the manner in which we propose to treat the 
subject. 
The question of treatment of septic pelvic diseases in women can 
not be condensed in a discourse of an hour, but we can select salient 
points, particularly those usually the subject of difference of opinion, 
not forgetting that we are only dealing to-night with methods that 
contemplate complete and perfect cure of patients with restoration of 
absolute physiological functions of perfect type. 
Little need be said of inflammatory affections of the cervix per se. 
Surface infections are usually curable by simple means, while the 
hyperplastic forms are disposed of by plastic methods, notably ampu- 
tation and the Emmet operation. 
The importance, however, of taking cognizance of cervical lesion 
lies in the fact of their being frequently the initiatory step in the 
production of both uterine and peri uterine disease. 
Limiting ourselves for the present to the uterus, the next most 
common affection is the invasion of the cavity of that organ produc- 
ing the condition commonly styled endometritis. The treatment of 
this difficulty has always presented so many disheartening failures 
that the presentation of the subject to any society always leads to the 
most enlivening discussion, as well as to the most dissenting opinions. 
It is most refreshing, however, to witness the pertinacity with which 
the subject is constantly being presented, and, no doubt, good will 
come of it all, for it represents the fact that our entire profession real- 
izes the logical fact that in the cure of endometritis lies the keynote of 
success in the eradication of a very large proportion of septic 
troubles. 
The cavity of an infected uterus, if curable, is only so by following The Cure of Septic Pelvic Diseases in Women. 
3 
the same general surgical rules that govern the treatment of any in- 
fected cavity—namely, opening, cleaning, and draining. To gain the 
desired result, then, these conditions must obtain in all but in an in- 
finitesimal number of cases. Just as we occasionally cure an abscess 
by aspirating, and it may be destroying or neutralizing the germ con- 
tents by a chemical agent, so it may be that rarely we may cure an 
endometritis by topical applications thrown into its cavity, but there 
is reason to believe that this seldom occurs. Usually the condition 
cures by reason of manipulations that are necessary for injecting, bet- 
ter drainage is established, and the fluid mechanically brushes out in- 
fected matter, or Nature manages gradually to establish cure by drain- 
ing and purging itself. When we inject a closed tubercular cavity or 
joint with iodoform we are simply destroying a specific’ noxious ele- 
ment with a specific remedy, and the same with occasionally other 
forms of pus sacs containing so-called sterile pus ; but how seldom 
we succeed in mixed infections, the conditions that hold good in the 
infected uterus. We then resort to the trinity mentioned above. We 
open, clean, and drain. Opening the uterus in gynaecology is called 
dilating, because the sphincter action of the lower uterine muscle pre- 
vents to a great extent the keeping of the cavity open. In all cases 
where dilatation is necessary, to use the words of one of your mem- 
bers, Dr. Pryor, “ tbe functions of the cervical ganglia must be so 
obtunded as to prevent uterine contractions.” If necessary to ob- 
tain this result, the cervix must be incised. Make a straight cut 
through the posterior lip in the median line to the vaginal junction, 
the beginning of the incision being well up above the internal os, 
and growing deeper until it strikes the posterior fornix, the dilatation 
being continued, however, with care after the incision, so as not to 
tear open the posterior cellular spaces too much or open the peri- 
toneal pouch, though such an event will not produce trouble, unless 
irrigation is employed and washes septic material into the general 
cavity, and, being unnoticed, no drainage is employed. The uterus 
must be cleansed, and the sharp curette is the most available instru- 
ment in our possession. We must use that even if reckless or clumsy 
fellows occasionally do harm with it. We can not always reach and 
remove all the diseased parts with it, I allow, but it is our best re- 
source, and by using it carefully but thoroughly we do the best we 
can. Then wash out with plain water, and mop out as dry as possi- 
ble by packing in a strip of gauze and withdrawing it. Then clean 
out with peroxide of hydrogen, the most searching disinfectant we 
have, this being done by soaking a strip of gauze in the peroxide and 4 
Fernand Henrotin, M. D. 
pushing ifipightly in the cornua of the uterus and packing the cavity 
lightly also, and then withdrawing it. Again introduce the dilator, to 
make sure of relaxation and good drainage, as well as escape of gas ; 
pack thoroughly with gauze well saturated and tightly wrung out of a 
ten-per-cent, sterilized emulsion of iodoform in glycerin. An ab- 
dominal fistula coming from an infected ligature, when it does not 
communicate with a large abscess, can frequently be cured by a week 
or two of washing out with peroxide, followed in a few days by injec- 
tions with iodoform emulsion, the ligature becoming re-encysted. 
Having seen this occur several times, the plan is suggested of disin- 
fecting the cavity of the uterus in septic endometritis in the same 
manner at one sitting, the hydragogue effect of the glycerin being 
supposed to add to the drainage. Though personally not having used 
it sufficiently often to form definite conclusions, it is simply presented 
as a reasonable suggestion with the understanding that harm might 
come from evolving sufficient gas with the peroxide to penetrate too 
far into the tubes, and that colic or toxic effects might result from the 
use of the glycerin, none of which effects, however, have been no- 
ticed. This method may not be new, and it may provoke harm and 
may have to be relinquished, but, as this Society is composed of intel- 
ligent practitioners, no better place could be obtained in which to 
offer suggestions for treatment. 
The vagina, in the disinfection of which very great care must be 
taken before, during, and after the operation, should be packed with 
iodoform gauze, and this vaginal gauze pack should be changed in 
twenty-four to forty-eight hours, and as frequently thereafter as neces- 
sary to prevent reinfection ; for it is manifestly absurd to dilate, cu- 
rette, and drain the uterus, taking away all dressings in three or four 
days and being content with carelessly ordering a vaginal douche, and 
reproducing the disease by vaginal infection when so much trouble 
has been taken with the operation. There is reason to believe that a 
reasonable number of cases fail to cure because within a few days the 
cervix is once more bathing in the same old vaginal microbian pool. 
The most explicit directions to the patient and nurse, or, better yet, 
if possible, the personal attention of the doctor to the perfect condi- 
tion of the vagina for the four weeks following, is a matter of more 
importance than is generally supposed to the success of this really 
most important operation. 
It will be noticed that this is a simple recital of the most ordinary 
methods as followed by many practitioners, and is given as a means 
of cure of a certain percentage of cases of endometritis. The Cure of Septic Pelvic Diseases in Women. 
5 
I recognize that the gentlemen before me are not students, to be 
inflicted by such recital of the alphabet of gynaecology were it not 
intended as a categorical repetition of simple facts in the efficacy of 
which your essayer desires to acknowledge his belief as well as a 
standard from which the derivations must be frequent to insure suc- 
cess. Intelligent men who are not gynaecologists of routine will prob- 
ably acknowledge that these methods will cure a certain number of 
cases of the common varieties of septic endometritis of not too long 
standing, no matter which form of infection may have produced the 
disease. A reasonable number of gonorrhoeal and semi-chronic so- 
called catarrhal cases, and a large number of puerperal cases, if taken 
at the proper stage, can be cured in this way ; and these procedures, 
perfected in details by the experience of practice, will very probably 
succeed more frequently than any other method. To systematically 
describe to you all the varieties of uterine septic invasions and 
their symptoms, together with their respective treatments, would fill a 
book ; rather allow your attention to be drawn to some of the most 
flagrant mistakes made in following out stereotyped treatment. To 
take exceptions to dilating, curetting, and packing, by indulging 
in a denunciation of dirty patient and dirty doctor and dirty curette 
and dirty vagina, is no argument against a practice that is recog- 
nized by the profession as having cured, and does cure, many. We 
speak of a rational procedure based on good surgical principles and 
accomplished in true surgical manner. Such a procedure often fails 
because of misapplication. To curette a uterus in a woman because 
she has gonorrhoea, failing to recognize that the uterus is not invaded, 
is a serious mistake in diagnosis, and may introduce the virus into the 
very organ it is sought to protect, but does not militate against the 
fact that many women whose uteri have been invaded can be restored 
to health completely by this very means of treatment. That all women 
are not cured after curettage who suffer from specific endometritis is 
no argument against the treatment, unless it can be shown that as large 
a number are harmed; and even then, no better substitute being of- 
fered, we still can hope to perfect the old methods. Ovariotomy 
formerly killed more persons than it cured. A misapplied agent is 
not necessarily a worthless one. A puerperal uterus large from ad- 
vanced recent pregnancy, for example, calls for the greatest amount 
of discriminating diagnostic intelligence in the application of the re- 
quired treatment. 
To use a sharp curette in clearing out the debris when the thick- 
ened walls are affected with thrombo-phlebitis or lymph-thrombosis 6 
Fernand Henrotin, M. F>. 
would probably be striking the first match to a general conflagration. 
The smooth, dull curette, or, better yet, the finger, or the forcible stream 
of clean hot water or weak solution of creolin, is the way to safety, 
and yet six weeks later that very uterus, the thrombi having been 
absorbed and corporeal metritis having subsided, may absolutely 
demand the sharp curette to put an end to a secondary septic endo- 
metritis, an advancing microbian host again threatening its integrity, 
this time by way of direct penetration from the mucosa. Here is an- 
other illustration which demonstrates the most common form of the 
misapplication of a valuable agent. A woman develops a septic en- 
dometritis due to any form of micro-organism. The process is a slow 
one, not particularly virulent. Nature is on the alert, and closes the 
portals of the Fallopian tubes at their uterine ends. She throws out a 
protective wall within the substance of the uterus, and at variable 
distances back of the mucous lining. The whole difficulty is confined 
to the body of the uterus. Hyperplastic conditions prevail, hyper- 
trophic connective-tissue development ensues, and in time we have 
an enlarged, completely sclerotic organ. The clinical picture is that 
of pelvic pains, with abundant purulent discharge and rather irregular 
profuse menstruation in the first stages. As the uterus becomes 
hyperplastic the leucorrhoea becomes thinner and more irritating and 
ichorous. The pains continue, but are more dull and reasonably 
bearable, and until atrophy begins the menses remain profuse. Ster- 
ility is, of course, absolute. The ovaries and tubes are normal as far as 
gross changes are concerned. Gradually, as years pass by, the process 
extends to the tubes and ovaries, but for years that woman, if left 
alone, will remain in good health ; she will never develop pus tubes 
or ovarian abscesses. Most such patients are in very fair health and 
grow plethoric. The whole process is so slow that acute distress is not 
known, and the woman, barring the few symptoms described, con- 
siders herself well. We all see many such. It is Nature’s cure. 
Some enterprising but not particularly discriminating gynaecologist, 
hearing her complain of a little backache, examines and discovers a 
large uterus. It feels heavy to the patient, and generally rests pretty 
well down in the pelvis. It is neither retroflexed nor anteflexed, be- 
cause it is too stiff and hard to bend. Menses rather profuse ; the pa- 
tient feels better during menstruation. Our friend does not realize the 
density of the unfortunate uterus nor the thickness of its wall. Diag- 
nosis : enlarged uterus, chronic inflammation, menorrhagia, and falling 
of the womb. Treatment : curette, etc. We all know of such cases. 
Some of you may understand how to cure them; if so, please publish The Cure of Septic Pelvic Diseases in Women. 
7 
the how. Our colleague dilates and loses his breath at the exertion 
necessary to dilate, or rather to tear through, the cervix. After many 
efforts of physical strength he worries a curette into the uterus, and 
wonders how little there is to scrape out and how small the cavity is 
considering the size of the uterus. A small strip of gauze is cork- 
screwed into the organ and the lady goes to bed, develops a tempera- 
ture, is nursed through a long fever, dies from pelvic abscess, or 
remains an invalid, or is obliged to have the ovaries and abscess re- 
moved, to bring on the atrophy that was coming about so nicely 
before she began to doctor. This is a true picture of the abuse and 
misapplication of a life-saving method of treatment. 
We are told by some of our noted abdominal surgeons who do not 
stoop to the spoon, that the curette is a murderous weapon, respon- 
sible for many deaths. So is the knife to him who is ignorant, un- 
trained, and without conscience—more so, for the sharper the tool the 
more danger. How much more they might accomplish if they took 
as much interest in the ideal physiological cure of women as they do 
in the perfection of abdominal work of the trenchant variety ! 
Every woman who comes to the operating table has been curetted. 
Of course she has. Ergo, the curette did the damage. Why she was 
curetted we wonder, but dare not say. Only a certain proportion are 
cured by dilating, curetting, and draining, because many are so 
operated on false indications ; because the work is slovenly or im- 
perfectly performed, which is no criticism to correct methods ; be- 
cause the shape of the uterus is such that all the parts of the mucous 
surface can not be reached ; and, lastly, because no methods of 
diagnosis have yet enabled us to determine the exact limitation of the 
disease either beneath the endometrium or up the first portion of the 
tubes. We scrape many patients to whom we do no good, but if we 
do the work perfectly we seldom injure. What can be more satis- 
factory than the treatment of the interior of the uterus in septic puer- 
peral cases of the proper type, or of the same procedure for the 
simple endometritis of the undeveloped uterus of the young, sterile 
wife, or of some forms of membranous dysmenorrhoea, or, if practiced 
very early, of many cases of gonorrhoea and other septic varieties? 
The younger men, who are doing large general work and see many 
septic cases in their incipiency, and who have sufficient ambition in 
gynaecology to learn clean proper methods, are doing magnificent 
work with the curette, and a great army of women who have had 
septic uterine trouble never get acquainted with the abdominal sur- 
geon, because, as the boys say, “they don’t have to.” 8 
Fernand Henrotin, AT. jD. 
To sum up the general rules that should govern the management 
of these cases, it may be said concerning the treatment of septic dis- 
eases confined to the uterus not calling for extreme radical treatment, 
that rational, sustaining, stimulating, gymnastic, dietetic, and alterative 
treatment, with the most careful attention to the condition of the ex- 
cretory organs, may be the only means of value at our command in a 
certain proportion of very chronic cases, but that a very large number 
of women can be cured by properly managed local interference ; that 
virtually all that is of value can be summed up in the intelligent ap- 
plication of the methods of opening, cleansing, and draining the 
uterus, and that the success of each individual will depend upon his 
discrimination in the application of these curative measures. 
G. Bouilly is right when he says that the notion of pyosalpinx has 
become such a prominent one that it has forced back to second place 
the knowledge and study of other lesions, and that the discoveries of 
the operating table frequently forces a modification of the diagnosis 
which attributed all the symptoms to a diseased tube. Infection in 
the pelvis originates in a large majority of instances in the cervix or 
in the uterine cavity. It travels by way of the lymphatics or the 
veins, or spreads by contiguity along the mucous tracts to the peri- 
toneal cavity, or directly penetrates the tissues irrespective of natural 
channels. The inroads of the infectious element is in proportion to 
its virulence and the resistance of the parts affected. Venous and 
lymph thrombosis, adhesive cohesion of affected parts, or effusion of 
exudate may arrest its march at any part of its progress. These dif- 
ferent conditions may coexist in the same patient and produce dis- 
seminated disease hardly to be diagnosed in a distinct manner. 
Septic affection may be limited to the uterus, or it may by the routes 
mentioned reach any of the pelvic organs. Lymphatic invasion of 
the broad ligament of pure type is rare, but has been proved to exist 
without disease of tubes or ovaries. 
Almost all authorities are now rallying to the opinion that many 
have gone too far in their crusade against the existence of pure 
cellulitis. Cellulitis from an infected thrombosis or the pure 
lymphangio-cellulitis does exist with or without tubal or ovarian 
trouble. I have seen the proof of this in operations several times, 
notably in one case that I saw operated in this city. The ovary is 
usually first involved; the tube becomes so later by direct penetration 
through its walls after it has become imbedded in the mass. Re- 
member that it is not denied that most cases of tubal disease result 
from the direct infection along the mucous tract. Bouilly mentions a The Cure of Septic Pelvic Diseases in Women. 
9 
very recent case in which he opened a phlegmon of the left broad 
ligament by an incision above the crural arch. A milder form of ap- 
parently the same difficulty existed on the right side which gradually 
subsided. Three months later the right side again began to give 
trouble, and a laparotomy discovered a large purulent ovarian sac, the 
right broad ligament the seat of an old indurated phlegmon, and the 
left side, which had been operated for suppuration three months be- 
fore, cured and with healthy tube and ovary. Two years later this 
lady conceived and was delivered normally at full term. 
Taking one short step further, I would acknowledge my belief that 
careful investigation in the future will demonstrate that an ovary can 
be the starting point to the development of an infection, and is so more 
frequently than we suppose. This is difficult to believe, and is only 
based on the fact that in several instances I have opened through the 
vagina apparently well defined ovarian abscesses, when to the touch, 
and occasionally the sight, the tubes and broad ligament seemed 
normal. This would mean that the infectious element in the lym- 
phatics to the ovary, finding a better pabulum for development in the 
ovarian, or rather peri-ovarian, tissue, would develop there primarily 
to the point of producing at least the first gross lesions before its 
presence could be noted in the broad ligament proper. 
Another clinical form of trouble might be mentioned, and that is a 
low grade of pelvic peritonitis, with subdued symptoms and involving 
all the organs in adhesions, fixing the uterus in adherent retroversion, 
filling Douglas’ pouch with adhesions, and by these producing altera- 
tion in nutrition of the organ, showing a tendency to the development 
of cystic ovaries. 
These few remarks upon the pathogenesis of pelvic diseases 
seemed almost necessary to the introduction of the question of treat- 
ment, as will become evident. 
The day that septic infection has reached beyond the bounds of 
the uterus, what can we do ? According to the general methods prev- 
alent at the present time, there is only one answer. If life is not 
apparently in danger, see your patient regularly, hypnotize her to the 
best of your ability, amuse her with poultices and hot douches, give 
her quinine as an antipyretic if her temperature goes up, or quinine 
as a tonic if it goes down, and tell her to have patience, and if she 
does not recover, when her tubes and ovaries are ready and ripe, 
yourself or one of your friends will remove them. If life seems in 
danger, let the organs go as soon as consent can be obtained. Sad 
outlook ! Some—yes, many—cases recover and only very few die. Of Fernand Henrotin, M. D. 
the many women brought to the operating table and operated, only a 
few would actually die in a manner that it would be said they die 
from the disease direct. But how few recover perfectly, except after 
passing through indefinite sufferings and repeated attacks, and when 
apparently well how many have perfect pelvic functions ? When you 
find a patient with an exudative mass against the uterus, and that 
organ fixed, can any of you tell her whether she will be ill one month 
or ten years? When the word pelvic peritonitis is uttered loudly in 
an assembly of women several begin to shudder. 
It seems horrible to contemplate removing the appendages at the 
outset of a disease, and yet it appears very very sad to wait, it may 
be for months, it may be for years, for Nature’s cure, with the ever- 
present shadow of a future mutilating operation. Your reader has 
proposed a method, surgical though it be, but not involving the re- 
moval of any organ, as a first step in the future treatment of these 
diseases. In doing this let it be understood that no attempt is made 
to prove that a cure-all has been found, or that it is a universally ap- 
plicable method, or that in itself it is even original. Its announce- 
ment consisted in the simple recital of personal experience, and ven- 
turing the hope that properly applied it might prove a great boon to 
suffering women, and that it would, moreover, tend most decidedly 
to a better knowledge of the different varieties of septic pelvic dis- 
orders and their respective treatment. The only originality claimed is 
that it is the first distinct announcement made of the curative value of 
such a procedure in the treatment of acute inflammatory affections as 
soon as the diagnosis is established. The dangers of the undertaking 
are so slight, and the benefit in some cases so striking, that it seems 
impossible to believe that in time it can hardly fail to prove a blessing. 
It will not cure every pelvic inflammation. What remedy or opera- 
tion cures every disease having pernicious elements ? It is only a 
question of time when it will have been proved what cases it will fail 
to cure and what patients are unfitted for its application. 
The operation consists, as you know, in the simple incision of the 
posterior vaginal fornix and the drainage of the affected seat of 
trouble when it is reached. The explanation of the technique gives 
a better understanding of the method. An incision is made following 
the contour of the posterior face of the cervix at its vaginal junction, 
but not going too high at the sides to provoke haemorrhage from the 
larger vessels. This incision is made by scissors, knife, or Paquelin 
cautery. When the indications point plainly to pus and long drain- 
age, use the cautery, and the edges, being seared, will not show a tend- The Cure of Septic Pelvic Diseases in Women. 
11 
ency to contract so quickly. From the center of this parallel to the 
axis of the vagina another incision is made of variable length to give 
free access. Of course the proximity of the rectum must be taken 
into account. Detach the retro-uterine connective tissue, always 
working against the posterior uterine surface. The uterus during 
the operation is held steady by downward moderate traction, the pos- 
terior or both lips of the cervix being held by a tenaculum. If you 
can determine the proximity of the peritoneal cavity, detach the tis- 
sues first in that direction. This penetration and detachment of the 
tissues is done with the finger, alternated, if desirable, with small 
nicks of the scissors. If working in dense tissues or infiltrated ones, 
occasionally withdraw the finger and look closely for the possible ap- 
pearance of pus. If you have reached the peritonaeum and have un- 
covered no pus, open the general cavity at once. This is very 
important. Almost the only source of danger in the operation results 
from neglecting this step. The reason is obvious. The manipula- 
tions may cause a leakage into the general cavity of pus from a 
fragile sac within. Even if you use but little force, the traction upon 
the uterus may do it. Pus into the dependent portion of the cavity 
does no harm if wiped out and drained. Retained pus without 
bounds will almost certainly kill. Moreover, it is a great advantage 
to explore the pelvis before doing anything further; therefore, if the 
cavity is open wash your hands, disinfect the vagina again by placing 
a gauze sponge in the wound and irrigating, and proceed to explore 
the pelvis from the inside, passing the volsella on the uterus to your 
assistant and using the left hand suprapubically the same as in 
bimanual examination, bidding the assistant to relax or increase the 
traction on the cervix as best suits your purpose. If you strike pus 
before the general cavity is opened you may follow' it up, the hand 
placed above indicating the direction by marking out a mass, and the 
finger within seeking the way of least resistance and resilient tissue 
characteristic of exudate. If the finger penetrates a well-defined 
cavity of pus or sero-pus behind or to the sides of the uterus, and it 
is evident by bimanual palpation that this constitutes the whole disease, 
and, to be reasonably sure of this, the result of your examination now, 
minus the exit of pus, must correspond with the conditions found on 
examination of the patient while anaesthetized just before the operation, 
and you are quite certain you have not opened the general cavity, 
you may stop then, and, after introducing drainage and packing the 
vagina, the patient may be put to bed. If you have any doubts 
about these points, clean off the whole field thoroughly, clean the Fernand Henrotin, M. D. 
vagina, clean your hands, put a little pack of gauze into the hole 
made by your fingers into the abscess, open the cavity of the peri- 
tonaeum behind, wash the right hand again, and introduce one or 
two fingers again and explore from within. If nothing is found, drain 
Douglas’ sac and place a good drain in the abscess cavity, and you 
will be safe. If the cavity is opened at first hand, before pus or ab- 
normal tissue has been encountered, it may be that immediately on 
entering there will be a gush of bloody serum or sero-pus. In such 
case empty the containing cavity thoroughly, enlarging the opening if 
you desire, mop out with iodoform gauze, and then proceed to ex- 
plore for further trouble. If nothing more can be found, simply 
drain the cavity. In these cases the intestines will usually be held 
aloof by more or less exudate, and careful consideration is necessary 
to determine whether or not to disturb further. If you have doubts, 
the tactile bimanual sense will indicate to you how to proceed. Do 
not hesitate, however, to insinuate the fingers between bowel and 
exudate, or in any direction that seems to be still thickened, making 
free to separate all adhesions in all directions ; there is more danger 
in doing too little than overdoing, and with the finger guided by in- 
telligent experience serious damage seldom occurs. It may be that you 
open the free cavity and nothing escapes. You now explore where you 
have before ascertained mischief exists. It may be extraperitoneal 
or intraperitoneal, or both. There may be a broad-ligament phleg- 
mon without peritoneal communication. In such case there will be 
found a mass at the side bulging into the cavity, but easily nearer the 
tip of the finger thrust in the tissues in that direction, but outside 
of the peritonaeum. 
In such cases a large, wide strip of gauze, with string attached if 
you desire, is packed into Douglas’ sac, carefully closing its open- 
ing, and the finger separates the tissues and penetrates the mass 
always beneath the peritonaeum. If only exudate is found, it is 
thoroughly penetrated in all directions and drained, and then the 
protective gauze taken out of the peritoneal cavity and replaced by a 
simple gauze drain, A mass may be found on one or the other side 
evidently intraperitoneal. It may be a pyosalpinx or ovarian abscess, 
or tubo-ovarian collection, or an abscess in the free cavity welled off 
by exudate. Here the long gauze pad is arranged in such manner as 
to shut off to the best advantage the healthy side, the mass is pene- 
trated, the pus, if any is present, is emptied, everything is wiped out, 
and the fingers reintroduced to explore, for, beware, there may be 
several pus cavities, and they must all be opened. An ovarian The Cure of Septic Pelvic Diseases in Women. 
abscess can sometimes be separated from adhesions and coaxed 
down very close to or into the opening, and there opened. In quite 
a number of cases, particularly those characterized by a posterior 
exudative mass, one can not individualize the different organs 
thoroughly. The finger penetrates exudate and separates adhesions, 
only feeling that he is in the peritoneal cavity, but not by any sense 
of having felt the peritonaeum. These cases, of course, make him 
feel that he is doing blind work ; but what matters it if, having 
opened and drained an abscess, you have not known exactly where 
that abscess was. Disentangle everything to the best of your ability; 
after having a few cases you will usually know where you are, and 
meanwhile you will cure the large majority of cases. In a reasonable 
portion of patients you will fail to find pus, and are met at the outset 
by a mass difficult to distinguish, but containing no liquid. These are 
intraperitoneal or extraperitoneal. When intraperitoneal it will soon 
be recognized that one is working the finger between intestinal folds 
glued together by exudate. When extraperitoneal, the fact can 
usually be established by the greater density of the tissues and the 
difficulty of getting very close to the opposing abdominal hand. A 
fibrino-plastic character of the disease does not prevent its absorp- 
tion if thoroughly penetrated and drained. No fear need be enter- 
tained about going too far ; the principle involved is that all parts of 
the inflamed area must be reached, and good and sufficient drainage 
established. If it can be determined that infection exists anterior to 
the uterus, an incision can also be made anterior to the cervix, and 
drainage established there. In all cases the operation is to be pre- 
ceded by thorough and efficient dilating, curetting, and packing of 
the uterus. Though it has taken so long to explain all these details, 
performance of the operation is usually very short. After the uterus 
is curetted, it often requires only a few minutes to do the work in 
simple cases. If the procedures just described are in time proved as 
innocuous, as there is reason to believe, and their value receives the 
indorsement of our profession, in the near future, when a physician 
curettes the uterus and finds a suspiciously dense area in its proxim- 
ity, he will simply make an incision as described and drain the in- 
fected area, thereby often aborting an extra-uterine disease in its 
very incipiency. Regarding the drainage after the operation there 
is this to be said : The opening through the vaginal wall is usually 
the first to contract, and must be made to correspond to the character 
and peculiarities of the particular case. 
If a large abscess is found, or much disturbance and breaking up Fernand Henrotin, M. 1). 
of adhesions has been necessary, surgical sense dictates the necessity 
of a large drainage tract, and the vaginal buttonhole may be increased. 
If Douglas’ pouch dips backward to a sufficient extent to threaten 
obstruction, the post-vaginal structures must be incised sufficiently to 
make an easy descent, not forgetting, of course, the proximity of the 
rectum. One of the drawbacks of the drainage by gauze is the tenac- 
ity with which it adheres to contiguous parts when removed, and the 
pain renewal of the dressing gives the patient. This may to a great 
extent be obviated by draining with gauze wrung nearly dry after 
soaking in iodoform emulsion of glycerin—sterile, of course. Drain- 
age is to be removed after different lengths of time, according to the 
variety of cases in which it has been used. If a serous effusion has 
been found in the cul-de-sac, and nothing else, in forty-eight hours 
the gauze is removed and a very small wick left in. Or, in such 
cases, the opening may be partially closed by sutures and only a wick 
left in from the beginning. If a large pus sac has been opened and 
much exudate is present, and no signs of retained secretions become 
evident, the packing may be left in four or five days and then 
removed. In fine, surgical experience is to guide the surgeon. Re- 
newal of the dressing gives pain, and its frequency should be a matter 
of consideration. 
Generally, after three or four dressings, the vaginal opening will 
remain patent long enough to allow the case to come to a successful 
close. A short, wide retractor, and two extra long ones, rather nar- 
row, are of advantage, the first to retract the perinseum in making the 
primary incision, the last to push in the peritoneal cavity when one 
desires to look in and wipe out after the opening is made. Most of 
the manipulations in exploring and penetrating are made with all 
retractors withdrawn. 
Dangers and Drawbacks of the Operation—Hcemorrhage.—In a 
number of cases haemorrhage will be considerable. One of the 
causes is the failure to follow the exact middle of the uterus and 
getting away from the vessels at its side. This mistake is easily 
made, because the uterus is frequently pushed to one or the other 
side by a mass on the opposite side. Carefully noting the direction 
of the uterine canal in the preliminary curettage can obviate this 
mistake. The haemorrhage from the vaginal vessels unavoidably in- 
cised is also often quite free, and particularly so in the bleeding from 
puerperal cases. As far as known, all haemorrhage is controlled by 
packing of the drainage gauze. 
Fistulcß.—In forty cases of my own, one recently returned ; The Cure of Septic Pelvic Diseases in Women. 
operated over a year ago, with a fistula discharging pus from an 
abscess sac opened at that time, the patient, however, having since 
been in perfect health. 
Failures.—Case I.—Mrs. C., B Avenue, had been suffering for 
three or four weeks with acute pelvic inflammation of severe type, 
with excruciating pain. A mass fills the pelvis from side to side, 
perfectly immovable. Uterus not to be outlined further than the 
fornices. Evidently cellulitis, and what not above. Incision made 
in the usual manner. Immobility of mass made operation well-nigh 
impossible. It seemed as if the finger never would reach the cavity of 
the peritonaeum. After penetrating the general cavity no exploration 
could be made, the tissues on either side being so thick and dense that 
headway could only be made by unwarranted force. Haemorrhage 
very free. Operation very unsatisfactory. After penetrating in sev- 
eral directions, gauze drainage was placed and the patient put to bed, 
with the conviction that little or nothing had been gained. No reaction. 
Patient improved at times and then gradually relapsed. Laparotomy 
offered, but refused. Patient still ill, three months and a half now. 
Surgeon in charge says, “ Mass on the left side can now be outlined 
distinct from the solid pelvic roof.” Apparently not harmed by 
operation. Surgeon reports, “ She may be willing to submit to 
another operation the same as before.” This is a distinct and an 
undeniable failure. Probably not a proper case for this treatment. 
Case II.—Mrs. F. C. G., S P Avenue, puerperal case 
six weeks after confinement. Typical broad ligament. Phlegmon of 
right side. Expected to make inguino-crural incision, as mass seems 
adherent to anterior wall. When anaesthetized, thought it could be 
reached from below. Usual incision. Subperitoneal dissection be- 
tween folds of broad ligament, no pus being encountered. Peritoneal 
cavity opened. Ovary could just be reached. Seemed enlarged, but 
consistent. Thinking patient would recover, nothing further was done. 
Absolutely no result. 
Fever still continuing and mass still present. 
Partial Failure.—Case 111.—Mrs. R., moderate mass, right side. 
Penetration of mass. Evacuation of slight semi-consistent pus exu- 
date. Convalescence not well established. Irregular fever for 
three weeks. Gradual cure, patient being about in six weeks. Ir- 
regular menstruation and pelvic pains at menstrual time, but is 
about and apparently well since. Operation seven months ago. 
Opening in peritonseum not large enough. Gauze drainage not 
properly placed and not renewed often enough—only once on ac- Fernand Henrotin, M. D. 
count of pain. This patient could have been cured promptly if 
operation had been done more skillfully. In contrast with these, 
thirty-six cures, some of them magnificent, for diseases that we know 
are so intractable. By cures I mean to say that the thirty-six cases 
recovered and resumed their ordinary methods of living and were 
free from symptoms sufficient to bring them back to their physi- 
cians. I will not venture to say that none of these have had or will 
not have return of trouble. I presume some will. I can only say 
that none have had relapses to my knowledge; a large number are 
still under observation to determine their future, and are known to 
remain well one to four years after the operation. 
An Ideal Case.—Mrs. H., September, 1895, was taken with irregu- 
lar and rather profuse uterine haemorrhage with subdued pelvic pains; 
three weeks later had fever and took to bed. Twelve days later I 
operated, temperature having ranged from 102° to 104° the previous 
week. Usual incision. Penetration into general cavity. Left ovary 
normal. Right ovary as large as a large hen’s egg. Adhesions slowly 
and carefully loosened ; an enlarged ovary gradually worked down 
until presenting at the opening in the vaginal fornix unruptured. 
Incision through presenting part. Evacuation of two to three ounces 
of rich thick pus. No contamination of general cavity because of 
the protection of a long iodoform-gauze sponge placed in this prior 
to the evacuation. Cavity of ovary carefully sponged out and the 
organ replaced after being packed with a strip of iodoform gauze, 
the end of which is brought out of the vaginal opening. 
Further cleansing of all the parts, further packing of Douglas’ 
pouch. Temperature normal on fourth day and thereafter. Returns 
home after three weeks. Examination last week reveals no tumefac- 
tion in the pelvis. Slight induration of old point of incision. Uterus 
possibly a little enlarged yet, but perfectly movable. Has gained 
many pounds in flesh and is in perfect health. I forgot to mention 
the important pathological fact that the end of the tube was brought 
down and was absolutely perfect, the fimbriae not showing the least 
appearance of infection, and a probe passed an inch and a half 
up its channel without obstruction. I grant you, it might have been 
a little safer to exsect that ovary for the future welfare of the patient, 
but, in view of the excellent result, the operator will be forgiven the 
sentiment that gives him the pride of saying, “ Now the woman is 
well, and nothing was removed.” 
I might give you long recitals of interesting results obtained by 
this means, but having already encroached upon your patience and The Cure of Septic Pelvic Diseases in Women. 
17 
stated at length the most important facts which I desired to bring to 
your attention, but little remains except to apologize for the length 
of this paper by saying that if but a mite has been added to perpetu- 
ating your interest in this matter, good will result. No particular 
priority or originality is claimed. These operations have been done 
from time immemorial by men in all countries. Pus sacs and infect- 
ed areas have been incised, punctured, and penetrated by trocars 
and cautery, and scissors and knives, no doubt for ages passed. If 
any originality belongs to the work it is the enunciation of the prin- 
ciple that, “it having been proved that in the large majority of cases 
of para-uterine and peri-uterine septic diseases, ordinary medical 
means or simple local treatment is of little or no value, these demon- 
strations tend to accentuate the fact that such affections should be 
attacked from their incipiency in a surgical way, and that the proper 
method is in the adoption of the standard rule—cut, clean, and drain 
right from the beginning.” 
All cases may not be so cured ; but tell me what surgical opera- 
tions have shown better results in their early history? Much remains 
to be done in this line. Some few cases may be made worse, and 
some few not benefited, but the results of such procedures at the 
hands of experienced men will determine boundaries, and the discov- 
eries unveiled in operating patients in this early stage of the disease 
is almost certain to bring about a perfection of symptomatic diagnosis 
that will in the future make infinitely more perfect the best methods 
of cure by making fine discrimination of cases possible. If a virulent 
fluid from an infected uterus finds its way into the general cavity 
before Nature has sealed the tube, the very first drop may seal the 
doom of the patient, and yet we know that if at the dependent por- 
tion of the cavity that drop found a drain, nothing more than a 
simple local evidence of trouble would result. The surgeons of the 
near future will learn to interpret symptoms and place his drain in 
time to avert many a calamity, and work in the direction which I have 
endeavored to point out may be of great assistance in reaching such 
ideal results. Unthinking and unknowing people sometimes com- 
plain of too much surgery, but the lessons learned by us of the great 
achievements of the past rather spurs us to do more, provided it is 
done well. This form of treatment is suggested for trial, with a presen- 
tation of the evidence of its apparent efficacy by your invited referee. 
Where better could it be presented for a verdict than from the Society 
that counts among its members Emmet, still on guard over the fate 
of cellulitis ; or Munde, or Thomas, who so frequently fought for vag- Fernand Henrotin, M. D. 
inal incision ; or Polk, whose words for conservative work are still 
fresh to our memories ; or Pryor and many others here who have 
struggled so honestly to bring to gentle suffering women the greatest 
boon possible from gynecology—namely, the cure of pelvic septic 
disease ? 
Gentlemen of the New York Obstetrical Society, I thank you for 
your flattering invitation. 
353 La Salle Avenue.