[Reprinted from the American Journal of Orstetrics and Diseases of 
Women and Children, Vol. XXIX., No. 4, 1894.] 
ACUTE PUERPERAL CELLULITIS 
AND 
TRUE PELVIC ABSCESS. 
BY 
CHARLES P. NOBLE, M.D., 
Philadelphia. 
It is my purpose in this communication to report my expe- 
rience with acute puerperal cellulitis and true pelvic abscess, 
collecting together in one paper the various cases which I have 
reported from time to time. The time has now come when such 
a communication will be received in a proper spirit-that is, as a 
report of conditions carefully observed at the bedside, and there- 
fore as a contribution to scientific medicine. The first whirl of 
excitement which followed the discovery of the real nature of 
chronic pelvic inflammatory troubles has passed by. Alen are 
no longer blinded by the prejudices of the era. when all pelvic 
inflammation was regarded as cellulitis. A sufficient time has 
now elapsed to enable them to recover from the reactionary 
wave, during the height of which it was believed that all pelvic 
inflammation was necessarily tubal in origin. Practitioners of 
medicine are very prone to be ruled by the dogmas of a few 
leaders in professional thought, and gynecologists are no excep- 
tion to this rule. During two generations they gave implicit 
adherence to the dogma of Nonat, Churchill, and Emmet, and 
during the present generation no less implicit adherence to that 
of Tait and his disciples. It is now time to accept all the facts 
in the case, whether or not they agree with prevailing theories. 
Ca.se I.-This patient I saw operated upon, May 8th, 1888, 
by Dr. D. Longaker, who gave me the following history: Mrs. 
F., aged 26, Illpara. She was delivered of the third child seven 
weeks ago by a natural and easy labor. On the fifth day she 
had a chill, and chills and fever continued thereafter, also great 
pain. Dr. Longaker saw her seven weeks after labor, and 
operated for a clearly defined mass situated mostly in the left 
side of the pelvis, rising up above the brim of the pelvis and 
extending from the symphysis pubis to the iliac crest. An 
exploratory celiotomy showed that both uterine appendages 
were of normal size, but were somewhat fixed by recent adhe- 2 
NOBLE I ACUTE PUERPERAL CELLULITIS 
sions. "Neither right nor left ovary nor tube formed any part 
of the mass ; these structures could be distinctly outlined apart 
from it." Fluctuation was distinct in the swelling, as made out 
by the intra-abdominal finger. A second incision was made 
above Poupart's ligament, and about half a pint of pus was 
discharged. The pus cavity was located in the left broad liga- 
ment, and extended between the uterus and bladder into the 
right broad ligament. The patient made a good recovery, but 
has borne no children since; this is probably because effectual 
means were taken thereafter) to prevent conception. 
Case 11.-This patient was seen at the Philadelphia Lying-in 
Charity during my service there as senior assistant physician. I 
am unable to find any published notes of the case. My recol- 
lection of its salient points is very clear and distinct. This 
patient was infected after labor, and after a number of days 
presented the usual evidences of suppuration, together with the 
signs of intense inflammation in the right side of the pelvis and 
in the right inguinal region. A hard mass of exudate formed 
in the right groin, which could be distinctly outlined by palpa- 
tion. There was every evidence that this was a case of true 
pelvic abscess, but, influenced by the teaching that all pelvic 
suppuration is intraperitoneal, an abdominal section was made 
by Dr. Charles Meigs Wilson, assisted by myself. The uterine 
appendages were carefully examined, and it was evident that the 
pus accumulation was entirely distinct from them and that it 
was external to the peritoneum. The abdominal incision was 
closed and the pus let out by an incision made above Poupart's 
ligament near the anterior superior spine of the ilium. This 
patient made an uninterrupted and quick recovery. 
Case III.-This case I saw in consultation with Dr. Himmel- 
wright, March 2d, 1890. The history, as given to me by Dr. 
Ilimmelwright, is as follows : The patient had a miscarriage, 
January 3d, in the second month of pregnancy. One week later 
symptoms of pelvic inflammation appeared, and a diagnosis of 
peritonitis was made. The patient got about by February 1st. 
After a week pain was felt in the right inguinal region, and 
gradually increased in intensity, extending to the lumbar region. 
After another week (February 15th) she was unable to walk 
erect and to put her foot firmly on the ground, but had to stoop 
forward. During this time the temperature remained normal 
and there were no chills. At times the pulse was slightly AND TRUE PELVIC ABSCESS. 
3 
accelerated. The pain continued to increase, and on February 
27th a swelling was noticed in the right lumbar region. March 
1st the temperature rose to 101° F. and the pulse to 120, and 
there were slight chills. March 2d I saw her. The tempera- 
ture was normal, the pulse about 90. The right inguinal region 
was tender, suggesting, indeed, appendicitis, but there were no 
symptoms to warrant the supposition. A semi-fluctuant swell- 
ing was found in the right lumbar region. The next day this 
swelling had increased, and a hard mass was felt in the right 
inguinal region, extending as high as the ribs. The swelling in 
the lumbar region was opened, and two or three pints of pus 
escaped. Introducing my index finger, it passed around the 
ilium into the iliac fossa. A rubber drainage tube was intro- 
duced and irrigated daily with a dilute solution of peroxide of 
hydrogen. This discharge gradually decreased and the tract 
rapidly healed, closing from the bottom. 
It may be asked, " Why do I claim this as a case of true pel- 
vic abscess ? " The abscess was undoubtedly situated in the 
false pelvis, on the right side. I had my finger in it. The 
entire absence of bowel symptoms excludes perityphlitis. The 
fact that, on examination, the uterus was found movable and the 
broad ligaments free from exudate (no fixation of the append- 
ages), excludes pyosalpinx. Hence, I take it, the abscess was 
due to the breaking down of an infected pelvic gland situated 
behind the peritoneum, in the right iliac region. 
Case IV.-This case was in every way similar to the first. 
I saw the patient, in consultation with Dr. Langrehr, five weeks 
after labor. 
The perineum had been torn and was sutured some hours 
after labor. Septic infection occurred, and for three weeks the 
temperature ranged between 100° F. and 103° F. During this 
time there was no pain or distention of the abdomen, or tender- 
ness of the uterine appendages, on examination. The perineal 
wound became inflamed, however, and the stitches were re- 
moved. During the fourth week all the symptoms abated. At 
the beginning of the fifth week the fever increased and ten- 
derness in the left inguinal region, became marked. Purulent 
matter had been discharged per vaginam, but whether or not it 
came from the abscess which had formed was questionable. On 
examining the patient five weeks after labor I found her much 
depressed, in a typhoid condition, with a swelling above the 4 
NOBLE I ACUTE PUERPERAL CELLULITIS 
pubes and to the left. Under chloroform a mass of exudate 
was felt in the left broad ligament, extending between the ute- 
rus and the bladder, and plainly palpable above the pubes. My 
diagnosis was true pelvic abscess. I advised median section for 
an absolute exclusion of complicating pyosalpinx ; then a second 
incision parallel with Poupart's ligament, to evacuate the abscess. 
This was done by Dr. Langrehr on the following day. The 
uterus, ovaries, and tubes were found healthy. The omentum 
was in places densely adherent. The abscess was situated with- 
in the broad ligament and extended upward behind and two 
inches above the ramus of the pubes. It contained about six 
ounces of thick pus, which was evacuated by an incision in the 
left inguinal region directly above Poupart's ligament. The 
ultimate recovery was perfect.1 
Case V.-Mrs. G.,2 aged 30, Ilpara, was delivered, January 
18th, 1893, of a living child, after a normal labor. The placenta 
was delivered by the introduction of the hand. The following 
day Mrs. G. had a temperature of 104° F. and was suffering 
much from pain in the right groin and from tympany. On the 
night of the 20th I saw her in consultation. The temperature 
was 103° F., the pulse 110, and there was marked tympany and 
much tenderness in the right groin. A striking feature in the 
case was that, although the bowels were very much distended, 
the abdominal wall itself was not very tense. The coils of dis- 
tended bowels could be very plainly observed through the abdo- 
minal wall. The bowels had not been moved for four or five 
days. The patient was put upon quinine, strychnia, and digi- 
talis, and the bowels were freely moved. Vaginal and intra- 
uterine douches of corrosive sublimate were employed, although 
the lochial How was not foul-smelling. The patient's condition 
remained very much the same until the seventh day, when the 
right broad ligament became infiltrated, so much so as to be 
plainly palpable above the brim of the pelvis in the right groin, 
while from below the anterior and right quarter of the pelvis 
was filled with exudate closely attached to the pelvic wall and 
displacing the cervix backward into the hollow of the sacrum. 
This exudate began to disappear about the fourteenth day, and 
was absorbed very rapidly.' Convalescence was further inter- 
1 The first four cases have been reported in the Medical News of August 
29th, 1891. 
2 Annals of Gynecology and Pediatry, June, 1893. AND TRUE PELVIC ABSCESS. 
5 
rupted by a nephritis, possibly of septic origin, and also by 
severe intestinal pain accompanied by diarrhea, presumably due 
to inflammation of the large bowel. This patient was seen in 
consultation by Drs. Goodell and Parish. She eventually made 
a good recovery. 
Case VI.-Mrs. H., aged 28, Ilpara, was delivered of her 
second child in March, 1891, the labor being conducted by a 
midwife. She was infected and was extremely ill. I saw her 
with Dr. Leopold five weeks after the labor. At that time she 
was prostrated, with a rapid pulse, " leaky " skin, chills, irregular 
temperature-in fact, the classical symptoms of septic intoxica- 
tion. 
On examination the right broad ligament was found indurated 
and a mass of exudate extending on the right side of the abdo- 
men almost as high as the umbilicus. From the extent of the 
mass it was supposed that a right pyosalpinx with an intraperi- 
toneal abscess existed ; but in view of the puerperal history and 
the existence of a cervical laceration, the possibility of a true 
pelvic abscess was discussed. A median abdominal incision was 
made April 16th, and the abdominal viscera in the lower right 
quarter of the abdomen were found fused by adhesions. The pa- 
tient took ether so badly, becoming cyanosed while still partly 
conscious, and the pulse was so w'eak, that I and the gentlemen 
present were convinced that to attempt the separation of the 
adhesions and the evacuation of the pus from above would 
result in her death on the table from ether. An unsuccessful 
attempt was made to reach the pus by an incision made near the 
anterior superior spine of the ilium without giving more ether. 
The exploration was not pushed, owing to the patient's bad con- 
dition. The patient was then put to bed, and improved for 
some days. Operation was again proposed, and chloroform 
selected as the anesthetic, which produced as much cyanosis as 
ether had done. An incision was now made directly over the 
broad ligament, the uterus was located, and the index finger was 
forced into the broad ligament, evacuating several ounces of 
pus. With rubber drainage a satisfactory convalescence fol- 
lowed. 
October 27th, 1892, I operated on Mrs. H, to cure a ventral 
hernia which had formed at the site of the third incision. On 
opening the abdomen I was surprised to find that the adhesions 
throughout the right side of the abdomen, which had been uni- 6 
NOBLE : ACUTE PUERPERAL CELLULITIS 
versal eighteen months before, had disappeared, except a point 
of adhesion between the omentum and hernial sac, and another 
between the omentum and broad ligament. Both appendages 
were perfectly healthy. This fact demonstrates what was be- 
lieved when the pus was evacuated-namely, that it was not a 
pyosalpinx, but an abscess of the broad ligament. 
The disappearance of the very extensive adhesions in this 
case is worthy of record as showing that peritoneal adhesions 
are not necessarily permanent. 
It is of interest to report that during the summer of 1893 
this patient was delivered of a living child after a normal labor, 
and that she is at present in good health.1 
Case VII.-Mrs. F., aged 18, was confined Mav 8th, 1893. 
She had a mild puerperal sepsis and was in bed for two weeks. 
The following month she was constantly sick, being in and out 
of bed, suffering with pelvic pain, anorexia, and having more or 
less fever. (The temperature and pulse I do not know, as I was 
not in attendance.) She came under my care six weeks after 
her confinement, and was admitted to the Kensington Hospital 
for Women. Examination showed a large inflammatory mass 
in the pelvis, absolutely anchored to the left pelvic wall. She 
was under observation for two weeks, with the temperature fluc- 
tuating between 99° and 102° F., with the general evidences of 
mild septic absorption, such as anorexia, sweats, chilly sensa- 
tions, and increased pulse rate. 
Believing that pus was present in the pelvis, either in the 
form of a true pelvic abscess or a pyosalpinx, an abdominal sec- 
tion was made on June 26th, 1893. The following conditions 
were found : The uterus was fairly well involuted, and was dis- 
placed upward and backward by a mass in the left broad liga- 
ment. The right broad ligament and the right Fallopian tube 
and ovary were entirely normal, as was demonstrated not only 
by touch, but by delivering the ovary and tube through the ab- 
dominal incision. The omentum was adherent to the anterior 
face and upper border of the left broad ligament in front of the 
Fallopian tube. This adhesion was separated. The left ovary 
and tube were found to be entirely normal, the mesosalpinx 
being normal, soft, and movable. This was demonstrated not 
only by touch but by vision, the woman being in the Trende- 
lenburg posture, so that the entire left side of the pelvis was in 
1 Reported in Annals of Gynecology and Pediatry, June, 1893. AND TRUE PELVIC ABSCESS. 
7 
plain view. The left broad ligament was very much infiltrated 
with inflammatory material, and firmly anchored to the anterior 
and left bony wall of the pelvis. Fluctuation was not apparent. 
It was determined to close the abdomen, and, if septic symptoms 
persisted, to open the broad ligament from below. That portion 
of the omentum which was adherent to the broad ligament was 
ligated and cut off. A small gauze drain was placed against the 
broad ligament where the omentum had been separated, so that 
should pus make its appearance at this point it would find its 
way out through the abdominal incision. 
The patient's convalescence was uninterrupted ; the tempera- 
ture rapidly dropped to the normal, and her general condition 
steadily improved. The gauze drain wras removed, good union 
of the abdominal incision was obtained, and the patient was dis- 
charged from the hospital at the end of four weeks. In the 
meantime not only had her general condition very much im- 
proved, but the pelvic mass had almost disappeared. 
This patient consulted me January 9th, 1894, to ascertain the 
cause of a suppression of menstruation of three months. I found 
her to be between three and four months pregnant. A careful 
examination of the left broad ligament failed to discover any 
evidence of the former cellulitis, the left broad ligament feeling 
exactly like the right one. 
The evidence of the existence of acute puerperal cellulitis as 
a primary condition in this case is absolute. There was not even 
a complicating pelvic peritonitis, in the ordinary sense of that 
term, merely a point of adhesion between the omentum and the 
broad ligament, which was, of course, due to a small, circum- 
scribed area of peritonitis. I was able to demonstrate these con- 
ditions to a number of physicians who were present, including 
among others Dr. Fullerton, of the Woman's Hospital. 
What I wish especially to insist upon is that in this case 
neither Fallopian tube was involved in the inflammatory process, 
that both were entirely normal. The left Fallopian tube and 
its mesentery were scarcely even congested. The circumscribed 
area of peritonitis where the omentum was adherent to the 
broad ligament was plainly due to the fact that the inflamma- 
tion had extended directly through the broad ligament to the 
peritoneum, leading to the adhesion of the omentum. That 
this is possible has been denied by those who maintain that all 
pelvic inflammation is due to infection which has spread through 8 
NOBLE : ACUTE PUERPERAL CELLULITIS 
the Fallopian tubes. In this case the conditions present were 
unmistakable. 
We thus have seven cases, in all of which, except the third 
and fifth, an abdominal section was made, so that we have the 
evidence not only of the usual physical examination, but also 
that obtained from an intraperitoneal examination. In Cases 1, 
2, 4. and 7 the abdomen was opened and the uterine appendages 
were examined, and it was demonstrated that they were either 
free from disease, or, at the most, lightly attached by recent 
adhesions. In these four cases there is not a shadow of doubt 
that the disease was in the broad ligament, and that it spread to 
the broad ligament directly from the uterus or vagina by way of 
the lymphatics. 
Case 6 was undoubtedly not a case of pyosalpinx, and I have 
no question myself that the pus was located in the broad liga- 
ment. A carping critic might affirm that, even although it was 
not a pus tube, the pus was intra- and not extraperitoneal, and 
that it was due to suppurative peritonitis. My opinion that the 
pus was in the broad ligament is based upon the fact that the 
pelvic exudate was anchored to the anterior and right pelvic 
walls, and that when I cut down upon the mass I recognized 
the uterus and tore through the broad ligament with my finger 
in front of the Fallopian tube. 
The evidence in Cases 3 and 5 is not so absolute as in the 
others, and they are included in this list, not for the sake of 
demonstrating the occurrence of puerperal cellulitis, as is done 
by the other cases, but because of their relative bearing upon the 
subject. 
The foregoing cases demonstrate several interesting facts with 
reference to obstetrics and gynecology : 
1. That in the puerperal state pelvic cellulitis and true pelvic 
abscess occur as the result of septic inflammation. 
2. That inflammation may spread from the vagina or uterus 
along the pelvic lymphatics to the broad ligaments without 
involving the Fallopian tubes. 
3. That peritonitis can be set up by the spread of inflamma- 
tion from the broad ligaments to the peritoneum without involve- 
ment of the Fallopian tubes. 
4. That very extensive pelvic exudate and intraperitoneal 
adhesions can be absorbed. 
It hardly seems worth while to bring evidence to bear in AND TRUE PELVIC ABSCESS. 
9 
support of our first proposition, and it would not be called for, 
were it not that a few men of wide experience maintain the 
contrary. Being able to present absolute evidence in the shape 
of carefully and thoroughly observed cases occurring in my own 
practice, I shall not take the time or trouble to make references 
to the literature. 
What I have said concerning proposition 1 is equally true 
of proposition 2, which is distinctly proven by certain of the 
foregoing cases. Case 7 is a beautiful illustration of the fact 
that a very extensive puerperal cellulitis can be present and yet 
the Fallopian tubes be entirely healthy. In this case they were 
scarcely, if at all, congested, and the mesosalpinx was entirely 
free from infiltration. 
The third proposition is likewise proven, especially by Cases 7 
and 4. In both of these cases the omentum was adherent to the 
broad ligament, although the tubes were free from disease. I 
have no doubt that pelvic peritonitis is usually due to the spread 
of inflammation from the endometrium through the Fallopian 
tubes to the peritoneum, but these cases show that this rule is 
not without exceptions. Numerous other exceptions have come 
under my observation. For instance, a short time ago I did a 
hysterectomy for a fibroid tumor, in which the tumor, being 
impacted in the pelvis, was adherent to the rectum and poste- 
rior pelvic wall, over an area of at least nine square inches, and 
yet in that case the Fallopian tubes were entirely normal. In 
several cases of appendicitis I have found the peritonitis to 
extend to the pelvis, the Fallopian tubes having nothing to do 
with its occurrence. Moreover, it is a well-known fact that 
when small tumors, especially dermoids, become wedged in the 
pelvis or become twisted upon their pedicles, peritonitis ensues; 
likewise, that in cases of malignant disease of the abdominal 
or pelvic organs adhesions are almost always present. There- 
fore it must be admitted that pelvic peritonitis can occur inde- 
pendently of salpingitis. 
Case 6 demonstrates our fourth proposition. In that case the 
entire right lower quarter of the abdomen was fused together 
by recent peritoneal exudate, and light adhesions had formed in 
the left half of the pelvis; yet, eighteen months later, when the 
abdomen was reopened, the entire mass of adhesions had been 
absorbed, with the exception of a small point between the omen- 
tum and right broad ligament and another small point between 10 
NOBLE C ACUTE PUEPERAL CELLULITIS AND PELVIC ABSCESS. 
the omentum and the hernial sac. Owing to the very extensive 
character of the adhesions in this case, it is a striking example 
of the fact that recent adhesions can be entirely absorbed. 
Two women of the seven whose cases have been detailed in 
this report have been delivered of living children since their 
recovery from the attack of acute puerperal pelvic cellulitis. 
The subsequent history of four of the other five women is un- 
known to me. The fact that two of these women have borne 
children is of interest, because of its bearing upon the question 
of the relation of pelvic exudates to sterility. As this paper has 
dealt only with demonstrated facts, I shall merely suggest that 
the occurrence of pregnancy after the existence of extensive 
exudates forming during the puerperal state, is best explained 
in many cases by the fact that the condition present is a puer- 
peral cellulitis rather than a diseased tube. It is a severe tax 
upon my credulity to accept the statement that extensively dis- 
eased tubes, more especially pus tubes, can so far recover as to 
permit the occurrence of pregnancy, and I believe that the true 
explanation in not a few cases of pregnancy following the 
recovery from puerperal pelvic inflammation is that the disease 
was originally in the broad ligament and not in the Fallopian 
tube. 
In conclusion, I wish to say a few words concerning the rela- 
tive frequency of acute puerperal cellulitis and inflammation of 
the Fallopian tubes. I believe as firmly as any one that pelvic 
cellulitis and true pelvic abscess are comparatively rare con- 
ditions, and that the usual variety of pelvic inflammation is a 
salpingo-peritonitis. I have not met with pelvic cellulitis except 
in the puerperal state, and have no reason to believe that it 
occurs except as a result of infected wounds of the vagina and 
perineum. As such conditions are very infrequent, a pelvic cel- 
lulitis in the non-puerperal state would be a surgical curiosity. 
I have added these remarks lest it might be inferred by the 
unthinking that I am desirous of supporting the old and aban- 
doned theory of Nonat and Emmet concerning pelvic inflam- 
mation. At the same time I am glad to be able to present 
incontestable proofs of the occasional occurrence of acute puer- 
peral pelvic cellulitis and true pelvic abscess. 
2134 Hancock street.