Reprinted from 
Annals of Gynaecology and Podiatry, 
July, 1892. 
The Causes and Treatment of Sinuses Resulting from 
Abdominal Section. 
BY ANDREW F. CURRIER, M.D., 
OF NEW YORK. The Causes and Treatment of Sinuses Resulting from 
Abdominal Section.1 
BY ANDREW F. CURRIER, M.D., 
OF NEW YORK. 
One of the most impressive, and, I 
may say, important facts, in connec- 
tion with the history of morbid con- 
ditions in animal life, is the constant 
effort of nature—or more properly of 
the vital forces—to protect the body 
from the results of injury. It matters 
little what the nature of the injury 
may be, whether mechanical or chem- 
ical, we find this conservative and 
salutary influence ever present—ever 
alert to repair existing damage—to 
anticipate that, which may be. Keen 
observers among the ancients recog- 
nized this influence, but were unable 
to explain it, except by calling it vis 
medicatrix natures. It remained for 
modern pathological anatomy and 
chemistry, with their minute and 
laborious investigations and instru- 
ments of precision, to analyze this 
influence and its associated processes 
and give to the world the magnificent 
contribution of knowledge which con- 
stitutes pathological science as we 
understand it to-day. What a debt 
the world owes to such men as Vir- 
chow, and Cohnheim, and Lister, and 
Koch, and Pasteur, and a host of 
others, most of them our contempo- 
raries, for their profound and patient 
labors in this field of inquiry! Thanks 
to these labors we can understand, as 
our forefathers could not, how an in- 
jured bone protects itself with a zone 
of callus, how white blood-cells absorb 
and digest poisonous germs, how the 
peritonaeum throws out a wall of 
exudate as a means of defence, and 
why. These wonderful processes are 
suggestive of something more than 
the so-called “ blind processes of 
nature;” they speak to us of law 
working by intelligence. 
Not long since I saw in the practice 
of a friend an extreme illustration of 
this conservative disposition of nature 
for the repair of injury, which may 
serve as the basis thought in the dis- 
cussion of the question which is under 
consideration. The patient was a 
young Irish woman, about 20 years of 
age, who had been operated on several 
months prior to the time when I saw 
her for tubercular peritonitis, the 
abdominal wound having been left 
open for drainage. The peritonaeum 
had secreted freely, but instead of 
agglutination of the visceral and pari- 
1 Read before the Section on Obstetrics and Gynae- 
cology, at the meeting of the American Medical 
Association, held in Detroit, Mich., June 7-10, 1892. ANDREW F. CURRIER. 
2 
etal surfaces the parietal surface re- 
mained free, while a wall of new 
tissue gradually formed over the 
omentum and intestines, completely 
isolating them from the parietal peri- 
tonaeum. This wall, or cuirass, had its 
upper limit several inches above the 
umbilicus, extended well into the 
flanks laterally, and apparently had 
its lower limit at the brim of the 
pelvis, though the bladder, uterus and 
I believe the appendages were wholly 
outside of it, in the great sinus be- 
tween the layer of new tissue and the 
abdominal wall. This latter circum- 
stance may have been due to the fact 
that the drainage-tube dipped into 
the pelvic cavity behind the uterus. 
This new membrane did not appear to 
be very vascular, was of a dark-brown 
color and, of rather friable structure. 
It showed no tendency to adhere to 
the parietal peritonaeum, secreted 
more or less fluid, and, so far as I 
could learn, showed little tendency to 
contract. In fact here was an ex- 
ample, on a colossal scale, of the 
sinuses, which are of such common 
occurrence after the performance of 
abdominal section. The literature of 
this subject is very meagre ; not 
that the subject is not frequently 
broached in society discussions, but 
so far as I have been able to ascertain 
it has not been systematically investi- 
gated. Perhaps the reason is that 
the subject can best be studied post- 
mortem, and the lesion in itself is 
seldom a cause of death. (I have 
been unable to find records of autop- 
sies in which dissections of abdominal 
sinuses have been made.) 
The object of the sinuses in ques- 
tion, if that expression is allowable, is 
evidently a conservative one, result- 
ing from the secreting function of 
the peritonaeum. It is the same pro- 
cess which results in bands and 
adhesions in all' portions of the ab- 
dominal and pelvic cavities. It is 
suggestive of the function of the 
cuttle-fish, which throws out ink, ob- 
scures the water in which it swims, 
and then escapes from its enemies. 
The exudate which is thrown out be- 
comes organized, containing connec- 
tive tissue and blood-vessels, like 
products of inflammation elsewhere, 
but the organization is a low one, and 
while it tends to contract like exudates 
elsewhere, it frequently does not con- 
tract sufficiently to obliterate the 
lumen of the sinus, in case a distinct 
lumen has been formed; and, also, 
retrograde metamorphosis and absorp- 
tion may not occur, so that the annoy- 
ance of a persistent opening, with the 
discharge of a greater or smaller 
quantity of pus, may continue in- 
definitely. There results a severe 
trial to the patience, and possibly to 
the strength, of the sufferer, and a tax 
upon the ability and ingenuity of the 
surgeon which he may not be able to 
meet successfully. 
We may consider the causes of this 
unfortunate condition as constitu- 
tional, irritative, and septic. 
(i) Perhaps it would be better to 
use the term predisposing in place of 
constitutional. Cases in which the peri- 
tonaeum, from any cause whatsoever, 
has contracted the habit, as it were, of 
throwing out excessive secretion, are 
by virtue of that very habit favorable 
cases for the formation of sinuses after 
abdominal section. This is notably 
true in connection with tubercu- 
losis of the peritonaeum, although it 
is also true that the effect of opening 
the peritonaeal cavity in such cases is 
frequently curative, and that if sinuses SINUSES RESULTING FROM ABDOMINAL SECTION. 
3 
form the necessary retrogressive 
changes occur with greater relative 
frequency than in non-tuberculous 
cases. Predisposition to sinus forma- 
tion is also present, in connection with 
syphilis, malignant disease of the peri- 
tonaeum, or disease of any of the ab- 
dominal viscera in which the visceral 
or peritoneal circulation is seriously 
interfered with. In cases in which 
an abundance of adhesions, either re- 
cent or ancient, is found in the ab- 
dominal or pelvic cavity, as the result 
of an inflammatory process, we are in 
the presence of an irritable peritonae- 
um with a predisposition to sinus for- 
mation under favoring conditions. 
The mere agglutination of coils of 
intestine to each other may be the first 
step in this process, and should these 
become adherent to the parietal peri- 
tonaeum in the vicinity of the abdom- 
inal wound, and the latter fail to close, 
or be reopened by a force from above 
or below, the sinus would be complete. 
(2) The cause which seems more 
fruitful than all others in the produc- 
tion of sinuses, I have termed irrita- 
tive. Perhaps it would be better to 
speak at first of mechanical irritation, 
for septic causes are also irritative, but 
act chemically as well as mechanically. 
Drainage and suture or ligature ma- 
terial,of whatever substance composed, 
is the principal means by which this 
irritative action is caused. At present 
we are considering only its irritative 
action as a foreign body, without 
reference to septic elements, which 
are frequently associated with it. Chief 
among these irritative agents are glass 
drainage tubes. It matters little 
whether their calibre be large or small, 
when used too long in some cases, and 
when used at all in others, whether 
properly or improperly adjusted, the 
result will be a sinus. Their presence 
irritates the sensitive peritonaeum of 
the intestines and omentum which 
snug'ly embrace them. The exuding 
secretion in a short time (Tait says in 
seventy to eighty hours) forms a mould 
around the tube, the intestines are 
agglutinated to the mould and to each 
other, and thus a cavity is formed 
which is walled off from the abdom- 
inal viscera. When the drainage tube 
is removed the concentric pressure 
of the surrounding structures upon the 
walls of the sinus may cause them to 
collapse, and disintegration and ab- 
sorption may gradually accomplish 
their complete removal. But in the 
unfavorable cases these results do not 
ensue, but the sinus walls become 
more completely organized, and the 
consequent phenomena of granulation 
may continue indefinitely. 
Sinuses may also be caused by the 
irritation of too many or too large 
sutures or ligatures, or by the loosen- 
ing of ligatures around tissues which 
have shrunk or atrophied. Such an 
irritation may be an aseptic one, as 
has been described by Bumm. Such 
sinuses are without the well-marked 
wall which occurs when the drainage 
tube has been the irritating cause. 
They are formed by the agglutination 
of coils of intestines, the exudate 
varying in thickness, of course, with 
the intensity of the process and the 
sensitiveness of the peritonaeum to 
irritation. The track of such sinuses 
may be long, irregular and intricate, 
and they may contain pockets of con- 
siderable capacity, which will give 
rise to no end of uncertainty and sur- 
mising in attempts at exploration and _ 
treatment. That ligatures were the 
cause of sinuses was long since ob- 
served by the earlier ovariotomists, ANDRPAV F. CURRIER 
4 
and this fact induced some of them to 
endeavor to dispense with ligatures 
as far as possible. Thus Keith sub- 
stituted the actual cautery for the 
pedicle ligature, and Peaslee devised 
a plan for cutting and removing the 
pedicle ligature after it had been in 
position long enough to insure free- 
dom from haemorrhage. These meth- 
ods have never been improved upon, 
though they have been forgotten or 
ignored by many abdominal surgeons. 
The use of gauze as a means of drain- 
age within the abdomen is a distinct 
indication of progress. . The irritation 
which it causes is probably less in- 
tense than results from the use of any 
solid material. The gradual with- 
drawal of the gauze is probably more 
favorable to the breaking up of newly 
formed plastic material than the with- 
drawal of the drainage tube, and the 
entrance and development of poison- 
ous germs within the peritonaeal cavity 
is certainly as little facilitated by this 
as by the use of any drainage material. 
These and other considerations have 
induced some surgeons to discard the 
drainage tube in favor of gauze, espe- 
cially in view of the fact that drainage 
with gauze seems to be quite efficient 
The matter is of so much importance 
that it seems worthy of more extensive 
study and discussion than it has yet 
received. The same objections which 
have been urged against glass drain- 
age tubes are applicable to tubes of 
rubber, bone, or other more or less 
firm material. It is assumed that the 
subject of drainage of the abdominal 
cavity is intrinsically so important 
that it will be universally admitted 
that substances should be used which 
will be certain to provoke the least 
irritation. 
(3) The subject of sepsis as a cause 
of abdominal sinuses is as yet too 
obscure to admit of careful and exact 
statements. Sinuses not infrequently 
occur when no drainage tube is used. 
The abdominal wound is carefully 
sealed, but sinuses result. It has 
already been stated that ligatures 
may by their very presence as foreign 
bodies excite much irritation, but in 
how many instances there are also 
foci of irritation in the form of blood, 
pus, or serum, within the abdomen or 
pelvis, or poisonous material which 
has been introduced from without, 
which the peritonaeum cannot or does 
not absorb or successfully isolate. 
Bumm has stated that the gonococcus 
alone will not cause a septic peri- 
tonitis, that it is infectious only upon 
mucous surfaces, and that its injuri- 
ous effects cease when it has tra- 
versed the mucous membrane of the 
Fallopian tube; that when it reaches 
the peritonaeum it becomes harmless 
and is encapsulated. Others have 
denied this statement, and have re- 
ported cases in which gonococci have 
produced mischievous results upon 
the peritonaeum. Possibly such re- 
sults may be due to mixed infection, 
in which, as Bumm states, the strepto- 
coccus is associated with the gono- 
coccus and causes peritonaeal injury. 
However this may be the investiga- 
tions and observations with reference 
to the question immediately at issue 
have been mainly clinical. As Sanger 
has observed (Deutsche Med. Wocken.,- 
XVII, 1891, p. 145), experiments 
such as those of Heinricius, Loebker 
and Delbet upon cadavera and ani- 
mals, furnish no convincing argument, 
and we are still very much in the 
dark as to the exact role which is 
played 'by micro-organisms in this 
matter. The results which attend SINUSES RESULTINCx FROM ABDOMINAL SECTION. 
5 
the formation of abdominal sinuses 
are certainly deleterious. The con- 
dition is that of a granulating wound, 
which is not only annoying to the 
patient, but destructive to vital force, 
like persistently granulating pro- 
cesses in any situation. There is 
more or less interference with the 
functional activity of the intestines, 
and danger to vital organs, such as 
results in all cases from prolonged 
suppuration. Consequences with 
which we are all familiar in such 
cases are fistulae of the intestines and 
bladder, prolonged vesical irritation 
and cystitis, inflammatory diseases 
of the kidneys, anmmia and intensifi- 
cation of pre-existing tubercular or 
syphilitic processes. Whatever bene- 
fit may have been derived from the 
performance of the original operation 
and the removal of diseased struc- 
tures, is neutralized by the new morbid 
condition which has been developed, 
and a very important problem is fur- 
nished for our consideration, for which 
no really efficient means of treatment 
has as yet been devised. Treatment 
is rendered the more difficult from 
the fact that we are frequently unable 
to explore the cavities as thoroughly 
as is requisite, on account of their 
sinuosities, on account of the large 
areas which are frequently involved, 
and on account of the danger of 
penetrating the intestines, or the 
peritoneal cavity in case active meas- 
ures of treatment are adopted. The 
alternatives with which we are con- 
fronted, in the matter of treatment, 
are simple expectancy, palliative 
measures, or radical ones, which mean 
reopening the peritoneal cavity, ex- 
tensive dissection and possible in- 
ability, even then, to remove the diffi- 
culty. Expectant treatment consists 
in doing nothing; in throwing the re- 
sponsibility of the situation upon the 
natural reparative forces. This may 
be considered the method of laziness, 
or of despair, and yet it is frequently 
astonishing to see how capably na- 
ture manages such situations, if only 
suitable measures are adopted for the 
maintenance of the general nutrition. 
With a fair degree of vitality of the 
tissues and functions a spontaneous 
cure not infrequently results. It is 
not improbable that many cases which 
pass from our observation are cured 
in this way; but there are others 
which remain uncured as long as the 
patient lives, causing varying degrees 
of annoyance, but not sufficient to 
compel re-entrance into a hospital 
and the adoption of radical proce- 
dures. 
The palliative method of treatment 
offers a wide range of measures for 
selection, the degree of success vary- 
ing with the vitality of the patient, 
the area of the sinus and the adapta- 
bility of the measure to the given 
condition. A prerequisite to success 
is.cleanliness, which means not only 
cleanliness of the external surface of 
the body contiguous to the opening 
of the sinus, but cleanliness of the 
walls of the sinus, its secretions being 
removed with sufficient frequency 
and thoroughness. This is not always 
an easy matter, and sinuses frequently 
fail to heal on account of the reten- 
tion and decomposition of secretions. 
Irrigation should be practised at least 
once a day, and my preference is for 
simple hot water, hot Thiersch solu- 
tion, or hot solution of creolin or car- 
bolic acid. The abdominal opening 
should be sufficiently large to permit 
free exit of the discharges. Applica- 
tions of the nitrate of silver, twenty 6 
ANDREW F. CURRIER. 
or thirty grains to the ounce, some- 
times induces satisfactory healing ac- 
tion. A few years ago Dr. Robert: 
Morris recommended the use of a 
solution of trypsin as an application 
to the walls of sinuses, for the pur- 
pose of digesting the cicatricial tissue 
and inducing a healthy reparative ac- 
action. This was recommended by 
me in two cases in which I was con- 
sulted. The cicatricial tissue was in- 
deed digested, but intone of the cases 
an opening into the bladder was 
effected, and in the other an opening 
into the small intestine. The former 
was cured by persistent drainage of 
the bladder, the latter by resection of 
the intestine. This substance must, 
therefore, be used with the greatest 
caution. In a number of cases I 
have packed the sinus with iodoform 
gauze with good result in sinuses of 
small calibre, but without such result 
in those which were extensive. 
Theoretically, it would seem that 
thorough drainage from abdomen to 
vagina would be efficient, but I have 
one case which has been treated in 
this way for three months or more 
and still remains unhealed. If a 
pedicle ligature is a cause of irritation, 
the sinus may still refuse to heal after 
it has been removed. For obstinate 
cases there remains only the radical 
procedure of reopening the abdomen, 
breaking up all adhesions and dissect- 
ing away all adventitious tissue. This 
may be an operation of great magni- 
tude, and I have known it to fail even 
with the most skilful operators. It 
seems to me, however, that it is the 
true method for the treatment of ob- 
stinate cases, and I doubt not that in- 
creased experience in technique will 
make it successful even in such cases. 
In all cases it must be remembered 
that violence in exploration, in injec- 
tion, or in irrigation, are to be rigor- 
ously avoided. We must not forget 
that we are in intimate contact with 
the thin and often friable wall of the 
intestine, and that too much manipu- 
lation will almost inevitably result in 
a more serious condition than that 
from which the patient is already 
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ERNEST W. CUSHING, M.D., Boston. 
PAEDIATRY. 
RICHARD C. NORRIS, M.D., Philadelphia. 
COLLABORATORS. 
Dr. AP0ST0L1, Paris. 
Prof CHARPENTIER. Paris. 
Dr. ANDREW F. CURRIER, New York. 
Dr. G. A DIRNER, Buda-Pesth. 
Dr. A. DOLERIS. Paris. 
Prof. GEO. F. ENGELMANN, St. Louis. 
Prof. WILLIAM GOODELL, Philadelphia. 
Dr H. C. HAVEN, Boston. 
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Dr. M. SAENGER. Leipsic. 
Prof. EUSTACE SMITH, London. 
Prof. T. G. THOMAS, New York. 
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