Pelvic Inflammation in Women 
A PATHOLOGICAL STUDY. 
BY 
WILLIAM WARREN POTTER. M. D., 
BUFFALO, N. Y. 
REPRINTED FROM 
THE AMERICAN GYNECOLOGICAL JOURNAL, 
DECEMBER, 1891. PELVIC INFLAMMATION IN WOMEN—A PATHO- 
LOOICAL STUDY.1 
WILLIAM WARREN POTTER, M. D., BUFFALO, N. Y. 
As pelvic inflammations and their resultant complications 
and residues comprise the largest proportion of the disorders 
that are brought to the notice of the gynecologist (Winckel 
says 33 per cent), and as many of the essential principles of 
pathology and treatment relating thereto are still under obser- 
vation and not fully established, the importance of frequent 
discussion of these cannot be questioned, and their interest is 
always great. 
While it is not expedient at this time to pass in review the 
anatomy, physiology and histology of the female pelvic viscera 
with minute precision, I shall yet endeavor to make the thoughts 
presented as clear and consecutive, as is possible in the time 
that I feel warranted in appropriating. 
The relations of the organs to each other and their enor- 
mous vascular and nerve supply are well known to all, and are 
simply referred to for the purpose of reminding you of one of 
the reasons—an essential one—why these inflammations prevail 
with such amazing frequency. This intricate and labyrinthine 
arrangement of tissue, fibre, vessel, and nerve has its wise pur- 
poses to fulfill in health, and its weaknesses that become manifest 
in disease. It permits the highest state of nutrition so neces- 
sary to the healthful performance of the various functions im- 
posed on these organs, and it is equally a source of innutrition, 
when once these vessels and nerves become irritated and ob- 
structed by the various morbid processes that provoke and 
maintain blood-stasis. 
When Emmet, who was one of the first to call attention to 
the importance of a knowledge of pelvic disease, first advanced 
his doctrine of pelvic cellulitis, it was seized upon by a large 
1 Read before the Mississippi Valley Medical Association at St. Louis, Oct. 16, 1891 2 
number of gynecologists as the most rational pathology that 
had yet been made known ; in it was supposed to lie a true 
solution of the many difficulties that had previously surrounded 
a most perplexing field, and the pathway out had, under his 
guidance, become an easy one. It was a very plausible and 
seductive theory that the avenue of approach of all inflamma- 
tions in this region was the pelvic connective tissue, and that 
from this tissue they spread, if unarrested, into the other organs 
that it surrounded, overlapped or interlaced. Hence, pelvic 
cellulitis was the great first cause of all the sexual woes of 
woman, and to arrest or subdue it was the gynecologist’s shib- 
boleth. ' With a strange tenacity Emmet still clings to the main 
features of his early pathology, though admitting that there 
are a few exceptional cases where the order is reversed, the in- 
vasion beginning in these in the tubes or ovaries, and extending 
thence to the areolar tissue. 
When Bennet, in 1843, asserted that to inflammation of 
the cervical canal was due the greater part of the sexual woes 
of woman, it was accepted with an almost universal belief. 
Bennet asserted with dogmatic zeal, that from cervicitis came 
ulceration, displacements, leucorrhcea, menstrual derangements, 
even ovarian disorders, and that by the application of strong 
caustics to the offending os and cervix all these could be cured. 
This was the beginning of the caustic treatment which ran riot 
until arrested in its mad career by Sims and Emmet. These 
two —master and pupil—did the sex a service that must remain 
unrequited from everlasting to everlasting, in laying bare the 
faults the monster Bennet had unleashed and which others 
could not or would not curb. Sims, the surgeon, addressed 
himself to repairing the damage caustics had done, by invoking 
surgical means to accomplish the end sought. He would rend 
with the knife the stenotic wombs the silver stick had caused. 
Emmet, the physician, sought the same end by gentler agencies 
—those of cleanliness, heat, soothing applications, and the 
hygienic and nutritive aids of rest and food. 
Emmet stoutly denied that ulcerations (so-called), erosions, 
and other manifestations that Bennet attributed to inflamma- 
tion of the cervix, existed at all per se, and affirmed that these 
numerous visible changes were due to arrested or impaired 
nutrition with only one possible exception, viz.: when consecu- 3 
tive to cervical laceration. To this latter he also attributed the 
so-called pelvic cellulitis in a considerable proportion of cases. 
Hence, when erosions did not disappear under the milder means 
addressed to this care, he would freshen the torn surfaces, cutting 
away all the proliferations, and unite them with sutures—the ope- 
ration to which the name trachelorrhaphy has become attached. 
If Emmet made war against the ancient heresy of Bennet, 
and waged it with a surprising and deserved success, he has 
equally resisted the advances of the modern pathology which 
has nearly driven his pelvic cellulitis from the field. He seems 
to be as unwilling to accept the views of Price, Tait, Hegar, 
McMurtry, W ylie, and their followers, as he would be to return to 
the obsolete and heterodox doctrine of Bennet. Nevertheless, 
the world moves, and we must move on with its progressive- 
ness, else we shall find ourselves sitting with folded hands, 
watching the busy life around us, “forgotten, uncared-for, the 
slaves of our own inactive wills.” 
For a better understanding of the true pathological intra- 
pelvic state whose manifestations we call inflammation we are 
indebted to operative surgery which has dared to open up the 
peritoneal cavity to daily exploration. This has demonstrated 
the relation of diseased tubes and ovaries as well as puerperal, 
specific, and traumatic infections to pelvic inflammations. It 
has led to the recasting of opinions in regard to the origin of 
these in flammations, as well as to the morbid changes that 
are taking place within the pelvic cavity during their various 
stages of progress. 
The feeling is fast laying hold of the men who are at con- 
stant work in this department of medicine that these inflamma- 
tions generally take origin in some disturbance of the ovary or 
Fallopian tube and extend into the contiguous structures as the 
inflammation progresses; or, if the cause be puerperal, the nidus 
resides in the uterus itself, and so travels up and down, right 
and left, hither and yon, according to its severity, or the resis- 
tance it meets. 
A pelvic inflammation may be so slight in a few instances 
as to give little discomfort, and it may pass to recovery without 
treatment. A severer form occasions subserous congestion, 
transudation of serum, and exudation of plastic lymph. In 
still more severe cases serum is poured into Douglas’s pouch 4 
much as it is into the pleura during the course of pleurisy with 
effusion. Lastly, we may have suppuration—the so-called pel- 
vic abscess—which demands prompt surgical treatment. 
The residues which these acute inflammations leave behind 
—their sequelae—depend upon the severity and extent of the 
invasion. The slighter forms may leave equally slight traces, 
or none that constitute a disability; in other words the resolu- 
tion is complete. But in the higher grades of inflammation, 
where the products are deposited over a great extent of surface 
—over uterus, tubes, ovaries and ligaments, these organs become 
matted together in a greater or less degree—they become en- 
tangled and bound down by strong adhesive bands, just as we 
observe happens in the pleural cavity. These adhesions contract 
and grow firmer with time; the ovaries, imprisoned in their 
relentless grasp, become sensitive, painful and swollen, or 
degenerate or become atrophied under their influence. Each 
recurring menstruation seems only to increase this woeful con- 
dition until finally pyosalpinx or even abscess of the ovary 
results from the retained secretions, and pent-up fluids; or sec- 
ondary pus-sacs may form outside these organs in the connective 
tissue, constituting what has been described as true pelvic abscess. 
It would be difficult in such a case, unless familiar with it 
from the outset, to fix the precise starting point of the inflam- 
matory process, but at this stage and in such a case there 
remains little to do, except to open the abdomen, remove the 
pus whether in ovary, tube, or sac, and break up the adhesions 
as much as possible. In a woman who must earn her bread in 
the sweat of her face, there should be little delay in resorting 
to surgical interference. Such can ill-afford to spend much 
time with expectant methods. The argument against unsexing 
a woman by removal of her organs has small weight here, for 
the disease itself has already destroyed her procreative power, 
or else made pregnancy a dangerous complication to happen. 
This simple grouping of the essential features of pelvic 
inflammation, imperfect and unsatisfactory though it may be as 
a pathological picture, is, nevertheless, a faithful setting forth 
of the salients of the disease as far as now understood. The 
discussion might be prolonged to an entire afternoon’s discourse, 
but as I am talking to a learned audience, elementary details 
have been omitted. 5 
It will be observed by an examination of the modern liter- 
ature of this subject that the terms perimetritis and parametritis 
are gradually disappearing. No little confusion has resulted 
from the use of these terms, and it is therefore well that they 
should be dropped. And so, too, with cellular abscess, for it 
may be questioned whether there is any such condition, the 
pus-sac being really the diseased tubes and ovaries, or secondary 
to such conditions. After adhesions are formed, pus may bur- 
row in many directions, usually following the route of least 
resistance. It may traverse the cellular tissue planes, but the 
original seat of the abscess is within the peritoneum and in the 
tubes or ovaries. I have seen a pus-degenerated ovary not 
larger than a small English walnut, when taken out of the 
abdomen leaking pus guttatim, so to speak, from the site of the 
pavilion, which at intervals through this leakage, caused by 
overflow or contractions, had set up recurrent inflammation until 
the surrounding peritoneum had no rest—only recovering from 
one attack to find another about to be precipitated. And yet 
the mass was so small as to be felt with difficulty, and the 
diagnosis before section was of course obscure. 
Perhaps I cannot interest you more than to quote what 
Mr. Tait says in his latest work about cellulitis and peri- and 
parametritis. These are his words: 
“ In the employment of the terms perimetritis and para- 
metritis, as introduced by Virchow and advocated by Matthews 
Duncan, we have introduced a wholesale confusion into gynec- 
ology which will take many years yet of industrious work to 
get right. This confusion has been vastly aided by Dr. Em- 
met’s teaching about cellulitis. If parametritis and cellulitis 
be relegated to their proper place—and they may be taken to 
mean the same thing—it is one of the rare conditions we have 
to deal with among the special ailments of women. 
“ By perimetritis we mean an inflammatory action of the 
peritoneal investment of the uterus, so that the products of the 
diseased action are found chiefly, or it may be entirely within 
the serous cavity. 
“ By parametritis we mean inflammation of the cellular 
tissue in the neighborhood of the uterus, the results of the pro- 
cess being mainly found outside the peritoneum. Perimetritis 
is a much more fatal disease than parametritis, and occurs with 6 
greater frequency in association with two particular conditions. 
These are parturition either at full time or prematurely, and 
gonorrhoeal infections. . . . By far the larger number of 
cases of perimetritis, or pelvic peritonitis are the result of some 
traumatism of parturient women, and most of them, therefore, 
come under the care of the obstetric physician. 
Puerperal and other forms of septic perimetritis are very fatal, 
for it rapidly becomes general peritonitis. In recent years I 
have proposed in such cases to open and clean out the peritoneal 
cavity, and I have followed out this plan in five cases, of which 
two have been successful. . . . Before the light came, 
which was shed upon these ailments by modern abdominal 
surgery, I believed as others did and do still, that parametritis, 
or pelvic cellulitis, was a common disease; and in my writings 
up to 1878, it is evident I confused cases of damaged uterine 
appendages with pelvic cellulitis. The latter disease is rare, 
and occurs in two forms, depending for their characters on the 
situation of the disease. If it is situated in the inner half of 
the broad ligament, it is to be recognized as a mass lying close 
to the uterus and in front of it, between the uterus and bladder, 
aud into the bladder it generally bursts. If it exist in the 
outer half of the broad ligament it is to be recognized as an 
ill-defined mass lying on the brim of the pelvis, and fading off 
on that ridge. In this position it bursts over the brim of the 
pelvis and constitutes the familiar ‘ pelvic abscess, ’ whose 
sinuses go on for years ... I treat all such cases, as I 
shall afterwards tell, by abdominal section and drainage, and 
the patients are cured in as many days as it takes them months 
to get well if treated in any other way.” 
Though somewhat lengthy, this excerpt could not well be 
shortened without doing imperfect justice to the authoi’s views. 
It is interesting as giving the matured opinions of a man who is 
never dull in expression or dry in thought, and who has an 
experience of more than 2,000 abdominal sections made with 
his own hands, from which to enrich literature and to fortify 
his opinion. Moreover, his educated finger-tips seldom fail 
him in diagnosis; but when in doubt and the patient is in ex- 
treme danger or great suffering, he does not hesitate to open 
the abdomen to ascertain the cause, relying upon his marvelous 
skill, great dexterity and scrupulous care to cure his patient; 
and these seldom fail. 7 
Mr. Tait’s views are in striking line with those fore-shad- 
dowed by Bernutz and Goupil thirty years ago. Listen a 
moment to M. Bernutz. After challenging the correctness of 
M. Nonat’s pathology of what he called peri-uterine phlegmon, 
Bernutz goes on to say: “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 that is 
very commonly met with. . . . Lastly I conclude that 
inflammation of the pelvic serous membrane is symptomatic, 
and that it is generally symptomatic of inflammation of the 
ovaries or Fallopian tubes. Thus, great interest is attached to 
the study of this affection, and it is very important to under- 
stand thoroughly the symptoms, in order to describe satisfac- 
torily the uterine, and more especially the tubo-ovarian disease 
wrhich occasions it. It follows from all this that 
unless we take 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, or any other malady. Thus, 
we can only lay hold, as it were, of the two ends of the patho- 
logical problem, the primary disease, and the serous inflamma- 
tion—the intermediate gap wre can oidy fill after death.” 
Strange prophesy! and yet so nearly true. Only now the in- 
termediate gap has been filled during the life-time of the 
patient, thanks to the aseptic surgery of the present. How 
singular that this almost perfect pathology should slumber in 
lethal repose so long ! Strange that the masters of a quarter of 
a century should have overlooked it so completely. But there 
it is, as true a picture as can be drawn to-day, only lacking the 
“ intermediate gap ”—but which has now been supplied by the 
courage and skill of a few men who have dared to say that they did 
not knowq and then opened Pandora’s box to see what it contained. 
Fortunately, they have been able to rightly interpret the meaning 
of the curious contents they have exposed to view, and We need 
not now wrait for the intermediate gap to be filled up after death. 
I cannot stop without speaking of another contribution to 
this important subject, that of Bumm, published in the Archives 
fur Gynakologie (B. XXXV. H. 3.), W'ho has made some im- 
portant observations writli the view of determining the true 8 
cause of so-called cellulitis. Where pus is present he thinks it 
much easier to decide as to its cause than in a case of simple 
serous exudation. Cellulitis, he says, is usually divided into 
the infectious and traumatic varieties, hut he punctured a sup- 
posed traumatic exudation in five cases, two of which he found 
to be of gonorrheal origin, while the fluid of the other three 
contained streptococci. His conclusions from experiments on 
animals are that wherever streptococci are present, there must 
be infection from without, that they are never found in the 
healthy genital secretions; that anto-infection is extremely im- 
probable, and that the legitimate inference from his studies is that 
there is no purely traumatic cellulitis; that, where pelvic cellular 
inflammation arises, it is directly attributable to the operator, 
and not to the operation—to infection and not to traumatism. 
But T detain you too long; there is so much of interest con- 
nected with this subject that one finds it difficult to pause. It 
is possible that the studies of Bumm may lead to a further mo- 
dification of the present classification of causes of pelvic in- 
flammations. We shall see. Meanwhile, the following for- 
mulated by McMurtry may be named as about the best grouping 
of cases I have seen. 
1. Inflammation of serous and cellular intra-pelvic, tissues 
cannot be separated clinically nor histologically, hence they 
cannot be properly distinguished by the terms perimetritis and 
parametritis. 
2. The pelvic cellulitis of Emmet, which corresponds to 
the peri-uterine phlegmon of Nonat, is as rare as inflammation 
of the cellular tissue elsewhere. 
3. Pelvic inflammation is, generally speaking, peritonitis 
resulting from disease of the ovaries or Fallopian tubes, or 
both. 
4. Pelvic peritonitis presents every grade of activity, and 
is always symptomatic, never idiopathic. 
We may name three general groups of these inflammations: 
1. Those of Puerperal origin. 
2. Those of Gonorrheal origin. 
3. Those of Miscellaneous origin. 
Under the latter are included all infections carried to the 
endometrium by unclean instruments, tents or medicinal agents 
or those arising from traumatism. 9 
Since all our efforts in the study of disease ultimately lead 
us to the goal of treatment, and raise the question, How can we 
best apply our therapeutics with a view to speedy cure? Tt is pre- 
sumed a word or two on that subject, in conclusion, will be 
pleasantly received even though they appropriate a little more 
of your valuable time. 
Would I operate on all cases of pelvic inflammation? you 
ask. I answer, no. It is well known that large inflammatory 
exudations do exceptionally disappear when treated by rest, 
counter-irritation, hot sit/, baths, vaginal douches, and attention 
to the digestive organs and general health. It must be born in 
mind, however, that many of these cases are reported cured, 
whereas, in reality if the history of each were followed it would 
be found to be, in many cases, one of repeated relapses. 
So, after all, complete restoration to health under the tentative 
plan, will depend upon the condition of the tubes and ovaries. 
If the tubes have been secreting pus, or if blood or serum is col- 
lected in them, future trouble—it may be after years—will 
surely come. Hot douches and iodine, curetting and electricity 
will not avail in such cases, and may result in positive harm. 
Non-sargical treatment in these cases simply removes the pro- 
ducts or residues of peritoneal inflammation, but cannot do 
much, beyond the beneficial influence exerted by ixst on all 
inflamed organs, for a diseased tube or ovary. Neither has 
electricity in such given anything but negative results. A 
frequently recurrent pelvic peritonitis is strongly suggestive if 
not positively pathognomonic of leaky tubes. 
The question then arises, Is abdominal section to be had 
recourse to in all these cases of chronic pelvic peritonitis? To 
this the answer may well be in the affirmative, if there is danger 
to life. But when life is not in danger, is the woman to live 
inactively, and constantly harrassed by pain—a chronic invalid? 
It is then for her to select. Non-surgical treatment will not 
cure her. 
In concluding this desultory presentation of a most im- 
portant subject, I desire to modestly, yet earnestly add, that 
the object of my visit to this enterprising society of progressive 
men wil1 have miscarried if I have not succeeded in impressing 
the importance attached to careful study of these cases by each 
TREATMENT. 10 
and every member, many of whom I presume enjoy the honor- 
able distinction of general practitioners. It is of the first as 
well as final importance that early recognition of conditions be 
made, with a view of placing the patient under the supervision 
of competent surgical skill, before the damage to important 
viscera shall be too great to justify the expectation of successful 
operation. 
28Jj. Franklin Street.