INFECTION AFTER ABDOMINAL OPERATIONS, AND ITS 
TREATMENT 
HUNTER ftOBB, M. D. 
Professor of Gynecology, Western Reserve University, Gynecologist to Lakeside 
Hospital, Cleveland 
IT is a well-recognized fact that the honest student in any subject often 
learns less from his successes than from his mistakes. Among the 
many benefits which the science of bacteriology has given to us is to 
be reckoned the power of determining definitely the true nature of certain 
processes which, during the life of the patient, were hidden from, and mis- 
taken by, the clinician, and which formerly escaped the notice even of the 
most painstaking and careful pathologist. 
Among these conditions are those which are the result of a septic infec- 
tion which has not given rise to the characteristic symptoms of septicemia 
and in which death has often been regarded as having been due to shock, 
pneumonia, heart-failure, suppression of urine or some more or less intangi- 
ble cause. This vagueness is now, thanks to the bacteriologist, becoming 
rarer every day; and if his decisions are not always conducive to the mainte- 
nance of the self-satisfaction of the operator, nevertheless they are to be 
received with submission, ana the lessons taught by them should be taken 
to heart, in order that no avenue of danger may remain unguarded, and no 
time may be lost in rectifying, as far as possible, any untoward condition 
which directly or indirectly may have resulted from some perhaps unavoid- 
able imperfection in our operative procedures. 
Autopsies are on record at which none of the local lesions which attend 
septic inflammation were demonstrable to the naked eye. The examination 
of coverslips, however, made from a small amount of fluid in the pelvic cavity, 
has shown that organisms were present in large numbers, and culture tubes 
inoculated with the same fluid gave the characteristic growths. Experiments 
have shown that the poisoning resulting from a peritoneal infection is some- 
times so intense as to cause death before the appearance of any marked local 
reaction in the peritoneum itself. In the fatal cases in which it has been 
Head before the Cleveland Medical Society June 10, - impossible to secure a complete autopsy, even in which during life the ordi- 
nary symptoms of such a condition were absent, we have not the right to 
state positively that death was not due to septic infection. 
One frequently reads in the literature reports of patients dying of intest- 
inal obstruction or intestinal paresis following abdominal operations. The ob- 
struction in the great majority of cases was not present before the operation, 
and if such a condition follows immediately afterwards or within several 
weeks of the operation, we cannot feel sure that the condition has not occurr- 
ed as the result of an infective agent, introduced or set free at the time of oper- 
ation, without having excluded this by a careful microscopic examination of 
the exudate. 
But, besides serving as a means of correcting our errors and making 
us even more careful in our operative technic, it seems to me that the fact that 
such untoward symptoms are not infrequently associated with the presence 
of septic infection affords us valuable indications for treatment. My recent 
experience certainly has led me to the opinion that in many cases, in which the 
patient, after operation, does not progress satisfactorily, the abdomen should 
be reopened and irrigation should be freely employed. 
Occasionally we can accomplish all that is necessary by opening the 
vagina behind the cervix, separating adhesions and washing out the lower 
portion of the pelvis with salt-solution and afterwards employing a gauze 
drain. In most cases I prefer, however, to employ the abdominal route, 
since I believe that in this way it is possible to separate adhesions to much 
better advantage, while at the same time one can sponge out any fluid or other 
material that may have accumulated in the pelvis and carry out irrigation to 
better advantage. 
It has therefore become my custom whenever a patient complains pf fre- 
quent attacks of pain in the abdomen or of pain that is more or less persistent, 
with or without marked distention, throughout convalescence, or even when 
these symptoms begin after the patient seems to all practical purposes to have 
recovered from the operation, to try for a short time the measures that are 
ordinarily carried out for the relief of such conditions, and then if improve- 
ment does not speedily take place, to reopen the lower angle of the incision, 
gently separate adhesions, freely irrigate the pelvis with sterile normal salt 
solution and finally introduce a piece of gauze for drainage. 
Even in some instances in which the temperature is practically normal and the pulse not over 90 and no vomiting is present, but in which the ab- 
dominal pain persists or is so marked that it requires the use of morphin to 
relieve it, I believe that we should irrigate and drain as soon as possible, par- 
ticularly in the case of those patients who cause us anxiety by seeming better 
one day and worse on the next. When the abdomen becomes distended from 
the very first and when the bowels are not relieved by the usual methods, and 
the patient is surely getting weak or ndt improving, I do not think that we 
should waste any time before reopening the incision and washing out the 
pelvis thoroughly. Even in those cases which have already been drained, 
if the temperature and pulse become much increased,even though we may 
not have vomiting and distention to contend with, I believe we should wash 
out and establish our drainage afresh. The drainage-tube or the gauze drain 
may not suceed in carrying off the material which is producing the symptoms 
and yet in such cases we may succeed in washing it away by irrigation. Even 
in the most desperate cases thorough irrigation and drainage can never do 
harm and the good results which may follow the procedure are sometimes 
simply astonishing. The secondary operation will not, in the majority of 
cases, shock the patient to any extent as all the necessary measures can be 
carried out while she is in bed. The lower angle of the wound should be re- 
opened, a two-way catheter carried down to the lower portion of the pelvis 
and irrigation with sterile normal salt-solution can then be carried out. 
In cases in which the symptoms are not so urgent, that is, when the pulse 
is not over 120, I do not hesitate to give the patient a small amount of ether 
in the operating-room, and then thoroughly explore the pelvic cavity through 
the line of incision, in order to let out any fluid that may have accumlated. At 
the same time any adhesions that may be binding down some portion of the 
intestine are generally separated. After this I irrigate with large quantities 
of sterile salt-solution and introduce gauze drainage. 
The following cases will be of interest in demonstrating the conditions 
met with and the treatment that was carried out in the individual cases. 
Case I—Porro-Cesarean Operatioyi for Large Interstitial Myoma Obstructing 
the Pelvic Canal 
On the third day the pulse rose to 125 to the minute and the temperature 
to 102° F. There was at the same time some slight abdominal distention. 
The bowels were thoroughly well opened. The pulse increased in frequency 
to 140 and ranged between this and 160. The temperature by the mouth was 102.5° F. Seeing that the patient was assuredly getting worse, I determined 
to open the lower angle of the incision and to irrigate the pelvis and institute 
drainage. This I did on the evening of the fourth day without anesthesia 
while the patient was in bed. On opening the lower angle of the wound a 
small amount of bloody fluid escaped. The pelvis was then thoroughly irri- 
gated with salt-solution and a strip of gauze was introduced into the cavity 
of the pelvis. The pulse after this gradually decreased and the temperature 
also came down somewhat. The pelvis was irrigated daily for two weeks 
with Thiersch’s solution and a fresh strip of gauze reapplied each time. The 
patient’s general condition improved but the pulse remained at or above 120 
most of the time. Two weeks after this the pulse increased to 140 and the 
temperature ranged between 102.5° and 104° F. Having decided that we 
had not sufficient drainage I made a thorough opening through the posterior 
vaginal vault and thus established a communication with the opening from 
above. This was done with the patient under an anesthetic and although she 
remained in a critical condition for about 12 hours after this procedure she 
then began to steadily improve; the temperature and pulse soon became nor- 
mal and the patient made a thorough convalescence and is now perfectly well. 
In this case we had in all probability to deal with a localized septic infection 
which had not progressed to the formation of pus. We made many cover- 
slip examinations from the secretion in the pelvis, and also inoculated agar- 
agar tubes and only on one occasion were we able to demonstrate the pre- 
sence of the staphylococcus pyogenes aureus. It seems justifiable to assume 
that this woman would have succumbed to the septic infection had we not 
opened the abdomen early and thus reduced the amount of toxic material that 
was being absorbed. The opening through the vagina undoubtedly allowed 
of a more thorough escape of the pent-up inflammatory material. 
Case II—Double Salpingo-Opohorectomy for Interstitial Myoma of the Uterus 
The tumor was about the size of a child’s head, spreading out between 
the layers of the broad ligament and extending close to the pelvic wall on 
either side. The patient had suffered a great deal from menorrhagia and 
metrorrhagia. Dilatation and curetment had been carried out with some 
benefit. 
Owing to the weak condition of the patient I decided not to expose her 
to the risks attending a hysteromyomectomy, which would have been con- siderable on account of the fixation of the tumor in the pelvis. The tubes 
and ovaries were removed without any special difficulty. The abdomen was 
then closed without drainage. 
The third day after the operation the patient began to complain of in- 
termittent attacks of sharp pains in the lower portion of the pelvis, which were 
referred to the left side. Her temperature and pulse were practically normal 
and the bowels had been opened daily after the second day without any dif- 
ficulty. On the 10th day after the operation the pain in the lower abdomen 
began to be so severe that it was necessary at times to give her anodynes. 
On the 12th day the lower angle of the wound was reopened down to the 
peritoneum, as there seemed to be some slight skin-infection at this point, 
and -a very small amount of purulent fluid escaped from this part of the in- 
cision, but at no other point of the incision could any pus be discovered. 
Coverslip and cultural examination of the pus showed the presence of the 
skin coccus. After this, at intervals of every three or four days, the patient 
would have sharp attacks of pain in the lower 'abdomen, with at times some 
slight elevation of the temperature and quickening of the pulse. At the end 
of the third week the temperature one evening rose to 103° F. and the pulse 
to 120. At the end of the fourth week she seemed to be very much better 
in every way as she had not any elevation of temperature, and the pulse 
rate being about 100, and as there had been but very little pain for over a 
week, she was allowed to be taken to her home. I told her at the time that 
I did not think it wise for her to go under the circumstances, but as she and 
her family insisted upon it, it was impossible for me to keep her in the hos- 
pital any longer. After she had been at home two weeks she began to have 
these same periodical attacks of pain in the lower abdomen; these were ac- 
companied with some distention particularly referable to the left lower zone 
of the abdomen at a point corresponding to the position of the sigmoid flexure 
of the colon. At this point a marked bulging could be observed which some- 
times attained the size of the closed fist and appeared to be very hard; on per- 
cussion a tympanitic note could be generally elicited over this area. This 
condition of affairs kept up for two weeks and a half longer with the attacks 
occurring at intervals of about every week or ten days, and after each attack 
the patient seemed to be more prostrated and the general condition more un- 
favorable. I concluded that there certainly must be some localized septic 
process which was gradually involving a considerable portion of the intes- tines as well as of the tissues in the lower part of the abdominal cavity. By 
vaginal examination one could detect a distinct sense of induration of the left 
broad ligament but no points of tenderness and no fluctuation. Having de- 
termined that there must be some dense adhesions binding down the intes- 
tines and also that the localized inflammation was spreading in all probability 
from an infected left pedicle, after consultation with her attending physician, 
I decided to first puncture through the posterior wall of the vagina, in order 
to allow any fluid that might be present to escape, and to separate any ad- 
hesions. If this were found not to be satisfactory I was then prepared to open 
the abdomen and separate the adhesions from above and to institute drain- 
age. The patient having been anesthetized and placed on the table the pos- 
terior vault of the vagina was opened, but no fluid escaped nor could the 
parts be satisfactorily felt. I therefore reopened the incision and found the 
omentum slightly adherent to the line of incision, and also to the upper sur- 
face of the uterus; but even there no bloody fluid or other accumulation, so 
far as one could detect, escaped. I then separated some intestinal adhesions, 
and also freed the portion of the intestine that was attached to the pedicle 
on the left side. The knuckle of intestine which corresponded to the bulging 
mass that had been detected through the abdominal wall seemed (in the hurry 
of the operation) to be the upper portion of the sigmoid flexure of the colon, 
and this suggested to my mind at the time that there was some accumulation 
of fluid at this point; I therefore punctured the intestine with the exploring 
needle but with negative results. I then separated the adhesions around this 
place and washed out the lower portion of the abdominal cavity with several 
liters of sterile salt-solution at 112° F., and introduced a considerable quan- 
tity of gauze for purposes of drainage. During the progress of this secondary 
operation the patient seemed to be in a condition of collapse for a considerable 
portion of the time, and everything was done as quickly as possible. Hypo- 
dermics of strychnin were given at intervals of every few minutes during the 
operation and were kept up for some time after. As soon as she began to 
recover from the anesthetic, the breathing was stimulated by inhalations of 
oxygen which seemed to improve her shallow respirations and also to stim- 
ulate the circulatory apparatus. This was kept up at regular intervals for the 
first 24 hours, and together with the hypodermics of strychnin and brandy, 
and with nutritive enemeta seemed to greatly improve her condition. The 
temperature never went up above normal after this operation and the pain never returned. Her mental condition became unbalanced for a few 
days during the first week, but these symptoms soon disappeared and the pa- 
tient made a prolonged but thoroughly satisfactory recovery. I fully be- 
lieve that had I not opened the abdomen she surely would have died of 
a chronic peritonitis which though localized was gradually but surely spread- 
ing. This secondary operation was performed six weeks after the primary 
operation. 
Case III—Operation for Densely Adherent Tubes and Ovaries the Result of 
Infection following an Induced Abortion 
The tubes and ovaries on both sides were low down in the pelvis especi- 
ally on the right side and were intimately attached to the broad ligaments. 
It would have been almost impossible to separate the right tube and ovary 
from the broad ligament without practically tearing them out. I therefore 
tied the ovarian artery close to the pelvic wall and also the anastomosing 
branches of the uterine and ovarian arteries near the cornu of the uterus. I 
then dissected out the tube and ovary from the broad ligament on this side. 
On the left side the tube and ovary were also densely adherent but they were 
removed after separating some dense adhesions. 
The abdominal cavity was irrigated with salt-solution and sponged dry 
and the abdomen closed without drainage. Convalescence immediately fol- 
lowing, the operation was perfectly satisfactory with the exception that she 
complained of some pain in the right lower portion of the abdomen. It 
was, not, however, sufficient to require the administration of any anodyne. 
On the 10th day following the operation the pains began to be more intense 
in the lower part of the abdomen and at times she would have some slight dis- 
tention, especially marked on the right side. The bowels were acting thor- 
oughly well all during this time and the temperature was never above 100° F. 
the pulse being usually between 80 and 100; there was no vomiting. On the 
11th day she began to complain of considerable pain in the lower abdomen, 
which on the 12th day became still more marked. On the 11th day by vagi- 
nal examination I could not detect anything abnormal in either broad liga- 
ment, but on the 12th day I made another examination and could then dis- 
tinctly make out an indurated and fluctuating condition of the right broad 
ligament. The pulse at this time was between 90 and 100 and the tempera- 
ture between 99° F. and 100° F. On account of the constant exacerbation 
of the pain and on account of the increasing distention it was determined to reopen the abdominal wound, to thoroughly irrigate the abdominal cavity 
and to institute drainage. I started to open the abdomen under cocain but 
found that the manipulation produced so much pain that I was obliged to 
give the patient an anesthetic. As soon as the abdominal cavity was opened 
a considerable amount of a chocolate colored fluid escaped. I separated sev- 
eral adhesions binding the intestines to each other on the right side and also 
set free the intestines which were adherent to the uterus. The pelvis was 
thoroughly washed out with several liters of sterilized salt-solution, and 
gauze drainage was introduced down to the cul-de-sac and brought out at 
the lower angle of the incision. The abdomen was closed, the usual dress- 
ings were applied and the patient placed in bed again, the pulse being about 
130. After this operation the pain entirely disappeared and the pulse grad- 
ually came down to its normal condition. The patient from this time steadily 
improved and is now perfectly well. 
Case IV—Abdominal Section Performed for Left Parovarian Cyst the Size of a 
Cocoanut, with a Densely Adherent Right Tube and Ovary 
The tube contained pus. The operation was performed in the usual 
manner and the abdomen was closed without drainage. The patient’s con- 
valesence up to the 10th day, was perfectly normal, but she then began to 
complain of sharp pains in the lower abdomen. During the next three days 
it was necessary to apply flaxseed poultices locally and to administer hot 
vaginal douches in order to relieve the pains. The pain, however, was so 
persistent that it became necessary to give her morphin hypodermically. 
The pulse and temperature during this time were about normal and there was 
no vomiting. As the pain persisted and as some slight distention appeared 
in the lower abdomen I determined to institute drainage by the vagina. The 
patient was anesthetized and an opening was made into the peritoneal cavity 
through the posterior fornix of the vagina. After some adhesions had been 
separated a sac in the left broad ligament was entered. I could not de- 
termine the exact nature of this enlargement but imy fingers were evidently 
in a cavity which I took to be formed by the folds of the broad ligament. Ir- 
rigation of this cavity and of the pelvis through the opening made in Douglas’ 
pouch and the employment of gauze drainage relieved the patient of any 
further pain and her condition greatly improved, so that at the end of four 
weeks she left the hospital. She returned the following autumn complaining of more or less pain in the lower abdomen which, however, was not so con- 
stant as after the first operation. On careful examination some induration in 
the left broad ligament could be made out. I therefore advised her to have 
the adhesions separated thinking that in this way she might be relieved en- 
tirely. I opened the abdomen and found in one place the intestines adherent 
to the left broad ligament and to each other. The omentum was also adher- 
ent to the uterus and to the intestines in several places. I released the ad- 
hesions but during the manipulation the outer coat of the intestine was 
stripped off in several places, making it necessary to apply sutures. The 
pelvis was then thoroughly washed out with salt-solution and the abdomen 
closed without drainage. It is now six months since the last operation and 
the patient is perfectly free from pain and in every way is in a very satisfactory 
condition. 
Case V—Operation for a Densely Adherent Maltilocalar Cystoma of the Left 
Ovary with Chronic Adherent and Much Enlarged Fallopian Tube and 
Densely Adherent Right Tube and Ovary 
The intestines were adherent to each other in many places, also adherent 
to the tumor mass on both sides. The left tumor mass was densely adherent 
to the rectum posteriorly. The omentum was adherent to the uterus and 
also to the tumor masses on either side. The mass on the left side was separ- 
ated, after a great deal of difficulty, from the pelvic wall, but it could only be 
removed in pieces. It was so thoroughly incorporated with the broad liga- 
ment that it was found necessary to tie off the broad ligament on this side by 
means of interrupted sutures. On the right side in separating the adhesions 
the ovarian artery was ruptured, necessitating its immediate ligation. 
The abdomen was irrigated thoroughly with sterile normal salt-solution 
and gauze drainage employed in the lower angle of the incision, as there 
seemed to be a considerable amount of oozing. On the day following the 
operation the condition was satisfactory; the pulse was 130 and the temper- 
ature practically normal. The second night the pulse began to increase in 
frequency and the temperature also began to rise rapidly. Thirty-six hours 
after the operation the pulse was between 150 and 165, of poor volume and 
at times extremely difficult to count. The temperature by the mouth was 
104.5° F. She began to be very restless and her condition was anything but 
favorable. I decided to reopen the wound at once and to wash out the pel- 
vic cavity thoroughly with salt-solution and reapply the drainage. In remov- ing the gauze that had been in the abdomen a considerable amount of bloody 
secretion escaped. The abdominal cavity was irrigated with several liters 
of sterile salt-solution, through a two-way catheter. As this instrument 
could be carried down into the curve of the pelvis, the lower portion of the 
pelvis was readily washed out. Some fresh sterile gauze was then intro- 
duced. The temperature began to fall immediately after irrigation of the 
abdomen, so that by 8 o’clock the next morning (eleven hours after the oper- 
ation) it was down to 100° F., the pulse at this time being about 145 to 150. I 
then washed out the abdomen again in the same manner and kept up stimula- 
tion by hypodermic injections and by nutritive enemata. The abdomen was 
slightly distended but there was no vomiting. The temperature the next 
evening went up to 102° F. and the pulse to 144. After this the temperature 
steadily decreased to normal and she is now perfectly well. 
I consider that this case shows very well the beneficial results of cleansing 
the pelvis soOn, without waiting for the patients system to become thoroughly 
prostrated from the toxic effects of the material that was in the abdominal 
cavity. I feel convinced that she was absorbing a specific poison into her 
system which she was not able to withstand; and the improvement following 
the irrigation of the pelvic cavity was so rapid and so marked that there can 
scarcely be any doubt as to the correctness of these conclusions. 
No matter how careful our technic, we must be prepared and expect to 
meet with a certain percentage of such unsatisfactory cases in our abdominal 
work. But if we do not hesitate to reopen the abdomen early, or in some 
cases even late, a considerable number of cases that would otherwise die may, 
T feel sure, be saved. 
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