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 s.^.. 
 
 THE PELVIC VISCERA IN RELATION TO MICRO- 
 ORGANISMS IN HEALTH AND DISEASE. 
 
 BY 
 
 J. C. WEBSTER, M.D., F.R.C.P.E., F.RS.E. 
 
 Demonstrator of Gynivcology, Mi-Oill University ; Assistant (JyniccoloKist to tha 
 Royal Victoria Hospital, Montreal. 
 
 {Reprinted from the Montreal Medical Journal, Axigmt, 1897.) 
 
 r 1 .'' 
 
 
THE PELVIC VISCERA IN RELATION TO MICRO-ORGAN- 
 ISMS IN HEALTH AND DISEASE. 
 
 BY 
 
 J. C. Weuhtkr, M.D., F.R.C.RE., F.R.S.K., 
 
 Demonstrator of GyniecoloKy, McGlll University; Assistant Gyniecolo(j,ist to the 
 
 Royal Victoria Hospital, Montreal. 
 
 The bacteriology of the genital tract in various normal conditions : 
 
 la the Mew-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 vveeks gelatine-liquefying germs are I'arely found. 
 
 In Girls and Women various bacilli and cocci may be found in the 
 vagina, as well as sarcinas, yeast fungus, eta One of these germs is 
 very connnou and is called Doderlein's vaginal bacillus. The patho- 
 genic organisms flourish best when the vaginal secretion is alkaline ; 
 in acid conditions thej* are weakened in vital itj- 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 16 days after the operation the vaginal 
 secretion was carefully removed and alkaline agar plates innoculated. 
 In 62 cases the plates remained absolutely sterile. It was different, 
 however, with specimens taken from the vulva for 06 of these gave 
 I'ise to growths on the agar, only 4 being sterile. Of the 8 cases in 
 wnich 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 thr; same 
 cases only 3 cultures were obtained on alkaline plates. (These few 
 experiments are not, however, of particular value, for pathogenic 
 geiins without exception develop in alkaline media and not in acid 
 media.) 
 
s 
 
 In another series of oxporlmonts, 12 in nuniher, lio used ^rape- 
 sugar agar and obtained cultures 11 times, thus demonstrating the 
 frequency of non-pathogenic anaerobic g' rms in the vagina. 
 
 Doderlein 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 ulka- 
 line or acid is bactericidal to these organisms and he believes that the 
 acid secretion of Doderlein'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 innocuhited it with staphj'lococci. 
 The latter were soon destroye<l. If the secretion were previously 
 sterilised with steam the stapliylococci 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 investifjator : 
 
 1. The antagonism between the normal vaginal Ijacilli 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 eflfects 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 
 
8 
 
 from inriuinniatory areas, e. g., gonorrhea in the cervix, or by the 
 addition of solid organic debris. 
 
 Secretions poured into the vagina from intlanunatory conditions in 
 tlie uterus weaken the power of the vaginal secretion. In 10 cases 
 in which there was gonorrhteal intlamniation in the uterus, the 
 vaginal secretion c()ntaine<l numerous streptococci. If the vagina in 
 these cases were completely ilisinfected with strong antiseptics e. g., 
 carbolic acid, Ij'sol, 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 infiuence. He innoculated the 
 cervical can<),l with streptococci and staphylococci in 15 cases and 
 within 12 hours found the cervical mucus sterile. 
 
 The normal tuhe 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. 
 
 A,s regdvdn the infiued'^e of Mendriiatiov. — Jacobs and others.state 
 that the vaginal organisms are increased during the period of the 
 riow owing to the diminution in the acidity of the normal vaginal 
 secretion as a result cf the entrance of the blood. Strocranotf' ex- 
 amined the cervix durmg 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 l)y 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 li()uefy 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. 
 
 Sti'oganott" also found various microbes in the vaginal secretion, but 
 none of theuj would liquefy gelatine by their growth. 
 
 In the I'uerpeviiini, the use of antiseptic solutions in the vagina 
 
after labour is bei.ig i.jscarilod by many aufcliorlties, save where 
 dij^ital examination has been carried out, where labour is abnormal, 
 or where operations have been performed ; and in cas(!8 where the 
 patient may be depressed in health from various causes, c.r/, , nephritis, 
 heart ilisease, syphilis, anjemia, etc. 
 
 If, however, there be any inHanunatory condition in the cervix, 
 vagina or vulva (especially if of a possible gonorrho'al 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 .4,7^, Stroganoff finds various microbes in the vagina, n^a.stiy 
 rod-shaped, and smaller, on the whole, than those found duri.ig the 
 period of sexual life. 
 
 The vaginal secretion is only faintly aci<l ; 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 n)ay 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 n(>cessary to specify 
 these ; the germ which is of chief importance as an infective agency 
 is the bacterium coli commune. 
 
 Relaticn 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 ser' 3S of phenomena caused by 
 nature's resistance to the noxious influenciof the infecting organisms. 
 These processes are, therefore, not evil in themselves, but are bene- 
 
ficoMt and purpoaeful. The most important germs which lu-t as 
 intectiiifi; agents are : 
 
 Streptococcus pyogenes (most frequent source of trouble). 
 
 8taphyh)coccus 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 pneumonijB. 
 
 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 conflitions which favour their entrance are a favourable soil, 
 e. g., a raw surface, a tissue of impaired vitality, a general condition 
 of l)ad 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. ,7., 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 
 gei'm-development in a favourable medium lying within the genital 
 cunal. 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-acti<jn and various other 
 factors which have long been regarded as causal in the production of 
 pelvic intiammation 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 adflition t>f alkaline blood, more suitable for the growth of patlio- 
 genie germs which might enter the vagina, and making it more easy 
 for them to spread into the upper genital tract and attack the tissues. 
 
 I 
 
It is poa.Hil)Ie, also, tliat such iiiflnonct's as chill nnd fati^iio. by diiiiin- 
 ishirij,' the rcsiMtiii^ jxtwcr of the tissut's, reTi<K'r them iiiore siisccptilili' 
 to thu action of gfrnis. 
 
 ExcoHsiv(> coitus, especially at inenstruatioii, is said to lead to 
 iiiflaiiiniatory changes, espt cially in the uterus. There is, however, no 
 proof that the mere physical excitement can induce these. Most 
 likely it retpiirea 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 naturi! of 
 the vaginal secretion favouring the development of micro-organismal 
 growth. 
 
 In some of these cases, in which the inflammation is supposed to be 
 due to coitus, gonorrhd'a is the infecting agent ; either an acute 
 gonorrhoea existing in the man or a latent gonorrho'a in the man or 
 woman. In the former of these the virulent trerm attacks the woman 
 directly, its infectivity being unaffected by the action f)f coitus ; in the 
 latter the latent condition is stirred into a rentiwal of activity as a 
 result of the irritation and excitement of the excessive coitus. 
 
 The Influence of La hour has long been regarded as tnost important 
 among the factors causing pelvic inflammaticms. 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 lead to iiiflf^uimation, vi?.,tQQ eq/riy rising, w<ilking or working. It 
 
 I 
 
is very doulttful, howovor, if tlioso itifliUMices can Itring alxmt inctritlH 
 in tilt' utiTUs directly. 'I'licy act undou^tiMlly mainly by inipairinjif 
 till- vitality of the tissues and thus favouring infection It^ j^enns. It 
 is very noticealticf that these conditions are, in many instanctss followed 
 by no disturbance whatever. Ainonj^ the labouring classes may be 
 found a larg(! nundjer 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 al.so lead to condi- 
 tions which favour microbial infection, c. .9., bruises, tears, cuts ; the 
 irritaticm of a pes.sary 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 depre.ssing 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 sai«l here, since these 
 matters are fully discussed in works on bacteriology and surgery. 
 
 Different tissues are afiected, difl'erent reactions brought about and 
 different results proiluced. 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 N(fggerath published his first paper in 1872, on 
 the relation of gonorrluea to pelvic disease, an immense amount of 
 attention has been directed to this subject. In Great jBritain, Sinclair, 
 and in Germany, Sanger have been among the most prominent of those 
 who believe in the profound importance of this relationsnip. Gon- 
 orrluva may affect the pelvic soft parts in different conditions. 
 
 Acute Gonorrhijeal 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 Bumm'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 \vas based upon a 
 number of experiments of the following nature. Active gonococci 
 were placed in contact witb the vaginal walls for 12 hours, no vagini' 
 
 I 
 
8 
 
 tis being set up. He also excised a portion of the wall in a bad case 
 of iroiiorrlxva and failed to lind fjonococci in it. He believed that the 
 swelling and tenderness of tlie vagina, so often found in acute gon- 
 orrhoea, were due to the irritation of the discharge flowing down 
 from the cervix. 
 
 Schwarz, Touton, Dinkier and others have stronglj' opposed 
 Bumni's views and, more recently, he has n»odifled them, stating that 
 occasionally in the adult a true gonorrheal vaginitis may occur in 
 acute cases t^ 'igh not in chronic cases, e. g., when the mucosa is in a 
 delicate cond. .on 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 thi'ce cases (aged 21, 21 and 24 respect- 
 ively) of acute gonorrhoea and examined them with great care. In 
 some parts the epithelium was veiy thin in its inner layers, here and 
 there, the papillfe 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 connective-tissue, being most 
 deeply placed where the epithelium was thiimest. 
 
 In one of these ca.«es 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- 
 rh(eal vaginitis after extirpation of the uterus and appe'.idages. 
 
 Mandl believes, therefore, that there can be no doubt as to the 
 development of a .specific gonorrlid'al vaginitis, though I'lere 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 vulvo-vaginal jtarfs at the .saiue time. Sometimes, the former 
 may be at fli'st aflecteil ; soiitetiiiies, the infection iiiav attack — 
 
 7 
 
\ 
 
 I 
 11 
 
 I 
 
 lower structures antl 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. Ic may also affect, in some cases, the bladder, 
 ureters and kidneys. It may spread to the Bartholinian glands. 
 
 Latent or Chronic Gonorrfuen in the Female. — After the signs and 
 symptoms of an acute infection have passed aviray 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 iuflanniiatory conditions. It i.s, howtjver, very diflieult to 
 eliminate the influence of the pathogenic germs, as they can, in these 
 cases, so easily gain access to the gland. 
 
10 
 
 As regards the uterus, there seems Httle doubt that inflammation 
 may be set up in it V)y tlie action of the fronococcus, though as to the 
 frequency with wiiich 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 And 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 proportipn 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 afiect a considerable 
 area. It may be that in chronic conditions a few foci in the tissues 
 may serve to diff'use 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. 
 
 It is interesting to note the results of JMenge's exau]inations o^ 
 
11 
 
 fllsoaserl tubas. In 30 cases of hydrosalpinx and 3 of lupinato-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 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 ire absolutely sterile. 
 
 Kiefer states that genen^ily 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 gonorrhtieal pus escaped into the peritoneal 
 cavity without any 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, th(( tubercle bacillus in 2, and streptococci in 1 ; the 
 other three cases being sterile. Kiefer found the bacterium coli in 
 several ca.ses. 
 
 Sanger has laid great stress upon the marked liability of pregnant 
 and puerperal women to contract acute gonorrhcual infection and, 
 also, on the tendency towards the development, in these conditions, of 
 an acute exacerbation of what was once previously a slight intlam- 
 niatory process. Thus, a latont condition may develop into an acute 
 outbreak in pregnancy or the puerperiu.'n 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 gonorrhceal 
 trouble, without any freshly acquired infection. 
 
 It must, however, be romembered that similar phenomena may be 
 produced by the action of septic organisms which And 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 refei-red to by Sanger are of this nature. 
 
 Latent Gonorrhoia 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 gonorrha-a have passed awaj'. This power resides in a discharge 
 produced by the remains of the original gonorrhioal infection, and is 
 probably limited to the crypts of the mucous membrane. Tlie 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 
 describ(>d 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 aftbrd a suitable medium for streptococci or other 
 infective germs, which may spi-oarl iijiwards and lead to the various 
 disturltanccs which 1 have described. Very often a perfectly healthy 
 woman may be infected as a result of this latent gonorrli(i;al condir 
 
18 
 
 tion in the male, the most distressing pelvic troubles developing sooh 
 afterwards. 
 
 Gonorrheal infection of the mucosa of the rectum may follow 
 innnediately 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 descrioed 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 Vignal 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 diflTerences 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 thr; 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 varyiiip^ 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 tbc peritoneum. It is also accentuntiKl, 
 as Laruelle lias point(!(l out, if the intestinal secretion \n> present, even 
 thouf^h the latter be artificially sterilised. This germ is generally the 
 cause of peritonitis in hernial .sacs, in obstruction and 8tran;5uliition, 
 in appendicitis ca.ses and other intestinal ccndition;.. 
 
 Freshly filtered Huiil from the normal L.twel intnxluciMl i ito the 
 peritoneum generally .sets up peritonitis. The cau.se 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 al)sorption of the toxins in it. 
 
 The bad effect of fasces when introduced into the peritoneal cavity 
 is due to the presence of microbes, especially the bacterium coii, in it. 
 If sterilised fteces be introduced no bad I'esult 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 inflannnation is related, not 
 to infection from the uterus in the great majority of cases, but from 
 the rectum. 
 
 The oviirstretching of the rectum from constipation, so conmion in 
 women, the continual soaking of the wall in this state with toxic 
 matters in the bowel-contents, the occasional occurx'ence 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 BaciUun. — Tubei'culosis in the genital tract may be set up 
 in a variety of ways. 
 
 1. It may be primary, i. <?., the bacilli may enter from the outsid(> 
 by way of the vagina, being introduced V>y dirty instruments, liy 
 examining fingers, by sleeping with a tubercular per.son, 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 b^' the direct spread 
 from neighbouring tuberculous areas, e. g., tuberculosis of bladder or 
 bowel ; ulcers may perforate or abscesses burst leading to fistulous 
 communications. 
 
1» 
 
 W. Willimns states that one of the most frequent sources of genital 
 tubc'rcuh)sis is tubercular peritonitis. Weigert has shown that in this 
 disease tlxe i)acilli which become free in the peritoneal cavity tend to 
 sink into the pelvis settinjf up infection ; they are there in the best 
 position to b" swept towards and into the tubes and they nuiy 
 undoubtedly be carried into the tubes setting up disease without 
 infecting th« pouch of ])i)V glas at all. 
 
 3. The bacilli may be introduced directly into the vagina when 
 the patient has tuberculosis in some other region, e. ff., urinary tract, 
 intestines, lungs, the infection spreading from tKe discharges. 
 
 Kegar has pointed out that genital tuberculosis is rare in childhood 
 and after tl\e climactei-ic. 
 
 Infection by men suffering from genito-urinary tuberculosis is of 
 considerable int<!rest. 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 truinea-pig which had died of tuberculosis with salt 
 solution and injected the mixture into the peritoneal cavity of 15 
 fminea-pio-s ; 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 lound thorn afterwards in the semen of the animal. 
 
 Rohlfi", 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 r(;sult ; 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 vas 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. (Jartner believes that they are very scanty 
 in ih'i semen in such case.--. He injected tubercle bacilli in the trachea 
 and luni(s ol" male fruiiiea-pigs, setting; up inaction, and after three or 
 fcmr days obtained si-men from their tei^tieles. In .'{!2 cases, he found 
 tubercle '"icilli only in five, and the semen in thesu few instances, 
 when intruuiiced int») the peritoneum of other animals, set up only a 
 mild form of tulierculosis. 
 
 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 fiom the.so cases, severe tuberculosis 
 was set up. (Jartner, therefore, lielievt-s that yeiiital tuberculosis in 
 the male is a very much more serious danj^er for the female than 
 di.stant 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 ndxed gonorrlujeal and tubercular infection may take 
 place. Pyosalpinx may develop in tubercular .salpingitis ( ? due to a 
 combined septic infection). 
 
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 Barbiicci, Central, f. Path, u Path. Aiiat., Ot-t. 12, 1803. 
 
 Buiiiin, Der MieroorKftiiisiiuis d. Goiiorrhoihclu'ii Sc'hleiii)iiiuti'rkrankunKeii 
 Wii'.sl)ii(len, ls!)5, I'Iht d. TrippiTaiisteckuiit.; hehn Wcihlichi'ii Geschleetu 
 und ilire Fijl;j;eii, Miiiich. Medic. Wucheii.sclir., 1S91, Nr. ."lO, 'A. 
 
 Deiville, These. Paris, 1S87. 
 
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 Mafucci, Ceiitrnll)latt f. All«. Path. u. Path. Aiiat., 1891. 
 Mendl, Monatschrift f. Gelj. n. (Jyii., 1897, Vol. V , Hft. 1. 
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 Nd'gerri'th, Die latent Gonorrl'ue u. Weil)lichen Geshlecht., Bonn, 1872. 
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 S.iiiKcr, Die Tripperansti'ckunj; l)ieni weiblich Geshlechl. Leipsig, 1889. 
 Schwartz, Volkniann's SaniniluiiK Klin. \'(itrii}.;e, iNo. 279. 
 Sinclair, Gonorrlxeal Infection in Women, London, Lewis, 1888. 
 Spano, Gazette degli ospitali, 1893 
 
 StroKaiiotr, Monatschr. f.Geb. u. Gyn., Md. II., Centr.albl. f. Gyn., 1893, 1895. 
 Tavel u. Lanz, IJeli t die -Etiolofiiied. Peritonitis, Basel, 1893. 
 Tonton, berlin Klin. Woe ensclir., 1894. 
 Treves, Peritoniiis, London, Bale & Sons, 1894. 
 Walther, B!itrii<?ez. l^ati. Anat. u. All^. Path., Bd. 16, 1894. 
 Westermeyer, Inaug. Diss. Erlangen, 1»93. 
 Williams, Tuberculosis of the Female Generative Organs. 
 Zeigler, P., Ueber die intest. Form d. Peritonitis, Munch, 1893.