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UNIVERSITY C^^NNSVLVANIA PRESS 
JANUARY, 1894 
THE DIAGNOSIS OF PELVIC INFLAMMATORY 
DISEASES. 
BY HOWARD A. KELLY, M.D., 
Professor of Gynaecology anti Obstetrics in the Johns Hopkins University, Baltimore, Md.'< The Diagnosis of Pelvic Inflammatory Diseases.1 
HOWARD A. KELLY, M.D., 
Professor of Gyncecology and Obstetrics in the Johns Hopkins University, 
Baltimore, Md. 
So much attention has been paid 
to the treatment of pelvic inflam- 
matory diseases that I feel it will not 
be amiss to devote my remarks on 
this occasion exclusively to the diag- 
nosis. To the general practitioner 
the importance of appreciating the 
grounds upon which the diagnosis of 
these affections is made, is a matter 
of the greatest importance, and to 
him I desire especially to speak. 
ing a differential diagnosis between 
pseudo -pelveo -peritonitis and true 
pelveo-peritonitis. 
The term “ pelvic inflammatory dis- 
ease ” includes all affections of the 
tubes and ovaries resulting from in- 
fection of these organs or the pelvic 
peritoneum, also all inflammatory 
conditions resulting from traumatism 
or other causes not directly traceable 
to infection. 
That a consideration of this sub- 
ject from this stand-point is called for 
at present, cannot be questioned, for 
I find upon analyzing the last 200 
cases in my private case-book, many 
of which have been referred to me by 
physicians at a distance, that thirty- 
two, or 15.5 per cent., had no pelvic 
disease at all; in other words, an 
error in diagnosis had been made. 
As the result of this inflammatory 
process plastic lymph is thrown out, 
forming adhesions between the uter- 
ine appendages and the adjacent 
peritoneum and pelvic walls, pelvic 
floor, posterior surfaces of broad 
ligaments or uterus; it is by means 
of these adhesions that true pelvic in- 
flammatory disease is diagnosed. 
We will consider, therefore, first, 
in what way pseudo-pelveo-peritonitis 
simulates true pelveo-peritonitis; and, 
second, what are the means of mak- 
This concomitant inflammation of 
the peritoneum is called according 
to its location perisalpingitis, peri- 
oophoritis or perimetritis. The more 
common affections of the tubes and 
ovaries exciting this inflammation of 
the peritoneum are salpingitis, pyo- 
1 An address delivered before the Southern Surgical 
and Gynecological Association. 2 
HOWARD A. KELLY. 
salpinx, tuberculosis and abscess of 
the ovary, and hydrosalpinx is often 
associated with it. 
“ excruciating pain,” the doctor con- 
siders the diagnosis well established. 
The irresistible impression made 
by such a complex of symptoms as 
these—constant or frequently recur- 
ring pain in the lower abdomen, ex- 
treme tenderness, cachexia, and loss 
of health—is that a serious pelvic in- 
flammatory affection is present. 
PSEUDO-PEL VEO-PERITONITIS.1 
Pseudo-pelveo-peritonitis is usually 
found in hysterical women who fur- 
nish many of the symptoms of, and 
present a history often closely anal- 
ogous to, true pelvic peritonitis. 
Such cases have usually been long 
under the family doctor’s charge, 
when they are referred to the spe- 
cialist. Their history is one of dys- 
menorrhoea, extending over many 
years, intense enough in some in- 
stances to confine the patient to bed 
for two or three days at each period. 
Many of these patients are regularly 
addicted to opium or the bromides 
and the milder sedatives. Douches, 
plasters, blisters and topical applica- 
tions, per vaginam, have usually en- 
tered largely into the treatment. 
Upon such grounds, therefore, the 
diagnosis of “ inflammation involving 
the tube and ovary,” and often of 
“pyosalpinx,” is erroneously made. 
The correct method of making a 
diagnosis of pelvic inflammatory dis- 
ease is the following: 
TRUE PELVEO-PERITONITIS. 
All these symptoms just detailed 
must be considered as of subsidiary 
value in making a diagnosis, for it is 
often true that in the most aggravated 
cases, in which there is a large ac- 
cumulation of pus, dysmenorrhoea 
may not be present, and the patient 
may be free from pain for long 
intervals. 
As a consequence of the opium 
habit a well-marked cachexia is often 
present, which may prove mislead- 
ing. A certain number of these 
patients have spent days or weeks in 
bed on account of pains in the lower 
abdomen, simulating and thought to 
be peritonitis. 
Fever is a sign of value, but it is 
more frequently absent than present, 
only being observed when there is 
absorption from the diseased area. 
A collection of pus well encapsulated, 
as a rule, gives rise to no fever what- 
ever. Although in these pus cases 
emaciation and cachexia are some- 
times extreme, it is possible, on the 
other hand, for a patient to have 
a pelvic abscess, and yet remain 
in blooming health in spite of the 
abscess. 
From these symptoms the medical 
attendant often concludes that his 
patient has “ ovaritis,” “ salpingitis ” 
or “pyosalpinx;” and if, upon a super- 
ficial examination of the lower ab- 
domen, the patient complains upon 
pressure over one or both ovarian 
regions, and a digital examination 
discloses marked tenderness at the 
vaginal vault, sometimes amounting to 
Even when the patient gives a 
history of free discharge of “ pus ” 
from the vagina, this is not significant 
unless it has been carefully inspected 
by the physician, for patients often 
1 The prefix “ pseudo ” is not used in a strictly 
scientific sense. It is employed as a convenient catch- 
word to designate affections which convey the impres- 
sion of being what they are not. DIAGNOSIS OF PELVIC INFLAMMATORY DISEASES. 
3 
confuse muco-purulent leucorrhoeal 
discharges with the discharge of an 
abscess. 
The inferior and posterior surfaces 
of resisting masses detected through 
the vagina can be most distinctly felt 
by the rectum, filling out an area cor- 
responding to the base of one or both 
broad ligaments. 
The essential points in the diagnosis 
of pelvic inflammatory disease are dis- 
covered by a direct examination of the 
diseased organs by rectum, vagina and 
lower abdomen. In every case the 
lower bowel must be freely evacuated 
before the examination is made. In 
the course of this investigation the 
examiner must demonstrate evidences 
A peculiar roofed-in, board-like 
hardness on one or both sides of the 
vaginal vaults often characterizes pyo- 
salpinx and ovarian abscess. 
Where the evidences of disease are 
not so distinct as in the cases just de- 
of alterations in the size, consistency 
or mobility of ovary and tube. If the 
cervix uteri cannot be easily displaced 
upwards, but is more or less immo- 
bile, and hard resisting surfaces are 
felt lateral to the uterus, the diag- 
nosis of pelvic inflammatory disease 
may be made. (Fig. 1.) 
Area of board-like induration indicated by heavy parallel lines, 
tailed, and by digital examination 
through the vagina one is not able to 
detect more than a small mass of 
doubtful identity lateral to the uterus, 
a bimanual examination through the 
rectum and abdomen will often de- 
monstrate this to be an inflamed 
adherent mass attached to the broad 
ligament. 
Marked pain or wincing under the 
examination, and an ill-defined sense 
of resistance do not justify a diag- 
nosis of any kind. 
In making examinations by the 
rectum, it is necessary, in order to 
palpate the pelvic structures clearly, 4 
HOWARD A. KELLY. 
to introduce the finger up beyond the 
ampulla or rectal pouch, through the 
utero-sacral ligaments behind the 
uterus. 
that there was serious pelvic disease 
present. The efficiency of the tri- 
manual examination depends upon 
the fact that the normal uterus can 
he drawn down to the vaginal outlet 
without harm, and the tubes and 
ovaries also becoming displaced in 
proportion to the displacement of the 
uterus, are thus brought within easy 
touch. To dispense with an assistant, 
I have devised a third hand for the 
examiner in the form of a flat ten- 
aculum, corrugated on one side to 
prevent its slipping under the fingers. 
The tenaculum is introduced into 
the vagina and hooked in the ante- 
rior lip of the cervix, which is now 
drawn gently down toward the outlet. 
(Fig. 2.) 
Still more exact than the method 
just described is the bimanual exam- 
ination under anaesthesia} 
Several hundred cases are anaesthe- 
tized in my clinic at the Johns Hop- 
kins Hospital yearly, for the sole pur- 
pose of making an exact diagnosis, 
and I cannot sufficiently commend 
this method for the increased facili- 
ties of investigation which it affords. 
THE TRIMANUAL EXAMINATION. 
Where the ovary or the ovary and 
the tube are bound down by velament- 
ous or delicate bands of adhesions, 
there are often no alterations in the 
size of these organs, and the amount 
of mobility still retained may be so 
great as to prove deceptive to the 
ordinary vaginal or rectal examina- 
tion. 
If resistance is felt at any point, the 
traction must not be carried further 
until the cause of the resistance is 
ascertained. The corrugated handle 
is now grasped between the ball 
of the thumb and the last phalanges 
of the third and fourth fingers, and 
the uterus is thus .detained in its 
artificial descensus, while the index 
finger of the same hand is inserted 
into the rectum and easily carried 
up to the top of the uterus and 
laterally over the broad ligament, ova- 
ries and tubes. The ovaries are de- 
tected in doubtful cases by means of 
the utero-ovarian ligaments, always 
recognizable as prominent cords in 
the broad ligament immediately below 
the cornua uteri. (Fig. 3.) Upon 
running the finger out one of these 
cords, 1.5 to 2.5 centimetres (one-half 
to one inch), it comes in contact with 
an abrupt enlargement, which is always 
the ovary. If this is large, ill-defined 
in outline and more or less fixed, the 
diagnosis of inflammatory disease 
may be made at once. In order to 
Under these circumstances the most 
perfect method of examining the pel- 
vic structures at our disposal must be 
employed to establish the diagnosis, 
and we have recourse to the triman- 
ual examination conducted at the same 
time by the vagina, rectum and abdo- 
men, under ancesthesia. To avoid 
giving the anaesthetic twice, not infre- 
quently in my hospital practice the 
minute examination is made immedi- 
ately before the operation. Several 
times I have returned patients from 
the operating table to the ward with 
the note, “ structures sound, opera- 
tion not called for.” It had appeared, 
from the history and the ordinary 
bimanual examination in these cases, 
1 v. Johns Hopkins Hospital Reports, Gynaecologi- 
cal Fasciculus, No. 11. DIAGNOSIS OF PELVIC INFLAMMATORY DISEASES. 
5 
pelvis at the sides and behind the 
uterus. 
exclude inflammatory conditions, the 
finger must be passed around the 
ovary, clearly outlining its border 
and surfaces as it is lifted on the 
palpating finger. In this way the 
most delicate adhesions will be dis- 
covered. 
(4) It is possible in this way some- 
times to mistake a retroflexed fundus, 
an extra-uterine pregnancy or a my- 
oma, for inflammatory disease. This 
error on the part of the general prac- 
titioner, however, is in the right direc- 
tion, calling for a more exact investiga- 
tion or consultation with a specialist, 
and is therefore not detrimental to the 
patient. 
In conclusion, let me briefly reca- 
pitulate : 
(1) The history of the patient, asso- 
ciated with pain in the ovarian re- 
gions produced by deep abdominal or 
Utero-ovarian ligament used as a landmark in 
locating ovary. All surfaces of ovary brought into 
easy touch by means of corrugated tenaculum. 
Position A.—Tenaculum caught in cervix. Position 
B.—Uterus drawn down into vagina. 
(5) For a more delicate apprecia- 
tion of the exact condition of the pel- 
vic organs, and in many cases in order 
to make any diagnosis at all, a biman- 
ual examination by rectum and abdo- 
men under anaesthesia is necessary. 
vaginal palpation, cannot per se estab- 
lish a diagnosis of pelvic inflammatory 
disease. 
(2) An attempt to make a diag- 
nosis without directly palpating the 
pelvic organs is at best but more or 
less clever guess-work. 
(6) The writer’s trimanual method 
of examination by rectum, vagina and 
abdomen, is the most accurate of all, 
serving to detect the slightest irregu- 
larities of the uterus and ovaries, as 
well as the most delicate adhesions. 
(3) The diagnosis can be made with 
certainty when resisting masses are 
felt choking the posterior half of the