Pelvic Inflammations ; 
or, 
Cellulitis versus Peritonitis. 
BY 
THOMAS ADDIS EMMET, M. D., 
Surgeon to the Hospital, 
New York. 
BBPKINT I'KOM YOLXJMK XI 
(SjiticcoloQtcal 
1886, PELYIC INFLAMMATIONS; OE CELLULITIS 
VJEBSUS PEKITONITIS. 
BT THOMAS ADDIS EMMET, M. D., 
New York. 
What is pelvic inflammation ? Is it a cellulitis, a pelvic 
peritonitis, or do we have the two combined ? And under 
what circumstances do we find phlebitis and lymphangitis 
accompanying these conditions ? 
The term cellulitis, in this country, has come, by almost 
common consent, to signify a pelvic inflammation without 
reference to the special form, but its origin is generally sup- 
posed to have been in the connective tissue. Yet we have 
all recognized in practice different conditions, when, as ex- 
ceptions to the rule, it seemed evident that the origin could 
not have been confined to the cellular tissue. So close, in 
some parts of the pelvis, is the relation between the connect- 
ive tissue and the peritoneum covering it, that it seems im- 
possible for an inflammation to exist to any extent in one, 
without involving the adjacent structure. 
Below the dip of the peritoneum ; above the floor of the 
pelvis; between the rectum and vagina behind; in front of 
the uterus, bladder, and ureters, as well as about the ure- 
thra, a pure cellulitis of considerable extent could exist 
without involving the peritoneum. Inflammation of the 
connective tissue in these localities is generally accompanied 
by phlebitis, and is a frequent consequence of the pressure 
made during childbirth. But it is a matter of common ob- 
servation, that this form of pelvic inflammation tends rapidly 
to resolution, and the tissues soon regain a healthy state if 
septic poisoning do not take place. 2 
PEL VIC IN FLA MM A TIONS. 
"With the introduction from any source of septic matter 
—as after the reception of an injury due to childbirth, or 
after any surgical procedure—the lymphatics become inflamed 
and the peritoneum is rapidly involved. The opposing in- 
flamed peritoneal surfaces quickly adhere throughout, or par- 
tially so, as an effort of Nature to limit the extent of disease, 
and thus is shut in the product of the inflammation, which 
may remain encysted for an indefinite period. Then, by 
traction, or by direct pressure, the circulation in the blood- 
vessels becomes more or less obstructed, and the action of 
the absorbents is in like manner greatly impeded or arrested. 
The consequence is, that a condition Anally exists which re- 
mains long after the more acute symptoms have subsided, 
and is one not prone to change nor amenable to treatment. 
There has been a tendency shown in recent discussions on 
this subject to undervalue the importance of apparently lim- 
ited pelvic inflammations. My own conviction, and one 
based on a large experience, is, that the more circumscribed a 
pelvic inflammation seems to be, provided it is not a pure 
cellulitis, the more serious will be the consequences if its ex- 
istence be practically ignored. 
A general pelvic inflammation will always command the 
needed respect from the most careless observer, but an appar- 
ently limited one is to be the more feared, from the fact that 
it is almost always situated in the peritoneum, and is gener- 
ally the remains of a more extended inflammation. 
The pelvic vessels are the last in sequence of repair to re- 
cover their tone, and even after a limited inflammation but a 
slight provocation is required to produce a fresh attack, the 
results of which may be more serious than the previous con- 
dition. 
It has been held that, as a rule, little evidence of previous 
attacks of cellulitis can be found when operating for the 
removal of diseased Fallopian tubes, and my own experience 
has confirmed the accuracy of the observation. Yet it has 
cost me much thought to explain the existing condition ; for 
the evidence of touch has seemed so conclusive, that the THOMAS ADDIS EMMET. 
3 
pathological change, as detected from the vagina, could only 
be an enlargement in one or both broad ligaments. At as 
low a plane in the pelvis as such a mass would occupy, it 
would seem, in the absence of other proof, impossible to feel 
an enlarged Fallopian tube. In fact, the tube could not be 
reached from the vagina with the finger, so long as it remained 
in situ, with the same relation to the vaginal wall which it 
occupies in health. 
Exception has been taken, and justly, to the term “ thick- 
ening of the broad ligament.” This is one I have long used 
to express a certain amount of fullness felt on the side of the 
uterus, and which seemed to be situated between the folds 
of the broad ligament. This fullness is usually associated 
with a lateral version, by which the neck of the uterus is 
drawn to the more diseased side of the vagina; a condition 
which would seem, in the absence of any knowledge to the 
contrary, to be a natural consequence of inflammatory short- 
ening of the broad ligament. 
During the past winter, Professor Polk kindly invited 
me to witness an operation, in his service at Bellevue Hos- 
pital, for the removal of a diseased tube. The patient had 
suffered from a double laceration of the cervix uteri, and I 
had, at a previous examination, expressed the opinion that 
the subsequent condition was one of thickening and short- 
ening of the left broad ligament from an old cellulitis. At 
the operation, to my surprise, no broad ligament was found, 
and the enlarged tube Jay directly against the side of the 
vagina. The relative position, or line, with the fundus of 
the uterus and the ovary remained unchanged, and yet the 
fingers of the operator, as they grasped the tube, could be 
distinctly felt from the vagina, and in contact with its walls. 
This was so marked an instance, that the explanation pre- 
sented itself to me as soon as I was able to give the matter 
due thought. I recalled the fable of the two knights meet- 
ing at a cross-road, where a shield was suspended, which was 
of gold on one side, and of silver on the other. They dis- 
puted as to the material of which it was made. Each was 4 
PELVIC INFLAMMATIONS. 
right from his own stand-point, and all difficulty could have 
been avoided if either had looked on the other side. I 
mention this fable as applicable to the recent discussions on 
the relative importance of cellulitis and pelvic peritonitis as 
factors in the diseases of women. 
The question has been raised as to the existence of pelvic 
cellulitis in these cases, since its products found after death 
are so few, in comparison with those recognized as con- 
nected with inflammation of the peritoneum. 
Let us see if it is possible to offer an explanation. 
An increasing capacity of the vagina and rectum is one 
of the first indications we are able to recognize, proving that 
a cellulitis is rapidly clearing up. This is due to the shrink- 
ing away, as if by absorption, of the connective tissue, which 
has been inflamed, and from lateral traction the walls of 
these passages are thus separated. If the inflammation stops 
short of a pelvic abscess, and after it has entirely subsided, 
nothing can be detected by the finger in the vagina or rectum 
but a few attenuated bands, running in different directions, and 
these also disappear in time. By degrees the surrounding 
connective tissue, which had not been involved, is gradually 
drawn together, by its own elasticity, to fill the space which 
would otherwise remain unoccupied. The inflammation 
having been located below the dip of the peritoneum, and 
confined thus to the cellular tissue, nothing remains finally 
to mark the site, of even an extensive inflammation, but a 
small dense scar or line. After this re-distribution of the 
cellular tissue, the vagina or rectum slowly returns to its for- 
mer shape and size, as soon as the natural elasticity of the 
pelvic connective tissue can be again uniformly exercised. 
On the other hand, when an extensive inflammation has 
existed in the connective tissue between the folds of the 
broad ligament, it must necessarily involve the peritoneum 
covering it. In time this connective tissue also disappears, 
as a result of the inflammatory action, but it can not be re- 
placed, in consequence of its isolated position in relation to 
the cellular tissue in the other portions of the pelvis. As THOMAS ADDIS EMMET. 
5 
a result of inflammation of the peritoneum covering this tis- 
sue, adhesion of opposing surfaces occurs, and by the traction 
thus exerted the broad ligament is flattened out, so that 
Douglass’s cul-de-sac disappears on that side. The effect of 
this change is that the vaginal wall, in the neighborhood of 
the seat of the inflammation, must be raised up and bal- 
looned out, as I have already stated. The same traction 
would also draw the tube somewhat downward, until it and 
the side of the vagina would lie in contact. This, then, is 
the condition found by the surgeon when he operates for the 
removal of a diseased Fallopian tube. 
I feel justified in the belief that in all of these cases 
there has existed, at the beginning, an extensive inflammation 
of the connective tissue. In addition, lam disposed to 
think that the inflammation of the tube is secondary to the 
cellulitis in every instance, unless the primary inflammation 
originated from gonorrheal poisoning. 
As the connective tissue can not be again supplied, the 
broad ligament never regains its former length or shape; con- 
sequently in these cases the lateral version of the uterus re- 
mains a permanent deformity, or, if both ligaments were in- 
volved, an intractable form of retroversion is the conse- 
quence. 
If my observation is correct, it would prove that connect- 
ive tissue, without reference to its situation in the body, 
never regains its integrity after having been once inflamed. 
According to the degree and extent of the inflammation 
must the tissues involved be absorbed or break down into 
an abscess before the parts can be restored to health. If the 
surrounding connective tissue can supply the loss, the part 
will gradually return to its former shape, and the injury will 
in time be an unappreciable one. On the other hand, if the 
inflammation has been more extended, so that the loss can 
not be replaced, or if the tissues break down into an abscess, 
Nature can only repair the injury by adhesive inflammation 
of all the parts involved. We then have, according to the 
extent of injury, either a simple pit-like depression, or a de- 6 
PEL VIC INFLAMMA TIONS. 
formity due to traction, as the tissues shrink together. Under 
the arch of the pubis, where we can have the simplest form 
of cellulitis, pressure during childbirth, or an injury from 
any other cause, exciting a circumscribed inflammation, will 
produce this simple depression or pit, as there connective tis- 
sue is limited in extent. After more extended injury, in 
other parts of the body, we are all familiar with the deformity 
due to traction. When cicatricial traction is thus exerted 
after a surface has healed, as it is termed, by granulation, 
this traction is due not so much to the presence of the scar 
tissue, as to the absence of counter-traction from the sur- 
rounding connective tissue which was destroyed before the 
scar was formed. 
Dr. Henry C. Coe, of Hew York, at a recent meeting of 
the Alumni Association of the Woman’s Hospital, read a 
paper on The Exaggerated Importance of Minor Pelvic In- 
flammations, and this was published in the New York Medi- 
cal Journal, May 15, 1886, The results are given of a 
number of post-mortem examinations, in all of which, I be- 
lieve, some form of pelvic inflammation had existed. His 
report is a valuable contribution from a pathological stand- 
point, but he goes too far in assuming that cellulitis had not 
previously existed to the extent claimed by others. More- 
over, his deductions as to the value of local treatment in 
such cases are not in keeping with the experience of many 
other members of the profession. But I feel that we are in- 
debted to him for these researches, as his paper was the first 
to draw attention to the subject, and it will be the means, 
I hope, of our gaining eventually a more accurate knowl- 
edge of the true pathology of pelvic inflammations. 
In the past, when I have used the term “ thickening in 
the broad ligament,” I have not supposed that there existed 
between the folds of the broad ligament any deposit of 
lymph as a product of local inflammation; for I have long 
known the fact that the blood-vessels are not, as a rule, 
destroyed by cellulitis, but in time, from long-continued ob- 
struction to the circulation, and from a want afterward of THOMAS ADDIS EMMET. 
7 
tlie proper support, which tlie connective tissue can alone 
give, the veins become greatly enlarged. They thus lose all 
shape, and are often but mere receptacles, when the proper 
support and pressure to their walls ceases to be supplied 
through the surrounding fascia and connective tissue of the 
pelvis. 
I have already described elsewhere this condition of the 
blood-vessels, and wherever I have detected evidence of an 
old cellulitis, with this so-termed “ thickening of the broad 
ligament,” I have supposed that the enlargement was due 
to the dilated state of these veins. I have also long since 
learned from experience that the condition was one very 
easily roused to active inflammation, as a phlebitis, from sep- 
tic poisoning consequent upon any surgical interference or 
injury. 
Unless these enlarged vessels were injected before the 
post-mortem examination, they might be easily overlooked, 
as a large portion of their contents would be forced on, at the 
time of death, into the receptacles of venous blood through- 
out the portal system, spleen, and lungs. 
The same result would also take place in lessening the 
bulk of the connective tissue even in health, for it must 
occupy necessarily far more space in the pelvis while the cir- 
culation was being maintained than it would after the blood- 
vessels had been emptied by death. 
I have thus, as briefly as possible, attempted to reconcile 
opposing views. By looking on both sides of the shield, as 
it were, the condition found by the surgeon has been ex- 
plained, and the post-mortem appearances have also been 
accounted for. 
It is still a mooted question as to the manner in which 
the tubes become diseased, when gonorrhea has had no part 
in the origin of the inflammation. 
"When a peritonitis has been caused from exposure to 
cold, for instance, the inflammation could readily extend to 
the lining membrane of the tubes, and the pelvic cellular tis- 
sue may at no time become extensively involved. 8 
PELVIC INFLAMMATIONS, 
But with septic poisoning supervening, as upon a lacera- 
tion of the cervix, or after some surgical injury, I believe the 
connective tissue, veins, and lymphatics, in the neighborhood 
of the folds of the broad ligaments, become first involved. 
The inflammation of the peritoneum is then secondary, and 
does not reach the tubes until a much later stage. It is, how- 
ever, claimed that under these circumstances the inflamma- 
tion advances along the uterine canal to the tubes, and that 
any cellulitis which might occur would be of little moment. 
But there is not the slightest evidence in proof of this 
view, nor is it the probable course, unless the advancing 
inflammation has been produced by gonorrhea or its conse- 
quences. 
In case of a recent laceration of the cervix, it would be 
difficult to prove or disprove anything as to the route by 
which the inflammation may have extended. The most ra- 
tional supposition, however, would be that the poison was 
transmitted directly through the lymphatics situated in the 
connective tissue, which was involved in the common injury. 
But from a practical stand-point it is almost a loss of time to 
discuss, at any great length, the question as to the special 
tissue involved. 
If it could be proved that there was no such condition as 
cellulitis, and that all pelvic inflammations were confined ex- 
clusively to the peritoneum, nothing would be added thereby 
to our means of treatment. JSTor would we gain the slightest 
immunity from the consequences were the existing inflam- 
mation ignored. 
The prognosis should be a very guarded one as to the re- 
sult to be gained by local treatment, where we can establish 
the fact that the female has suffered from gonorrhea, or if 
her husband had done so shortly before marriage; moreover, 
we should be equally as careful in all cases, and without ref- 
erence to the cause, where the pelvic inflammation has been 
of long standing, and with the history of frequently recurring 
attacks. Tinder these circumstances, with a limited number 
of cases, no permanent benefit seems to result from local THOMAS ADDIS EMMET. 
9 
treatment, and the operation for removing the tubes and 
ovaries has to be resorted to eventually. 
But, fortunately, this is not the rule, for I have seen, at 
least among the well-to-do, some most unpromising cases re- 
cover entirely without the operation. But this result can be 
gained only after a long course of treatment, and one some- 
times extending over a period of several years. 
In our public hospitals we see a number of poor women 
suffering from some form of tubular disease, who have been 
admitted only after they have exhausted all their resources, 
with no other means of support for the future beyond their 
own efforts, and when they have lost apparently all recuper- 
ative power. Under these circumstances, and in the uncer- 
tainty of practical gain from local treatment, we may serious- 
ly consider the advisability of an operation, after having 
gained the consent of the patient by a truthful representa- 
tion of her condition. 
But I am convinced that the time has been reached when 
we should enter a protest, and that the profession at large 
should demand a recognition of some responsibility connected 
with the indiscriminate manner in which this operation is be- 
ing done all over the country, and by any one. During the 
past spring, a young physician from one of the western cities 
stated at the Woman’s Hospital that he was then on his way 
to England for the purpose of having “ Mr. Tait teach him 
how to take out tubes.” He seemed to feel that this was 
about the only knowledge necessary for treating the diseases 
of women, and he expected to devote himself to the practice 
as a specialty. 
I am certain from my own knowledge that those who 
operate most in Hew York city have obtained, so far as sav- 
ing life is concerned, as good results as have been claimed 
abroad. But if we could get at the true proportion of 
deaths after this operation, throughout the country, it would 
be found that the mortality has been a fearful one. Surely, 
for the good name of the profession, it should be recognized 
that it requires an expert to determine when this operation 10 
PELVIO INFLAMMATIONS. 
should be done, and that even more experience still is re- 
quired to perform it with safety and with benefit. 
I believe that the operation for removal of the tubes and 
ovaries should only be done as a last resort, and only after 
every other means has failed. 
In my public hospital experience the results of local treat- 
ment have not been satisfactory, in consequence of the want 
of proper food, sufficient sunlight, with fresh air, and other 
surroundings specially calculated to improve the general con- 
dition. 
But in private hospital practice I have certainly succeeded 
in restoring the health of a number of women where the 
operation had been urged as a last resort, before they came 
under my care, and where, indeed, it would have been per- 
formed if they had been in other hands. It is true that I 
have signally failed in some instances, and, after having ex- 
hausted every means of local treatment at my command, I 
have only gained apparently an improvement in the general 
condition. Yet it is a remarkable fact, that where I have re- 
fused to operate, and these cases have passed into the hands 
of others for the purpose of having it done, a very large pro- 
portion have died, and I can recall scarcely a single instance 
where the result was entirely satisfactory. In these cases 
which have passed directly under my own observation, the 
average amount of benefit derived has certainly not been 
great enough to compensate for the average risk of life. On 
the other hand, I must state that some of the worst cases I 
have ever met with have been seen in consultation. For 
some of these I have not hesitated to agree to the opera- 
tion, on account of certain existing circumstances, and, 
with a number, the result has seemed to justify its per- 
formance. 
But I believe that the operation is practiced too often, 
even by those who have the smallest death rate, and I pre- 
dict that five years will not pass before it will be necessary 
to offer an apology when its performance is suggested. The 
operation doubtless fills an important place in gynecological THOMAS ADDIS EMMET 
surgery. Hut its usefulness must l)e more clearly defined, 
and its practice greatly restricted, or tlie good name of the 
profession •will surely suffer in tlie future.