THE PELVIC VISCERA IN RELATION TO MICRO- 
ORGANISMS IN HEALTH AND DISEASE, 
BY 
J. C. WEBSTER, M.D., F.R.C.P.E., F.R.S.E. 
Demonstrator of Gynaecology, McGill University ; Assistant Gynaecologist to tha 
Royal Victoria Hospital, Montreal. 
{Reprinted from the Montreal Medical Journal, August, 1897.) THE PELVIC VISCERA IN RELATION TO MICRO-ORGAN- 
ISMS IN HEALTH AND DISEASE. 
BY 
J. C. Webster, M.D., F.R.C.P.E., P.R.S.E., 
Demonstrator of Gynaecology, McGill University ; Assistant Gynaecologist to the 
Royal Victoria Hospital, Montreal. 
The bacteriology of the genital tract in various normal conditions : 
In the JS ew-Born Child, in almost all cases, no germs are found in 
the vagina. Very soon, however, they enter, favoured by baths, 
washing, the application of oils, etc. Stroganoff states that a breech 
delivery of a female child favours their premature entry. Within 
the first two weeks gelatine-liquefying germs are rarely found. 
In Girls and Women various bacilli and cocci may be found in the 
vagina, as well as sarcinm, yeast fungus, etc. One of these germs is 
very common and is called Doderlein’s vaginal bacillus. The patho- 
genic organisms flourish best when the vaginal secretion is alkaline ; 
in acid conditions they are weakened in vitality or killed. As a rule 
no germs are found in the uterus or tubes. Menge has carried out 
an interesting series of experiments regarding the bactericidal proper- 
ties of the vaginal secretion in a large number of non-pregnant women. 
He introduced into the vagina a number of pathogenic organisms, viz.; 
bacillus pyocyaneus, staphylococcus pyogenes and streptococcus. In 
all cases he found that within 70 hours they had been destroyed or 
their virulence greatly diminished. 
He also carried out the following experiments. The vagina was 
carefully sterilised in the case of 70 women on whom abdominal section 
was to be performed. About 1.6 days after the operation the vaginal 
secretion wras carefully removed and alkaline agar plates innoculated. 
In 62 cases the plates remained absolutely sterile. It wTas different, 
however, with specimens taken from the vulva for 66 of these gave 
rise to growths on the agar, only 4 being sterile. Of the 8 cases in 
which the vaginal secretion gave rise to growths, the germs were not 
pathogenic. 
In 12 cases acid agar plates were also employed, cultures being 
obtained in 6 cases (mostly consisting of bacilli); while in the same 
cases only 3 cultures were obtained on alkaline plates. (These few 
experiments are not, however, of particular value, for pathogenic 
germs without exception develop in alkaline media and not in acid 
media.) 2 
In another series of experiments, 12 in number, he used grape- 
sugar agar and obtained cultures 11 times, thus demonstrating the 
frequency of non-pathogenic anaerobic germs in the vagina. 
Dbderlein has advanced the view that the micro-organism which he 
has called the “ vaginal bacillus,” of anaerobic growth, produces an 
acid secretion, which is the cause of the normal vaginal reaction and 
prejudicial to pathogenic organisms. 
Menge, however, believes that the vaginal secretion, whether alka- 
line or acid is bactericidal to these organisms and he believes that the 
acid secretion of Dbderlein s bacillus plays an unimportant part in the 
purification of the vagina. Of more importance is acidity due to 
other causes (found in the new-born child when no germs are present). 
But a considerable role is played by phagocytes and leucocytes which 
enter the vagina. The chief agents are, however, the anaerobic germs 
and their growth-products. In proof of these statements, Menge 
made the following experiments. He removed the acid secretion from 
the vagina in sterilised holders and innoculated it with staphylococci. 
The latter were soon destroyed. If the secretion were previously 
sterilised with steam the staphylococci lived for a considerable time 
or were not killed at all. 
If the secretion were made weakly alkaline, the cocci lived longer 
than in the acid solution. If the alkalised secretion were sterilised by 
steam before hand, the germs flourished vigorously. 
Menge believes that the tissue fluids possess this bactericidal 
action, and that this is found in the new-born child, whose vagina is 
free of germs. The absence of oxygen is also an important factor 
In the order of their importance the factors destructive to patho- 
genic microbes in the vaginal secretion may be arranged as follows 
according to this investigator : 
O O 
1. The antagonism between the normal vaginal bacilli and the 
pathogenic organisms. 
2. The products of the vaginal bacilli. 
3. The acidity of the secretion. 
4. The secretion of the vaginal wall. 
5. Leucocytes; phagocytes. 
6. The absence of free oxygen in the vagina. 
It is important to note that the vaginal secretion may vary greatly 
in its effects on pathogenic organisms. In some cases it may quickly 
destroy them ; in others it may only weaken them or destroy their 
virulence, as Winter has shown. Their virulence may be retained, if 
the nature of the secretion be altered, e.g., by dilution, by secretions 3 
from inflammatory areas, e.g., gonorrhoea in the cervix, or by the 
addition of solid organic debris. 
Secretions poured into the vagina from inflammatory conditions in 
the uterus weaken the power of the vaginal secretion. In 10 cases 
in which there was gonorrhoeal inflammation in the uterus, the 
vaginal secretion contained numerous streptococci. If the vagina in 
these cases were completely disinfected with strong antiseptics e.g., 
carbolic acid, lysol, corrosive sublimate, and then left for some hours, 
the streptococci again appeared in the vaginal discharge in 3 to 6 
hours. On the other hand, if at the same time the interior of the 
uterus were thoroughly disinfected with a 50 per cent, chloride of 
zinc solution, the cocci in the vaginal secretion thereafter disappeared. 
As regards the normal uterine canal Menge finds that organisms do 
not dwell in it, though the secretion be alkaline. The cervical mucosa, 
according to him exercises a protective influence. He innoculated the 
cervical canal with streptococci and staphylococci in 15 cases and 
within 12 hours found the cervical mucus sterile. 
The normal tube is always sterile. Menge examined 83 specimens 
and obtained a culture only from one, in which there was an infective 
endometritis associated with a carcinoma of the cervix. 
As regards the influence of Menstruation.—Jacobs and others state 
that the vaginal organisms are increased during the period of the 
flow owing to the diminution in the acidity of the normal vaginal 
secretion as a result of the entrance of the blood. Stroganoff ex- 
amined the cervix during the menstrual flow and found that in many 
cases it contained germs, though none that would liquefy gelatine. It 
is probable that some germs are washed out by the menstrual blood, 
and that the vaginal secretion loses some of its strength by the 
dilution which occurs. 
In Pregnancy, the vaginal secretion is believed to be very germi- 
cidal to pathogenic organisms. Stroganoff found plenty of ordinary 
vaginal bacilli, but rarely germs that would liquefy gelatine. Kronig 
performed a number of experiments on pregnant women, introducing 
various organisms into the vagina. He found that the streptococcus 
was killed before the staphylococcus, and showed that douching of 
the vagina with antiseptic solutions reduced or destroyed its germi- 
cidal power, and that the use of plain water slightly diminished it. 
He thinks, therefore, that prophylactic syringing before confinement 
can do no good and may be a source of harm. 
Stroganoff also found various microbes in the vaginal secretion, but 
none of them would liquefy gelatine by their growth. 
In the Puerperium, the use of antiseptic solutions in the vagina 4 
after labour is being discarded by many authorities, save where 
digital examination has been carried out, where labour is abnormal, 
or where operations have been performed ; and in cases where the 
patient may be depressed in health from various causes, e.g., nephritis, 
heart disease, syphilis, anaemia, etc. 
If, however, there be any inflammatory condition in the cervix, 
vagina or vulva (especially if of a possible gonorrhoeal origin) there 
is a very strong indication in favour of employing vigorous antiseptic 
douches. 
In Abortions, the vaginal reaction varies according to the amount 
of blood and debris found in the vagina. The germs also vary greatly 
in number and nature from time to time ; the pathogenic organisms 
are more apt to be found in the vagina and cervix in connection with 
abortions than in other conditions, probably chiefly due to the fre- 
quent digital manipulations that are carried out or to the carelessness 
of women in having themselves attended to. 
In Old Age, Stroganoff finds various microbes in the vagina, mostly 
rod-shaped, and smaller, on the whole, than those found during the 
period of sexual life. 
The vaginal secretion is only faintly acid ; in the neighbourhood of 
the cervix it is neutral or alkaline. 
In the cervix living germs were found in about 50 per cent, of cases, 
though very rarely were any of them able to liquefy gelatine in their 
growth. 
The Bacteriology of the Urethra.—Various germs may be sometimes 
found in the urethra in health. Gawronsky’s experiments may be 
quoted. He made cultivations from the urethral secretion in 62 
cases. In 15 of these bacteria were found, in 8 staphylococcus 
pyogenes albus, in 2 the bacterium coli commune. Amongst the nega- 
tive cases were 10 where the women had peri- or parametritis, 6 
prolapsus uteri, 3 pregnancy. 
The Bacteriology of the Intestines.—Various forms of micro- 
organisms are found in the bowel. It is not necessary to specify 
these ; the germ which is of chief importance as an infective agency 
is the bacterium coli commune. 
Relation of Micro-organisms to Pelvic Diseases.—At the present 
time the tendency is to attribute the great majority of inflammations 
which occur in the peritoneum, cellular tissue and viscera of the pelvis 
to the action of micro-organisms. The inflammatory processes are 
simply, to state the modern view, the series of phenomena caused by 
nature’s resistance to the noxious influence of the infecting organisms. 
These processes are, therefore, not evil in themselves, but are bene- 5 
ficent and purposeful. The most important germs which act as 
infecting agents are : 
Streptococcus pyogenes (most frequent source of trouble). 
Staphylococcus pyogenes aureus. 
Bacterium coli commune. 
The following are less often a source of trouble : 
Staphylococcus pyogenes albus. 
Staphylococcus pyogenes citreus. 
Staphylococcus epidermidis albus. 
Bacillus pyocyaneus. 
Diplococcus pneumoniae. 
Tubercle bacillus. 
These germs may gain entrance by the vagina, rectum, bladder, in- 
testines, or may be carried from some distant part by the circulation. 
The conditions which favour their entrance are a favourable soil, 
e.g., a raw surface, a tissue of impaired vitality, a general condition 
of bad health in which the power of resistance of the tissues is reduced, 
dying organic matter such as blood-clot, remains of placenta or mem- 
branes. 
In some cases the micro-organism e.g., the gonococcus is capable of 
attacking the tissues and of setting up specific reaction when the 
individuals are in a state of perfect health. The most common source 
of entrance for the various germs is, undoubtedly, the vagina. They 
may spread into the uterus and tubes and may infect the peritoneum 
and ovaries ; this may take place either by an extension of infective 
activity along the mucous membrane or by advance as a result of 
germ-development in a favourable medium lying within the genital 
canal. They may enter a raw, injured or diseased surface and then 
spread to cellular tissue, peritoneum, tubes or ovaries, or even to more 
distant parts by means of blood-vessels and lymphatics. 
The exact relationship between germ-action and various other 
factors which have long been regarded as causal in the production of 
pelvic inflammation has not yet been definitely established. 
Thus menstruation has always been considered important especially 
in relation to the development of inflammation in the uterus, a chill 
or some extra exertion being considered as playing a leading role in 
precipitating the inflammatory processes. 
Now-a-days, we are rather inclined to regard menstruation as a 
factor in altering the nature of the vaginal secretion, rendering it, by 
the addition of alkaline blood, more suitable for the growth of patho- 
genic germs which might enter the vagina, and making it more easy 
for them to spread into the upper genital tra.ct and attack the tissues. 6 
It is possible, also, that such influences as chill and fatigue, hy dimin- 
ishing the resisting power of the tissues, render them more susceptible 
to the action of germs. 
Excessive coitus, especially at menstruation, is said to lead to 
inflammatory changes, especially in the uterus. There is, however, no 
proof that the mere physical excitement can induce these. Most 
likely it requires to be combined with microbial activity; the irrita- 
tion of the tissues caused by the excessive movements in some 
measure depressing the vitality of the tissues and thus favouring 
infection by germs which might be present. When it occurs at the 
menstrual period there is also to be considered the altered nature of 
the vaginal secretion favouring the development of micro-organisrnal 
growth. 
In some of these cases, in which the inflammation is supposed to be 
due to coitus, gonorrhoea is the infecting agent; either an acute 
gonorrhoea existing in the man or a latent gonorrhoea in the man or 
woman. In the former of these the virulent germ attacks the woman 
directly, its infectivity being unaffected by the action of coitus ; in the 
latter the latent condition is stirred into a renewal of activity as a 
result of the irritation and excitement of the excessive coitus. 
The Influence of Labour has long been regarded as most important 
among the factors causing pelvic inflammations. In the puerperium 
many conditions favourable to the development of micro-organisms 
are present. The vitality of the tissues in general is impaired as a 
result of the fatigue of the pregnancy and labour ; the uterus is 
weakened by its great exertion in delivery, the condition of its circu- 
lation is greatly altered owing to the contraction and retraction of its 
musculature, and its tissues are below their normal standard of 
strength owing to the puerperal retrogressive changes which take- 
place in them ; the inner surface affords a large absorbing area; the 
placental site presents a number of opened blood-sinuses in which 
blood-clots are formed; blood-clot often lies in the uterine cavity and 
portions of the placenta and membranes may be left in it; the cervix, 
vagina and perineum are more or less bruised and very frequently 
lacerated. 
That the bruising and laceration per se can start an inflammation 
is very doubtful and, by many, is not at all believed. Were it not for 
the irritation of germs or their products, wounds would heal by direct 
union or by granulation, without the accompaniment of inflammatory 
processes. 
Certain other conditions in the puerperium are believed by many 
to|ea4 to inflammation, viz., too early rising, walking or working. It 7 
is very doubtful, however, if these influences can bring about metritis 
in the uterus directly. They act undoubtedly mainly by impairing 
the vitality of the tissues and thus favouring infection bj germs. It 
is very noticeable that these conditions are, in many instances followed 
by no disturbance whatever. Among the labouring classes may be 
found a large number of women who systematically rise early after 
child-birth and go to work, in whom no inflammatory changes, what- 
ever, follow. 
Injuries resulting from operative measures may also lead to condi- 
tions which favour microbial infection, e.g., bruises, tears, cuts; the 
irritation of a pessary may also act in the same manner. 
The influence of all diseases which weaken the system is one which 
acts as a predisposing cause. It is believed by several that in certain 
states, e.g., rheumatism, malaria, scrofula, constitutional syphilis, there 
is a special tendency to inflammatory changes in the pelvis, but their 
mode of action or their relationship to microbial action is not known. 
They would certainly act in one way viz., by depressing tissue vitality. 
Regarding the modes of action of the various forms of streptococcus 
and staphylococcus, their various life-histories and the changes brought 
about by them in the body nothing need be said here, since these 
matters are fully discussed in works on bacteriology and surgery. 
Different tissues are affected, different reactions brought about and 
different results produced. These differences depend upon the mode 
of entrance of the germs, their virulence, the nature of the soil on 
which they grow, the power of resistance of the tissues. 
Special reference must, however, be made to the part played by 
certain specific organisms. 
Gonococcus.—Since Noeggerath published his first paper in 1872, on 
the relation of gonorrhoea to pelvic disease, an immense amount of 
attention has been directed to this subject. In Great Sinclair, 
and in Germany, Sanger have been among the most prominent of those 
who believe in the profound importance of this relationship. Gon- 
orrhoea may affect the pelvic soft parts in different conditions. 
Acute Gonorrhoeal Infection.—All agree that the vagina may be 
readily attacked by the gonococcus in childhood. There is some 
difference of opinion as to the areas which it may attack in the adult. 
For many years Bumrn’s views have been most widely held. He 
stated in 1880, that this organism could not develop in the stratified 
squamous epithelium of the vagina, being limited in its attacks to the 
urethral and cervical mucosa. This statement was based upon a 
number of experiments of the following nature. Active gonococci 
were placed in contact with the vaginal walls for 12 hours, no vaginb 8 
tis being set up. He also excised a portion o£ the wall in a bad case 
of gonorrhoea and failed to find gonococci in it. He believed that the 
swelling and tenderness of the vagina, so often found in acute gon- 
orrhoea, were due to the irritation of the discharge flowing down 
from the cervix. 
Schwarz, Teuton, Dinkier and others have strongl}7 opposed 
Bumm’s views and, more recently, he has modified them, stating that 
occasionally in the adult a true gonorrhoeal vaginitis may occur in 
acute cases though not in chronic cases, e.g., when the mucosa is in a 
delicate condition or thinned as in old age. Sanger holds that the 
vaginal walls can be affected only in children, in young girls, in old 
women and in the pregnant, states in which the epithelium is particu- 
larly imperfectly developed, delicate or altered in vitality. 
Mandl has also carefully investigated this subject. He excised 
portions of the vaginal wall in three cases (aged 21, 21 and 24 respect- 
ively) of acute gonorrhoea and examined them with great care. In 
some parts the epithelium was very thin in its inner layers, here and 
there, the papillm being quite exposed. The surface was injected and 
swollen and had a red, raw appearance. In many parts the epithelium, 
as well as the subjacent connective tissue was infiltrated with pus- 
cells. Gonococci were found on the surface and in the entire thickness 
of the epithelium, many being within the pus-cells. In several places 
they were detected in the sub-epithelial connect! ve-tissue, being most 
deeply placed where the epithelium was thinnest. 
In one of these cases the uterus was absent so that the influence of 
a cervical discharge on the vaginal walls was out of the question. 
Doderlein has also recently described an undoubted case of gonor- 
rhoeal vaginitis after extirpation of the uterus and appendages. 
Mandl believes, therefore, that there can be no doubt as to the 
development of a specific gonorrhoeal vaginitis, though there are 
undoubtedly variations in the resistant power of the vaginal walls 
and in the degree to which they may be infected. Thickness, tough- 
ness and softness of the epithelium, the size of the interstitial spaces 
are important factors in determining the nature of the resistance. 
In examining sections of the vaginal wall, it is important to note 
the period of duration of the disease. In old cases, the degenerated 
cocci may easily fail to take on the stains and may so be overlooked. 
Very common sites of infection are the openings of the ducts of the 
glands of Bartholin and the small recesses about the urethral orifice. 
In most cases of acute infection the disease is set up in the cervix 
and vul vo-vaginal parts at the same time. Sometimes, the former 
may be at first affected ; soroetirqes, the infection may attack thq 9 
lower structures and spread upwards, or sometimes the cervical 
mucosa may remain unaffected. 
In some cases acute infection may spread along'the uterus and tubes 
to the peritoneum. It may also affect, in some cases, the bladder, 
ureters and kidneys. It may spread to the Bartholinian glands. 
Latent or Chronic Gonorrhoea in the Female.—After the signs and 
symptoms of an acute infection have passed away the virus may still 
remain in the various parts above noted, viz., the crypts about the 
outer part of the urethra, the ducts of the Bartholinian glands and 
the mucosa of the cervix. In this condition infection may spread and 
inflammatory reaction be set up in the whole urinary tract, the whole 
genital tract, and in the peritoneum of the pelvis. 
It is necessary to inquire into the cause of infection in these cases. 
Is the gonococcus the chief factor ? Is there a mixed infection of 
gonococcus and other pathogenic germs, eg., streptococcus, or is the 
infection due to the latter germ entirely, they having been started 
into activity and having been able to spread by the favouring influence 
which the products of the gonococcus exert ? 
These questions cannot be answered with accuracy. By many it 
has been believed that the gonococcus is capable of carrying infection 
directly to all the above mentioned parts, both in acute and chronic 
conditions. 
Now, the tendency is to limit the range of its activity. There are, 
however, many varying opinions. One fact seems to have been 
definitely established, viz,, that the products of the gonococcus can so 
alter the secretion in the vagina (rendering it neutral or alkaline) as 
to render it favourable to the growth and activity of streptococci and 
other pathogenic organisms. 
Regarding the spread of an inflammation from the urethra to the 
bladder and, it may be, to the ureter and kidney, it is now believed 
by many that the gonococcus is not the infecting cause, but strepto- 
cocci, which have developed under the favouring influence of the 
gonococcus growing in the urethra. 
With regard to the occurrence of inflammation in the Bartholinian 
glands, some believe that the gonococcus may be directly responsible, 
while others hold that it is the other cocci to which I have referred. 
I think that while the infection is due to streptococcus in most cases, 
it may also arise from the gonococcus entirely. The gland is lined 
with a single layer of cylindrical epithelium—the site most favoured 
by the gonococcus, and the organism itself may be found in the gland 
in some inflammatory conditions. It is, however, very difficult to 
eliminate the influence of the pathogenic germs, as they can, in these 
cases, so easily gain access to the glaiid, 10 
As regards the uterus, there seems little doubt that inflammation 
may be set up in it by the action of the gonococcus, though as to the 
frequency with which this occurs, and as to the conditions under 
which it is most likely to take place, accurate knowledge does not 
exist. In many cases of uterine inflammation, which clinically might 
be attributable to the influence of the gonococcus, the germ cannot be 
found at all. No doubt, in some of these cases the infecting agent is 
some other organism, e.g., streptococcus. 
It must be stated here, however, that Bumm, Gottschalk and 
Immerwehr have recently reported that in a considerable number of 
cases of uterine inflammation they could not find any germs in the 
secretions from the uterus. Menge also reports that examinations of 
scrapings of the uterine mucosa in 73 cases of endometritis revealed 
micro-organisms, including the gonococcus and tubercle bacillus only 
in a proportion of instances. These statements do not, in any way, 
prove that the infecting agency was “not in these cases of microbial 
nature. We do not yet know how they act in keeping up chronic 
irritation, nor how numerous they need be to affect a considerable 
area. It may be that in chronic conditions a few foci in the tissues 
may serve to diffuse an irritating influence sufficient to continue the 
altered activity of the tissues. If this be true, it is easy to understand 
why the microbes might but rarely be found in the secretion obtained 
from the uterine cavity and why, indeed, they might only occasionally 
be found in curetted parts of the mucosa 
In some cases the infection of the uterus may be directly due to 
the action of the gonococcus along with the streptococcus or other of 
the pathogenic organisms. 
It is important to note that the uterine cavity may become the 
seat of marked microbial development, if it contain detritus from a 
new growth, from retained membranes or placenta, or if the mucosa 
be injured. 
As regards the Fallopian tubes, there is ample proof for believing 
that the gonococcus may infect it and lead to inflammatory changes. 
A. Martin believes that the infection may travel not only directly 
through the lumen of the genital tract, but also through the lymph 
channels and connective tissue spaces in the parametrium. 
Here, as lower down in the genital canal, inflammatory changes 
may result from mixed infection, the gonococcus and streptococcus 
being both active, or the latter being the chief cause developing in 
the lumen under the favouring influence of the products of the 
gonococcus. 
Jt is interesting to note the results of Menge’s examinations of 11 
diseased tubes. In 80 cases of hydrosalpinx and 3of hmraato-salpinx 
no cultures could be obtained. In 122 specimens of purulent sal- 
pingitis he obtained the following results : 
In 75 cases the tubes were sterile. 
In 28 cases gonococci were present. 
In 9 cases tubercle bacilli were present. 
In 3 cases streptococci were present. 
In 1 case staphylococci were present. 
In 1 case bacterium coli commune were present, 
In 1 case saphrophytes were present. 
In 1 case anaerobic bacteria were present. 
In 3 cases various bacteria were present (in one case with strepto- 
cocci.) 
He found that 10 cases of pyosalpinx were absolutely sterile, thus 
differing very decidedly from Boisleux and Witte, who state than an 
abundance of germs were found in such cases. 
There can indeed be no doubt that in the great majority of cases 
the contents of a pyosalpinx are absolutely sterile. 
Kiefer states that generally pus collections in the tubes become 
sterile in 6 to 12 months, the cocci being probably killed by their own 
toxins. It is important to note, as Olshausin points out, that with the 
onset of fresh infection or exacerbations new cocci may be introduced 
and the infectivity of the pus increased. 
In regard to the pelvic peritoneum, Sanger believes that the gono- 
coccus is only capable of setting up localised pelvic inflammation, e.q., 
periovaritis, perisalpingitis. He thinks that it cannot initiate a wide 
peritonitis, which he believes due to a mixed infection, the active 
agent being streptococcus or some other organism. The gonococcus 
does not appear to survive long in the peritoneal cavity. 
Winter is also of this opinion and states that general acute peri- 
tonitis is never caused by the gonococcus. Kiefer also observed 11 
cases, in which fresh gonorrhoeal pus escaped into the peritoneal 
cavity without anjr reaction taking place, whereas virulent pus con- 
taining streptococci, or staphylococci always caused a reaction. 
Several observers have pointed out the frequency of localised pelvio- 
peritonitis after removal of pus-tubes. This may be due to foci 
present before operation in the peritoneum or cellular tissue, to oozing 
from the uterus through the interstitial portion of the tube, or to 
fresh infection with bacterium coli. 
As regards pelvic cellulitis, it is believed that the gonococcus may 
be the infecting agent sometimes, but that in the majority of cases 
one of the other organisms is the cause, 12 
The same may be stated in regard to the ovary. 
Menge found in 8 cases of ovarial abscess that the gonococcus was 
present in 3, the tubercle bacillus in 2, and streptococci in 1 ; the 
other three cases being sterile. Kiefer found the bacterium coli in 
several cases. 
Sanger has laid great stress upon the marked liability of pregnant 
and puerperal women to contract acute gonorrhoeal infection and, 
also, on the tendency towards the development, in these conditions, of 
an acute exacerbation of what was once previously a slight inflam- 
matory process. Thus, a latent condition may develop into an acute 
outbreak in pregnancy or the puerperium without the inciting 
influence of any fresh infection. 
Sanger also points out that in the puerperium a special variety of 
acute inflammation of the tubes and ovaries of a pure gonorrhoeal 
nature, may be due simply to a recrudescence of an old gonorrhoeal 
trouble, without any freshly acquired infection. 
It must, however, be remembered that similar phenomena may be 
produced by the action of septic organisms which find a favourable 
condition for development where gonorrhoea, recent or latent, has 
altered the state of the secretion in the genital canal. Possibly, there- 
fore, some of the cases referred to by Sanger are of this nature. 
Latent Gonorrhoea in the Male.—The particular work carried out 
by Ncegerath was to point out the importance of latent gonorrhoea in 
the male as a prominent factor in the production of various forms of 
inflammation in the female pelvis, e.q., endometritis, salpingitis, 
ovaritis, and localised peritonitis. He pointed out what is now 
generally recognised, that the male urethra may remain the source 
of an infective power long after all apparent signs and symptoms of 
acute gonorrhoea have passed away. This power resides in a discharge 
produced by the remains of the original gonorrhoeal infection, and is 
probably limited to the crypts of the mucous membrane. The excite- 
ment of marriage, of alcoholic indulgence, or of over-fatigue may 
stimulate these areas of latency into renewed activity and, as a result, 
the woman after coitus may be infected in the various ways already 
described by me. The manner in which the infection is brought 
about is not clearly known. In many of these discharges from the 
male urethra no gonococci can be found. Very probably, in such 
instances, the discharge may act by modifying the vaginal or uterine 
secretions so as to afford a suitable medium for streptococci or other 
infective germs, which may spread upwards and lead to the various 
disturbances which I have described. Very often a perfectly healthy 
woman may be infected as a result of this latent gonorrhoeal condb tion in the male, the most distressing pelvic troubles developing sOori 
afterwards. 
Gonorrhoeal infection of the mucosa of the rectum may follow 
immediately upon an infecting coitus, or it may afterwards follow 
as a result of the entrance into the bowel of gonococci from the 
vulvar discharges. Rarely it may follow rupture of a Bartholinian 
abscess into the rectum. The inflammation may be followed by an 
ulcerated condition. 
Bacterium Coli Commune.—This organism, first described by 
Escherich in 1885, is believed to be the most frequent infecting microbe 
which may extend from the intestinal tract into neighbouring parts. 
It is of great importance in relation to general peritonitis, as has been 
shown by Treves and others, but it also plays some part in local pelvic 
inflammatory affections. According to the researches of Yignal and 
others, this organism is found in the whole alimentary tract. Nor- 
mally, it is believed to number about 95 per cent, of all the organisms 
in the bowel (Treves). 
According to Tavel and Lanz there are many varieties of this 
organism, and also corresponding differences in its virulence. Accord- 
ing to the experiments by LeSage and Macaigne a culture outside the 
body is harmless and will not set up peritonitis when placed in the 
peritoneal cavity of animals, because under normal conditions the 
germ is not virulent. 
It may, however, become virulent under various conditions, e.g., in 
weakened, diseased or injured states of the wall of the gut, such as 
obstruction, strangulation, congestion, diarrhoea, compression, bad con- 
stipation, etc. 
If in such a condition of virulence, a culture of the germ be made, 
it has a distinct influence when placed in the peritoneal cavity of 
animals, varying according to the degree of toxicity. Thus it may only 
lead to slight constitutional disturbance with diarrhoea ; a localised 
purulent peritonitis may be set up ; or in some cases acute septicaemia 
may lead to death before any local signs of peritonitis are developed. 
P. Ziegler has pointed out that normally the bacterium shows no 
tendency to pass through the bowel wall; if however, the vitality of 
the wall be impaired, in addition to becoming virulent, it at once 
begins to penetrate the wall and may extend into surrounding tissues 
for a considerable distance. 
When the bacterium reaches the peritoneum it may set up an 
inflammatory reaction varying in extent according to its virulence 
(as well as other conditions). 
Paul Ziegler has shown that its activity is increased there, if fluids, 14 
especially blood, be present in the peritoneum. It is also accentuated, 
as Laruelle has pointed out, if' the intestinal secretion be present, even 
though the latter be artificially sterilised. This germ is generally the 
cause of peritonitis in hernial sacs, in obstruction and strangulation, 
in appendicitis cases and other intestinal conditions. 
Freshly filtered fluid from the normal bowel introduced into the 
peritoneum generally sets up peritonitis. The cause is the bacterium 
coli. According to Barbacci the peritoneal endothelium is damaged 
by this fluid, thus favouring an infection by the germs; and I have 
already pointed out that the activity of the microbe is increased by 
the presence of the intestinal fluid in the peritoneal cavity. If the 
fluid be in any quantity it has a depressing influence on the system 
on account of the absorption of the toxins in it. 
The bad effect of faeces when introduced into the peritoneal cavity 
is due to the presence of microbes, especially the bacterium coii, in it. 
If sterilised faeces be introduced no bad result follows. 
It is likely that a considerable proportion of local pelvic infections 
in women are due to this bacterium and it is possible that in nullipar- 
ous women the frequency of retro-uterine inflammation is related, not 
to infection from the uterus in the great majority of cases, but from 
the rectum. 
The overstretching of the rectum from constipation, so common in 
women, the continual soaking of the wall in this state with toxic 
matters in the bowel-contents, the occasional occurrence of cracks and 
ulcers in the rectal wall are all factors which favour the passage of 
the bacterium coli into the utero-sacral ligaments, surrounding cellu- 
lar tissue and peritoneum and even the uterus. 
Tubercle Bacillus.—Tuberculosis in the genital tract may be set up 
in a variety of ways. 
1. It may be primary, i. e., the bacilli may enter from the outside 
by way of the vagina, being introduced by dirty instruments, by 
examining fingers, by sleeping with a tubercular person, by coitus 
with a man suffering from genito-urinary tuberculosis. In such cases, 
the vagina and cervix may be first affected, the disease spreading 
afterwards along the uterine and tubal mucosa; or the upper genital 
tract may sometimes be first attacked, according to Whitridge Williams, 
the bacilli entering a denuded surface on the vaginal wall and being 
carried up by the lymphatics. 
2. The genital organs may become affected by the direct spread 
from neighbouring tuberculous areas, e.g., tuberculosis of bladder or 
bowel ; ulcers may perforate or abscesses burst leading to fistulous 
communications. W. Williams states that one of the most frequent sources of genital 
tuberculosis is tubercular peritonitis. Weigert has shown that in this 
disease the bacilli which become free in the peritoneal cavity tend to 
sink into the pelvis setting up infection ; they are there in the best 
position to be swept towards and into the tubes and they may 
undoubtedly be carried into the tubes setting up disease without 
infecting the pouch of Douglas at all. 
3. The bacilli may be introduced directly into the vagina when 
the patient has tuberculosis in some other region, e.g., urinary tract, 
intestines, lungs, the infection spreading from the discharges. 
Hegar has pointed out that genital tuberculosis is rare in childhood 
and after the climacteric. 
Infection by men suffering from genito-urinary tuberculosis is of 
considerable interest. Derville reports five cases in which the hus- 
bands of women with genital tuberculosis had tubercular epididymitis. 
Fernet reports four cases in which men with pulmonary tuberculosis 
infected their wives, but we do not yet know whether the semen in 
such cases may contain tubercle bacilli. Landouzy and Martin mixed 
the semen of a guinea-pig which had died of tuberculosis with salt 
solution and injected the mixture into the peritoneal cavity of 15 
guinea-pigs; five died of tuberculosis. Curt Jani found very few 
bacilli in apparently healthy testicles and prostates of several persons 
with tubercular phthisis. Gartner in reference to Jani’s description 
states that in tubercular patients, before death occurs, the bacilli may 
spread to various parts of the body and hence in this stage may often 
be found in the blood. 
Spano injected semen from a tubercular man into the abdominal 
cavity of eight guinea-pigs and produced tuberculosis in six cases. 
In two other cases by injecting it into the vagina, genital tuberculosis 
was caused. 
Mafucci injected large doses of bacilli into the jugular vein of a dog 
and found them afterwards in the semen of the animal. 
Rohlff, however, introduced semen from a tubercular man into the 
anterior chamber of the eyes of goats and rabbits with a needle punc- 
ture and got no result ; but the amounts injected were very slight and 
goats are not very susceptible to tuberculosis. 
Westermeyer introduced testicular tissue from a tuberculin pateart 
into the peritoneal cavity of rabbits without setting up tuberculosis, 
but he was not able to distinguish tubercle bacilli in microscopic ex- 
amination of the testicles. In a case of acute miliary tuberculosis in 
which bacilli were found in the testicle, injections of portions of it 
into the peritoneal cavity caused tuberculosis in the rabbit. 16 
Walter examined several testicles in cases of phthisis and found no 
tubercle bacilli in them. Gartner believes that they are very scanty 
in the semen in such cases. He injected tubercle bacilli in the trachea 
and lungs of male guinea-pigs, setting up infection, and after three or 
four days obtained semen from their testicles. In 32 cases, he found 
tubercle bacilli only in five, and the semen in these few instances, 
when introduced into the peritoneum of other animals, set up only a 
mild form of tuberculosis. 
In another set of cases he set up tuberculosis in the testicle by 
local injection and found that in 50 per cent, of the animals into 
which he introduced the semen from these cases, severe tuberculosis 
was set up. Gartner, therefore, believes that genital tuberculosis in 
the male is a very much more serious danger for the female than 
distant tuberculosis. 
The various parts of the genital tract, including the ovaries, may 
be affected, though the vulva and vagina are very rarely attacked- 
Sometimes a mixed gonorrhoeal and tubercular infection may take 
place. Pyosalpinx may develop in tubercular salpingitis ( ? due to a 
combined septic infection). 
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