Conservative Surgical Treatment of 
Para- and Peri-Uterine 
Septic Diseases. 
BY 
Fernand Henrotin, M. D., 
Professor of Gynaecology, Chicago Polyclinic; 
Surgeon of the Alexian Brothers Hospital; Consult- 
ing Gynaecologist, St. Joseph’s Hospital; 
Member of the American Gynae- 
cological Society, etc. 
REPRINTED FROM THE 
American Gynaecological and Obstetrical Journal 
for June, 1895. [Reprinted from the American Gynaecological and Obstetrical Journal 
for June, 1895.] 
CONSERVATIVE SURGICAL TREATMENT OF PARA- 
AND PERI-UTERINE SEPTIC DISEASES * 
Fernand Henrotin, M. D., 
Surgeon of the Alexian Brothers Hospital; Consulting Gynaecologist, St Joseph’s Hospital; 
Member of the American Gynaecological Society, etc. 
Professor of Gynaecology, Chicago Polyclinic ; 
The American Gynaecological Society is composed of experts who 
convene at regular intervals to discuss in a broad, dignified, and lib- 
eral spirit, various vital and important questions pertaining to the 
development of that branch of medicine in which they are especially 
interested. In most gynaecological societies the mere mention of the 
word “conservative” brings protests from all the ten-minute lapa- 
rotomists—suggestions of radical work being just as certain to stimu- 
late the most energetic expressions from general surgeons concerning 
the extreme views of the specialists. Without taking into considera- 
tion the dissenting views of the timid general practitioner of limited 
judgment, the exclamations of the two above-described gentlemen are 
becoming very fatiguing. The man of sense and conscience “ who 
comes to town to stay ” will be found all along the line as circum- 
stances demand and as reason dictates. He who serves his patients 
best will reap gratitude at present and reverence in future. 
Coeliotomy and removal of the uterine appendages as indiscrimi- 
nately applied in the past is a most unsatisfactory operation. In spite 
of the great work and valuable lessons of the Taits and the Prices 
of both hemispheres, the short incision and the radical excision must 
fall back where they belong—to the selected cases where they fulfill 
the indications, and which we now know are not so numerous as 
formerly imagined, for we have come to realize that in many cases 
the operation was too much, and in many not enough. The woman 
of to-day insists not only upon having a radical operation done suc- 
cessfully, but she also expects to be cured of her disease, with its 
* Read before the American Gynaecological Society, May 29, 1895. 
Copyright, 1895, by J. D. Emmet and A. H. Buckmaster. Fernand Flenrotin, M. D 
accompanying pains, aches, and discharges. The surgeon of exclu- 
sively great experience is positively not the best guide as regards 
operative indications. His dictum concerning technique and imme- 
diate results is invaluable ; whether he cures his patients of their 
diseases he seldom knows. The reason of this is evident. He does 
not practice medicine or surgery in the ordinary sense of the word. 
He reigns supreme over a college amphitheatre with its adjunct hos- 
pital, or he manages a large private sanitarium. Patients are sent to 
him by physicians who have learned of his great ability, and after a 
few weeks he sends them back cured of the operation, but frequently 
uncured of the disease. The doctor of one laparotomy always knows 
the result, both immediate and remote. A surgeon—of I should judge 
about three hundred laparotomies—in a discussion on this subject, 
mentioned that his results had been very satisfactory, that he did not 
have more than a dozen women who occasionally wrote to him con- 
cerning bad symptoms of pain or discharge. How deceptive ! Prob- 
ably twice as many were writing or visiting some other surgeon, while 
a much greater number were at home nursing alike their sufferings 
and their loss of faith in the medical profession, and wishing their 
ovaries back. 
This picture is a true one. A very reasonable proportion of my 
patients are complaining to me and a reasonable proportion of yours 
also, while you are listening to the same plaints, and quite an army 
are suffering in silence. 
Salpingectomy, salpingo-oophorectomy and oophorectomy fre- 
quently fail to cure patients with peri- and para-uterine septic disease. 
Hysterectomy has of late years been found efficient in curing many 
cases that were still suffering after the first-mentioned operations had 
been performed. The impropriety of leaving behind frequently 
the chief offender among the pelvic organs has become evident, and 
a great step has therefore been made in the cure of these disorders. 
The amount of sentiment wasted upon the emasculated uterus, as Dr. 
Polk calls it, has always seemed ridiculous. Under such conditions, 
it is simply a cloaca for the origin of haemorrhage, the accumulation 
of discharges, and the development of malignancy. Whether done 
abdominally or vaginally, this operation has a great future, and in 
spite of opposition has made wonderful strides because of the thor- 
oughness of its curative effects. In this country it is only a few 
years since it has been performed with deliberate intent, and all 
its indications in view. It had originally been performed in an 
emergency, as a matter of expediency, when the destructive pro- Surgical Treatment of Para- and Peri- Uterine Septic Diseases. 
3 
cess made it almost a necessity. Pean guided by bis great surgi- 
cal genius, first performed it, in his anxiety to cure a patient who had 
remained uncured after a salpingo-odphorectomy. To-day it is an 
established procedure, and the position of advanced, observant gynae- 
cologists, who are not hampered by tradition or custom, or afraid of 
their own stubborn, dogmatic expressions in the past, can be stated 
as follows : “In every operation for septic diseases of the female 
generative organs which demands the removal of the tubes and ova- 
ries, hysterectomy should also be performed, unless there are plain 
contra-indications forbidding it.” This means that this operation 
which ten or fifteen years ago was never done, which five years ago was 
rarely, and three years ago only exceptionally done, now, should be the 
rule. It does not mean more mortality, and it does mean more per- 
fect and complete cure. After you have laid violent hands upon the 
ovaries, it matters not what becomes of the uterus. This tragic cry 
that an organ should never be removed without cause is all nonsense, 
in view of the fact that it has been proved innumerable times to be 
an element of mischief. This is true conservative surgical treatment 
in pelvic septic diseases. 
But, gentlemen, before you touch the ovaries, then is the time for 
the display of your sentiment. 
Whatever men may say, women do recover from salpingitis and 
pyosalpinx, from ovaritis, peri-ovaritis and ovarian abscess, from cellu- 
litis and phlegmon of the broad ligament, whether these be of the 
catarrhal, puerperal, or gonorrhoeal variety. 
And they sometimes recover entirely and completely, so that this 
contingency, even if infrequent, must always be considered in form- 
ing surgical conclusions. Where surgical measures are considered 
proper and advisable, much depends upon the character and malig- 
nancy of the infectious material and the stage of the disease and 
amount of destructive process already present. 
Having expressed the opinion that total ablation of the internal 
genitals of women in some cases presents the highest type of con- 
servative work in the fact that it saves life and suffering, I beg leave 
to present for your judgment the result of some work I have done in 
the line of conservative surgical measures on the old lines of vaginal 
section. I will not weary you with extracts from the history of vagi- 
nal sections and punctures, written since time immemorial. What I 
have done is neither original nor a revival of the teachings of forgotten 
masters. 
Pus sacs, or serous sacs, or exudated masses have been punctured 4 
Fernand Henrotin, M. D. 
and incised in all manners and with all variation of instrumentation 
by surgeons for all times back. We have only to draw your attention 
to the writings of Laroyenne, Landau, Munde, and innumerable others. 
Some have used the exploring needle and a trocar, emptied the cavity 
of its contents, frequently using irrigation. Others have introduced 
metrotomes through the trocar. Others, again, have incised directly 
and largely the septic focus or penetrated these pelvic cavities with 
different varieties of cautery knives. There is no need of mentioning 
authorities upon this subject, for the task would be interminable. It 
means simply that surgeons, recognizing the presence of inclosed septic 
material, have followed the general surgical rule of emptying, washing, 
and draining. 
Sinclair, Munde, and others advise free incision of tubes which are 
adherent to the peritonaeum of Douglas’ sac, per vaginam, subsequently 
washing out the empty tubes. Shroder has repeatedly employed this 
method in reaching adherent pyosalpinx. And so with many others, 
among whom f might mention particularly Reclus, Gusserow, Bouilly, 
Formento, of New Orleans, Cabot, of Boston, More-Madden, etc. 
Vuilliet (Gazette medicate de Paris, October 29, 1892) says that he has 
not done hysterectomy or abdominal section in suppurating pelvic 
disease in two years. In eighteen cases he has adopted Landau’s 
method without accident, loss, or relapse, usually using a trocar, which, 
after carefully locating the sac, he plunges into the cavity. If no liquid 
appears he makes another puncture. He repeats this at the end of 
ten or twelve days ; if the fluid reaccumulates he injects after the 
second puncture one to two and a half drachms of bichloride solution. 
If fluid returns after three or four punctures, he then incises and 
tampons with iodoform gauze, using a knife like a metrotome, slipping 
it upon the trocar. This is substantially the method described and 
practiced by Laroyenne and Landau, both of whom have written 
masterly treatises upon the subject. Laroyenne and Goullioud, his 
pupil, claim an important place in the treatment of pelvic inflamma- 
tions for their method, which opens up largely by the vaginal route 
pammetric chronic collections and holds them open until cicatrized. 
Their method applies to the diverse fluid collections in the pelvis, 
tubal dilatations, serous or purulent effusions in Douglas’ sac, retro- 
uterine hsematoceles, parametric abscesses, etc. It suffices, they say, 
that the collection, large or small, should be clearly perceptible to 
bimanual palpation and be an inflammatory mass. It is not necessary 
to get fluctuation, which in the pelvis is difficult to make out. The 
immediate result is considerable ease, and eventually complete cure Surgical Treatment of Para- and Peri- Uterine Septic Diseases. 
5 
even in multiple pus focuses. Distant results, they report, have been 
almost constantly satisfactory. Noticeable in this is the length of 
time in which note is made of the patient’s condition. Laroyenne 
records in regard to ulterior condition all the cases which have been 
seen at least eighteen months after operation. Four women who had 
been operated upon afterward conceived and bore children. 
Ablation of the annexae remains as an ultimate resource in case 
pain continues ; then it is simply salpingo-oophorectomy without 
pus. 
The greatest recommendation of the operations of these various 
men is its lack of danger. Goullioud gives a series of seventy cases, 
with one death occurring twenty-eight days after operating, due to an 
abdominal rupture of an unexplored pyosalpinx. He eventually re- 
ports another series of sixty cases, with one death, due to secondary 
operation for artificial anus, the patient having afterward been oper- 
ated upon abdominally, and a faecal fistula remaining. 
Edmund Blanc, another pupil of Laroyenne, publishes a series of 
twenty-seven cases of chronic peri-uterine inflammation with serous, 
haemorrhagic, or purulent effusions. Many others, however, speak of 
the danger of these incisions and punctures, particularly the danger 
of wounding the ureters or the uterine arteries. Hoffmeier speaks of 
these dangers, and says it is necessary to use sharp or puncturing in- 
struments ; also mentions the difficulties encountered when one can 
not exactly locate the pus sac. 
There is no further need of multiplying these quotations, for not 
only does literature abound with them, but it is a subject with which 
you are all familiar, and the procedure is one which you all, at one 
time or another, have employed. Nevertheless, it seems desirable 
that in this age of wholesale ablations these simpler and often success- 
ful minor methods should not be lost sight of. Personally, I have 
frequently drained pus collections in the pelvis through the vagina, 
these pus collections being the result of chronic inflammatory condi- 
tions. It seems only reasonable to suppose that such operations may 
be successful, even in the most chronic forms of pyosalpinx. What 
happens in such cases ? Septic material traveling up the Fallopian 
tube, when the process is not too rapid, finds itself arrested at the 
abdominal opening by a closure of the ostium abdominalis. An abscess 
cavity is developed in the walls of the tube proper. After a time the 
uterine end becomes closed, and then we have an independent pus 
sac, not communicating with either the serous or the uterine cavity. 
This may rupture into the folds of the broad ligament and work its 6 
Fernand Henrotin, M. D. 
way toward the vagina. If widely opened and drained and packed, 
after a time all the so-called pyogenic lining membrane disappears, 
granulations fill the gap, the Fallopian tube becomes obsolete, and the 
patient is cured. 
One of the reasons of failure of many men in the past is due to 
forgetting to pay the proper attention to the condition of the adjoin- 
ing uterus, this organ being left unattended to and frequently giving 
rise to further trouble. Ido not mean to propose, as some most en- 
thusiastic followers of these various measures have done, the employ- 
ment of this vaginal incision as a substitute for more radical and 
complete work, but I am simply endeavoring to impress you with the 
absolute necessity of discrimination, and, with that intent, I quote 
the success some that others have attained in curing even the most 
serious forms of trouble by conservative measures. 
In treating chronic cases of inflammatory septic disease it is neces- 
sary to make sure that a patient is incurable by milder measures be- 
fore resorting to the radical operations. 
In the first part of this paper I have drawn your attention to the 
fact that many patients were cured of the operation while not cured 
of the disease, and that only the most complete ablations will suffice 
to cure some patients. But while we may, in the present state of our 
knowledge, be obliged to resort to the most serious radical operations 
to cure the patients entirely and properly, our minds should be con- 
stantly alert for the purpose of discovering methods by which the 
severer operations may be made available. The difficulty of under- 
standing and analyzing pelvic inflammatory diseases becomes self-evi- 
dent when we contemplate the many varieties of forms which the dis- 
ease may take. A simple so-called catarrhal invasion of slow progress 
following the mucous channels may result in a chronic hyperplasia, 
sclerosed condition of the uterus, tubes, and ovaries, producing a 
most serious deterioration of health, and yet giving but very moderate 
evidence of its seriousness locally. Lymphangitis or phlebitis may 
bring about suppuration in almost any of the pelvic organs, or any 
part of these organs, giving rise to the most diverse and complex con- 
ditions. These inflammatory foci may cause fluid accumulations of a 
serous, haemorrhagic, or purulent variety, or it may be only fibrino- 
plastic exudate, producing the most perplexing variety of symptoms 
and the most obscure localization. 
The gynaecologist of the future who has a conscience must learn 
to carefully discriminate between cases. This whole subject will soon 
have to be gone over again by some master possessing practical experi- Surgical Treatment of Para- and Peri- Uterine Septic Diseases. 
7 
ence and knowledge of the past, combined with an advanced special 
pathologic understanding. The day will come when it will not do to 
say “Take it out” or “Leave it alone” simply, but when, having 
found a proper curative method for each variety of case, or for each 
stage of the different varieties, the application of the remedy will corre- 
spond in the most exact manner to the particular conditions existing. 
Our concentrated attention should especially be turned toward the 
management of septic troubles in their incipiency. It is a part of the 
subject very improperly understood and presenting many difficulties. 
Patients, as a rule, depend for their care upon the general practitioner 
in the first stages of the disease. However competent and conscien- 
tious the gentleman may be, the multitudinous variety of his work 
makes it well-nigh impossible for him to devote special attention to 
this particular branch. 
The time to cure septic inflammatory diseases—that is, to cure 
them completely and perfectly—is within the first few weeks of their 
appearance. We all know that a few days may bring about such a 
change in the pelvic structure of woman that a lifetime of careful, 
conscientious treatment, by the most competent of specialists, will not 
eradicate. 
What means have we at our command this day to control or cure 
an invasion of septic material, either in the uterine cavity, or in the 
tube, or in the cellular tissue of the pelvis, or on the serous lining of 
the peritonaeum ? Mr. A., of New York, says dilate, curette, and pack 
at once, or the disease will be beyond your reach. Mr. 8., of Phila- 
delphia, says, Do not curette or do not pack, because you will bring 
about the most serious varieties of pelvic suppuration, for have I not 
noticed that all my abdominal sections have formerly been curetted ? 
therefore curetting produces pyosalpinx, etc. Then Mr. C., of Balti- 
more, says, Curette and do not pack; and Mr. D , of Washington, says, 
Use hot douches, and never enter the uterine cavity, but keep the 
parts clean and at rest, and your patient will recover. What a chaos ! 
The instrumentation of the uterine cavity, which in the hands of 
some apparently controls—cures the disease, becomes in the hands 
of others agents of destruction. An honest statement of facts must 
lead to the acknowledgment that many women suffer more from the 
doctor than the disease. Personally, I do not doubt that another 
decade will dispel many of the shadows hovering over the treatment 
of various stages of acute inflammatory affections of women. One of 
the most distressing experiences of the past has been the difficulty of 
preventing the disease from invading extra-uterine localities. A sep- 8 
Fernand Henrotin, M. D. 
tic endometritis will affect the tubes, or the peritoneal cavity, or the 
parametric spaces, or the ovary, in spite of our most enlightened en- 
deavors to control it. Once the disease has reached this point, with 
many men, no available means of treatment seems useful. Unfortu- 
nate women seem doomed to patiently wait for the surgeon’s knife, 
dallying with the hot douche and the warm poultice, if the difficulty 
seems so acute that curettage is inadvisable or seems dangerous. 
Allow me, with the object in view of endeavoring to fill this unfor- 
tunate gap in the treatment of inflammatory affections of women, to 
suggest for your consideration a method which has given me very 
satisfactory results in the treatment of acute inflammatory affections 
the last two or three years. Unfortunately, the number of cases is 
not sufficiently large to form a foundation for a very positive opinion, 
or the details explicit enough to lead to an analysis sufficient for dif- 
ferentiation. I can not state the procedure more definitely or plainly 
than by saying that for the last two or three years, whenever pelvic 
disease gave evidence of having penetrated beyond the cavity of the 
uterus, I have habitually made it a practice to make an incision behind 
the uterus, and digitally exploring the pelvis. However crude may be 
this explanation of the procedure, I am perfectly convinced of its 
great value. The vaginal incision, in the manner indicated, carries 
with it but little, if any danger. I have already pointed out to you 
how little risk there is encountered in puncturing or incising more or 
less chronic pelvic accumulations of a morbid kind by this route. In 
acute and early cases I have had occasion to operate within the last 
three years upon twenty-seven women, all of whom have made a satis- 
factory and, apparently, permanent recovery. This, however, repre- 
sents such a small number, with so little experience, that deductions 
are only to be made with a great deal of circumspection. When an 
infection travels by way of the lymphatics into the broad ligament and 
produces what is known as a “ phlegmon ” of the broad ligament, its 
march is frequently excessively rapid, and a swelling occurs on one 
side or the other of the uterus, characteristic of these forms of dis- 
orders ; or it may be that the infectious material travels by another 
lymphatic route, affecting the ovary only. Dr. William R. Pryor (Amer- 
ican Journal of Obstetrics, July, 1893) thinks that there are two sets of 
uterine lymphatics—one surrounding the surface and extending later- 
ally into the parametric spaces along the border of the broad ligament, 
the other following the course of the ovarian arteries, along the other 
margin of the broad ligament, and having their origin in a network sur- 
rounding the corpora lutea. Clinically, according to my experience, Surgical Treatment of Para- and Peri-Uterine Septic Diseases. 
9 
this seems to be true, for repeatedly have I been able between the 
folds of the broad ligament to enter into and drain ovarian abscesses, 
other parts seeming apparently healthy. 
The difficulty in presenting this matter to you properly seems to 
lie in the impossibility of differentiating the exact locality drained in 
each instance. Sometimes the finger penetrates posteriorly, apparently 
through the broad ligament, and separation of plastic exudate, lying 
between intestinal folds, is evident, showing the disease, in these in- 
stances, to have been a true peritonitis, the draining of which seems 
to be followed by amelioration. For many years I have followed but 
one rule in draining these cavities within the pelvis; this was, making 
an incision moderately circular, close to or rather slightly on the 
posterior surface of the cervix, and dissecting back the vaginal mucosa 
through the cellular tissue, to a point beyond which the wounding of 
the uterine artery seems improbable. 
This incision never extends beyond the outer limits of the cervix. 
When, in dissecting back, through the connective tissue, closely hug- 
ging the posterior wall of the uterus, sufficient room is not gained, a 
perpendicular incision, beginning at the middle of the posterior border 
of the first, and running downward, parallel to the vagina, in the 
median rhaphe, is made, taking care not to penetrate sufficiently deep 
to wound the rectum beneath. With the exception of an occasional 
slight nick with the points of curved scissors, the finger is used exclu- 
sively in the manipulation. The disengaged hand being now placed 
upon the abdomen, the operator is to proceed the same way as in mak- 
ing bimanual palpation, and gradually penetrate the tissues in the direc- 
tion of the center of the affected region. If the exudative mass is situat- 
ed at one side or the other, the finger penetrates backward until the 
bimanual sensation indicates that the peritonaeum, posteriorly, is almost 
reached. The finger now being turned to the right or left, as the 
case may be, and the superimposed hand being shifted to the affected 
side, there is usually no difficulty in penetrating the septic mass. As 
soon as the finger within reaches the exudative material, the sense to 
the touch will be self-evident. In the majority of cases an abscess 
cavity is found, a fact which is easily determined without withdraw- 
ing the finger. As, during these manipulations, the peritoneal cavity 
may have been accidentally opened, without our knowledge, it is bet- 
ter to retain the finger in the opening leading to abscess, and irriga- 
tion of the vagina may be practiced, with the finger still in situ, after 
which iodoform gauze is packed in the vagina, and in the wound 
proper up to the opening of the abscess ; the finger now being with- Fernand Henrotin, M. D. 
drawn, the pus is allowed to flow. Slight pressure may be practiced 
upon the abdominal wall, so as to empty the cavity as thoroughly 
as possible. The packing is now removed, the vagina once more 
cleansed, and the finger reintroduced into the abscess cavity a second 
time. Now comes an important part of the procedure, and that is 
the thorough exploration of the abscess sac, for the discovery of any 
additional collections in the neighborhood, each collection being 
treated in the same manner. The other side is now explored through 
the same vaginal opening, and, if necessary, the same procedures are 
here employed. Any hard, inflammatory masses are to be penetrated 
by the finger, whether they contain pus or otherwise. No instruments 
are to be used during any stage of the operation, after the vagina 
and submucous tissues have been incised. All inflammatory foci 
having been explored and penetrated, every portion of the cavity or 
cavities is to be carefully packed with iodoform gauze, wrung out 
in i-to-3,000 bichloride solution. I have no doubt the packing with 
plain gauze and sterilized water may answer as well and possibly bet- 
ter. The ends of the gauze strips are to be carefully retained, so that 
they all protrude in the vagina through the vaginal wound. A little 
additional packing can frequently be advantageously placed in this 
vaginal buttonhole, so that it will remain quite distended, allowing a 
free drainage. The vagina is now moderately packed with gauze, 
and the operation is thereby made complete. 
In some cases one will find the mass of exudate immediately 
posterior to the uterus in the median line. This inflammatory en- 
largement may be extra- or intraperitoneal. It matters not, it must be 
thoroughly penetrated and drained until it is evident by bimanual 
touch that the finger has reached its outermost limits. The finger is 
always, in all cases, to be worked from side to side until one’s surgical 
sense indicates that drainage is more than sufficient. In other cases 
the finger will come almost at once upon the peritonaeum, and the 
space at one’s command, opposite Douglas’ sac, may not exceed half 
an inch ; but if the finger now is turned to one side or the other, the 
layers of the broad ligament may be separated and the finger pushed 
in large masses at either side without opening into the general cavity; 
or, again, the finger being pushed to one side when the peritonaeum is 
reached, the parts separated may be felt thin, pliable, and apparently 
perfectly healthy, until the operator reaches on the posterior wall of 
the broad ligament a round or oval, soft, thin wall, fluctuating sac, 
evidently an ovarian abscess. At this stage I have repeatedly had my 
assistant introduce the finger to palpate the sac wall before penetrat- Surgical Treatment of Para- and Peri- Uterine Septic Diseases. 
ing it, and giving an exit to a large amount of pus. In a reasonable 
number of cases no pus is found, the enlargements consisting entirely 
of a conglomerate mass of exudate. Particularly is this true of those 
forms of disease which are apparently intraperitoneal. Personally, I 
believe it makes but little difference in the result if the general cavity 
of the peritonaeum is opened. A number of times, I am convinced 
that such was the case in my patients, but not the least reaction fol- 
lowed. In one instance, in a patient operated upon by a colleague, 
after this method, I pulled down a presenting portion of omentum to 
make certain of the fact, the patient recovering the same as the 
others. The packing is not removed for three, four, or five days, un- 
less the patient’s general condition indicates a retention of secretions. 
The wound may be kept open by a replacement of the packing three 
or four times, several days apart, but it has been my custom after 
eight or nine days, if the patient’s condition is favorable, to simply 
use vaginal douches, taking care that the vagina is kept as aseptic as 
possible. No irrigation is to be used at the time of the operation be- 
yond the vagina; but, if the abscess sac is large, it has been our cus- 
tom to introduce a small tube and irrigate freely after the second or 
third dressing. The effect of this procedure in some patients is sim- 
ply magical. The pains, hectic, and distress all disappear, and the 
patients, in the vast majority of instances, make a rapid recovery. 
A uterus that has been retroverted and retroflexed is lifted, in the 
retro-uterine cases, to a higher plane, and remains after the cure in a 
much more preferable position. At the end of two to three weeks it 
often has almost entirely regained its mobility, and an examination of 
several of these patients a number of months later has seemed to me 
to leave very little to be desired. 
In case the inflammatory affection has encroached upon the ante- 
rior vesico-uterine cellular pouch, bounded externally by the round 
ligaments, the same procedure can be used, making the incision in 
these instances anterior to the cervix and dissecting back between the 
uterus and bladder until the inflammatory center has been drained. 
Allow me to give you a striking illustration of the value of this 
method. Four years ago a young girl, fourteen years of age, who had 
apparently had several attacks of appendicitis, developed a pelvic in- 
flammatory affection which resulted in complete fixation of all the 
organs, the filling of the whole pelvis with large exudative masses, and 
resulting, after intense suffering and four months of critical illness, in 
an abscess, which, fortunately, made its escape by way of the rectum. 
After remaining well for a year and a half she suddenly developed 12 
Fernand Henrotin, M. JJ. 
another acute attack of the same variety. I had failed to examine 
her in the interval between these attacks, so that I can not tell how 
far and complete!) she recovered, though she was apparently in per- 
fect health. This, then, was a second attack, coming in a girl in 
apparent health, and ushered in by the most serious symptoms of 
rigors, fever, painful micturition, and painful defecation. Alarmed 
at the possibility of her having to go through the same ordeal as in 
the former instance, when her life was in such jeopardy, with the 
consent of her parents I immediately performed coeliotomy, intend- 
ing, if possible, to abort the threatened destructive process, and, if 
necessary, remove the offending organs. The condition of the parts 
forbade further operative procedures by way of the abdomen. The 
uterus, ovaries, tubes, and all parts concerned, were absolutely fused 
into one conglomerate mass, which meant that, in a girl of sixteen, I 
would be obliged to do a complete ablation, with the greatest danger 
to her life, and the blighting of her future. Closing my abdominal in- 
cision, I put her upon her back, and through the little narrow vagina 
I incised the vaginal roof close to the cervix, anteriorly and poste- 
riorly, penetrated both broad ligaments to their outermost limits, as 
well as the utero-vesical space, packing, as aforementioned, with 
gauze. No pus was encountered, but the disease was stayed. I 
examined this girl four weeks ago. She had been ill in bed only four 
weeks following the operation, and has now been fifteen months in 
perfect health. Her uterus is movable, though not to the same degree 
as you might expect in a perfectly healthy girl ; but there is no thick- 
ening and no enlargement, and no appearance of disease. 
For many years I have opened pelvic abscesses in this manner, 
never making use of any instruments beyond the first incision and a 
few nicks of the scissors in the second layer. Making the incision 
closely upon the cervix, adding to it the secondary incision at right 
angles down the vagina, if necessary, prevents haemorrhage from the 
vaginal vessels. Once having reached the cellular spaces, the finger 
can be guided inward within the pelvis. It is, to me, infinitely safer, 
and to be preferred to various methods of trocar puncturing, needle 
exploration, and cautery knives. It is simplicity itself, and requires 
only a few minutes for its performance. But this matter of opening 
abscesses is an old, old story. It is the application of this method of 
treatment for the cure of inflammatory pelvic affections in their very 
incipiency. 
Allow me to describe in a few short words my last case, as it rep- 
resents a perfect type of the value of this method : Surgical Treatment of Para- and Peri-Uterine Septic Diseases. 
13 
A young woman having forgotten herself, and being two days past 
her expected menstrual time, resorted to the services of an abortionist 
for the destruction of a supposed pregnancy, which, however, did not 
exist. Following the introduction of some instrument into the uterus, 
she suffered for two days very intense pain, accompanied by some 
fever. She was not, however, confined to her bed. The desired men- 
struation not making its appearance, at the end of six days she re- 
turned to the man’s office, and a second instrumentation was followed 
in thirty-six hours by a severe chill, high fever, and excessive pelvic 
pain. On the sixth day of her illness I saw her in consultation, finding 
an inflammatory swelling to the left of the uterus in the broad liga- 
ments. On the seventh day, under ether, I made the posterior vagi- 
nal buttonhole, penetrated the tissues with my left forefinger, and 
opened an ovarian abscess containing fully four ounces of pus. 
Eighteen days later this woman walked two blocks to the street cars 
and rode home. Her uterus was almost entirely movable ; there was 
no apparent discharge ; the woman was, to all appearances, cured. 
Bear in mind the salient points of such history ; refer back to 
cases of that variety which you have seen linger for months in bed, 
afterward returning for a laparotomy and an ablation of the append- 
ages. Remember that this woman was sick only seven days, and yet 
a good four ounces of pus were found in her pelvis, and at the end of 
three weeks she returned home apparently cured—that is, physiolog- 
ically, symptomatically, and, to all appearances, entirely cured. 
It is not only the application of the old surgical principle to evac- 
uate pus as early as recognized, but this operation strives to go 
further. It shows to us that, pus or no pus, the character of exudative 
material of the variety that is usually found in the pelvis is susceptible 
of absorption when broken up and drained. In some way, as happens 
within the peritoneal cavity when a drain is introduced, septic ma- 
terial from within seems to be drawn toward the breach that has been 
made, and if sufficient outlet has been provided, and if the parts are 
kept sufficiently aseptic to prevent mixed forms of infection at that site, 
the bacteria are usually destroyed and expelled, the exudative ma- 
terial is replaced by granulating tissue, and a cure results. No matter 
what success a man may have as a skillful enucleator of large and old 
pus sacs, he must indeed be bold who would deny the advantages of 
an early incision through the vagina if it can be followed by such 
good results as are apparently shown by cases as they have come to 
my notice. The objections that hold good against the vaginal incision 
in old pyosalpinx and other cavities which have destroyed, to a great Fernand Hcnrotin, M. D. 
extent, the organs in which they originate, have but little weight when 
applied to the procedure which I advocate. We are here simply in- 
cising, irrigating, draining localities permeated with recent lymph. 
The more I see of this work the more I have reason to believe that it 
is of value, and probably it will soon be determined that the earlier 
the operation is done the more striking its benefits. It is a question 
with me whether it will not be recognized in the future that an in- 
cision in the Douglas sac, performed at the very incipiency of a pelvic 
peritonitis, establishing a drainage for the primary serous effusion that 
occurs, will not prove an invaluable means of aborting and controll- 
ing these nefarious processes. It means the elimination of the 
noxious material as soon as it becomes palpable. 
I had almost forgotten to say that in every single instance when 
this operation is performed the uterus is to be carefully, thoroughly, 
and intelligently curetted. Failure to cure incipient septic disease of 
women arises most frequently from an inability to exactly locate and 
reach the exact seat of the affection. If a woman suffers from an 
endometritis, pure and simple, she can be cured by an intelligent and 
thorough curetting, if every vestige of the diseased tissue can be 
reached and removed. Here we have facing us the frequent inability 
to reach the cornua of the uterus, at the opening of the Fallopian 
tubes. In some cases, without our knowledge, the disease has already 
encroached upon the tubes themselves, and, to a certain extent, be- 
yond our reach. In other varieties, some of which also we are not 
able to diagnosticate, the virulent micro-organisms have penetrated 
through some of the aforementioned channels, beyond the uterine 
body, in one or the other direction, and my contribution to your 
understanding of this subject is an attempt to point out another 
method of combating these unfortunate affections, according to rea- 
sonable indications. The demonstration of the value of my sugges- 
tions will probably fall within the province of the consulting man, 
whose practice brings him face to face with these diseases in the first 
part of their course. The great hospital operator will probably see 
but few of these cases at a sufficiently early stage to verify the value 
of the proceeding. It has seemed to me to be a most valuable ad- 
junct in the treatment of the septic diseases of women, and is pre- 
sented to you with the hope that it may become a respectable addition 
to the methods in vogue for the conservative surgical treatment o 
these affections. 
353 La Salle Avenue.