Coeliotomy for Puerperal Septicaemia 
and Peritonitis. 
BY 
Charles P. Noble, M. D., 
Surgeon in Chief, Kensington Hospital for Women 
Philadelphia. 
Reprint from The American Gynaecological and 
Obstetrical Journal. [ Reprinted from the American GyN/Ecological and Obstetrical Journal 
for April, 1885. ] 
CCELIOTOMY FOR PUERPERAL SEPTIC/EMIA AND 
PERITONITIS.* 
By Charles P. Noble^M. D., 
Surgeon in Chief, Kensington Hospital for women, Philadelphia. 
The conditions under which it is desirable to make an abdominal 
section in the treatment of the inflammatory and septic complications 
of the puerperal state are as yet not definitely determined. The very 
practial nature of this subject-practical because of the large num- 
ber of women who annually lose their lives from puerperal septicaemia 
-renders it one of perennial interest to the practitioner as well as to 
the obstetrician and gynaecologist. This paper has been prepared at 
the invitation of your president, with the hope that it, together with 
the discussion elicited, may prove of service in the solution of some 
of the problems involved. Cases of puerperal sepsis or peritonitis 
may be divided into two classes. I. Those in which some pathologi- 
cal condition is present in the sexual organs of the woman before 
labor: 2 Those in which these organs are normal. 
The first class embraces those cases af sepsis or peritonitis caused by 
the bruising or rupture of tumors situated in the pelvis, or of pus sacs 
or other septic accumulations in the Fallopian tubes, or other pelvic 
organs. It is unnecessary to discuss this aspect of our subject at 
length, as there is little difference of opinion concerning it, and the 
nature of its treatment is reasonably plain. Puerperal peritonitis, due 
to the bruising or rupture of tumors during labor, has long been rec- 
ognized, being first called to the attention of obstetricians, perhaps, 
when it followed the tapping per vaginam or per rectum of ovarian 
tumors, which served as an obstruction to labor. Any variety of 
pelvic tumor (uterine fibroid, ovarian cyst, dermoid, etc.) may be 
bruised or have its blood supply cut off by torsion of its pedicle and 
become inflamed or gangrenous, setting up a more or less serious 
peritonitis. Dermoid cysts are especially liable to undergo inflam- 
matory changes when they complicate a labor, torsion of the pedicle 
and bruising being the usual causes. The cardinal points to which 
attention should be called in this class of cases are, that the birth- 
* Read before the New York Academy of Medicine, Febuary 28, 1895. 
Copyright, 1895, by J. D. Emmet and A. H. Buckmaster, 2 
Charles P. Noble, M. D. 
canal and the lymphatics are not involved; hence, the conditions 
present are very similar to those in non-puerperal peritonitis. Prompt 
operation, with the removal of the tumor, has been followed by a 
high percentage of cures. 
Puerperal peritonitis due to the rupture or bruising of pus-sacs or 
other septic accumulations in the uterine appendages, existing prior to 
labor, is not of frequent occurrence. This phase of our subject has 
not been systematically studied. The references to it in the literature 
are scanty. In 1891, in a paper entitled, Salpingitis considered in its 
Relation to Pregnancy and the Puerperal State, I discussed this sub- 
ject, and reported three cases in which the bruising of pus-tubes dur- 
ing labor had set up peritonitis. I have personal knowledge of two 
other cases which occurred in this city. Of thirty-two eminent Ameri- 
can gynaecologists, from whom I have received replies to a letter of 
inquiry concerning this among other subjects, I find that but three of 
them, Dr. Hirst of Philadelphia, Dr. W. E, B. Davis of Birmingham, 
and Dr. Edward Reynolds of Boston, have operated for peritonitis 
due to a pus-tube which had antedated labor. Each of these gentle- 
men operated upon one case. Dr. Coe of New York reports that he 
has assisted at such operations. My other correspondents either had 
no personal knowledge of such cases, or at the most have merely sus- 
pected that the diseased tube may have antedated the labor instead of 
resulting from infection after labor. This experience of my correspond- 
ents, together with my own, is, I think, conclusive evidence that this 
variety of puerperal peritonitis is not common, and therefore its im- 
portance is not so great as was anticipated some years ago.* The 
comparative infrequence of puerperal peritonitis due to this cause is 
explained by the fact, that women having even a single pus-tube, or 
other septic accumulation in the pelvis, are usually sterile. 
* In preparing this paper use has been made of material collected by means of a circular 
letter, which was sent to many eminent American gynaecologists. Replies have been received 
from thirty two of them, as follows : 
Drs. W. M. Polk, Egbert H. Grandin, Andrew F. Currier, Robert A. Murray, Herman J. 
Boldt, Malcolm McLane, Henry C. Coe, J. C. Edgar, Paul F. Munde, W. R. Pryor 
and A. Palmer Dudley, of New York, Drs. B. C. Hirst, J. M. Baldy, and E. E Mont- 
gomery, of Philadelphia: Drs. Howard A. Kelly and J. Whitridge Williams, of Baltimore 1 
Drs. James H. Etheridge and E. C. Dudley, of Chicago ; Drs. Edward Reynolds, J. R. 
Chadwick, E. W. Cushing and William H. Baker, of Boston ; Dr. J. H. Carstens of Detroit, 
Dr. A. L. Smith of Montreal, Dr. J. H. Kellogg of Battle Creek, Dr. W. E. B. Davis of 
Birmingham, Dr. R. S. Sutton of Alleghany, Dr. S. C. Gordon of Portland, Dr. M. D. Mann 
of Buffalo, Dr. Archibald MacLaren of St. Paul, Dr. R. B. Maury of Memphis, and Dr. 
H. D. Fry of Washington. Coeliotomy for Puerperal Septicczmia and Peritonitis. 
3 
The grave dangers resulting from the bruising or rupture of a dis- 
eased uterine appendage during labor, render the occurrence of a 
pregnancy, in a woman the subject of such conditions, highly unde- 
sirable until the diseased organ has been removed. Parturition under 
these circumstances is too dangerous to be encouraged, and concep- 
tion should be avoided until the source of danger has been removed 
by operation. 
The relative dangers of puerperal peritonitis of this variety, and the 
results of operation done for it, can not be determined at this time. 
The subject is too new, and our experience is too limited for more 
than inferential opinions. Theoretically the prognosis from operation 
should be relatively good, because as the uterus and pelvic connective 
tissues are not involved, the conditions are more nearly those of oper- 
ation for peritonitis in a non-puerperal woman. At all events, it is 
a safe conclusion, that the proper method of treatment to be pursued 
is prompt operation, irrigation and drainage. 
The second class of cases, in which sepsis or peritonitis results from 
infection of the birth-canal, in women having normal sexual organs 
previous to labor, is a far more important one than that just considered. 
This is a common type of so called puerperal fever. It embraces cases 
in which the infection is limited to the utero-vaginal canal, those in 
which the infection has spread to the broad ligaments through the 
pelvic lymphatics or veins, and those in which the infection has spread 
to the peritonaeum, either by way of the Fallopian tubes or by way of 
the lymphatics. Because it is convenient we will consider first, cases 
of puerperal peritonitis, which, as we have seen, may arise either 
through the spread of the septic inflammation by way of the Fallopian 
tubes to the peritonaeum, or by infection spreading through the lym- 
phatics either directly through the uterus to its peritoneal covering, or 
by way of the lymphatics of the broad ligaments. I am not aware of 
any investigations which have definitely determined the clinical history 
of the two varieties of puerperal peritonitis to which reference has been 
made. I belive it is true that in the first variety ( by way of the Fall- 
opian tubes) relatively speaking, the inflammatory element is more, 
and the septic element is less, marked, whereas the reverse is true in 
the second class of cases ( by way of the lymphatics ). In the first 
class of cases, I belive that it is common to have marked efforts at 
localization of the peritonitis, by means of the pouring out of inflam- 
matory lymph, and that where this result is accomplished many of 
these cases go on to a natural cure, and that more of them result in 
the formation of post-puerperal pus-tubes and of circumscribed intra- 
peritoneal collections of pus. On the other hand, in the cases in which 4 
Charles P. Noble, M. D. 
septic lymphangitis is a marked feature, the element of peritonitis is 
merely an epiphenomenon, the condition present being a general sep- 
ticaemia. 
Puerperal peritonitis of the first class may end in death or recovery 
within a few days, or it may continue for several or even many weeks. 
Lymphatic peritonitis is of relatively short duration, many cases having 
a fatal termination after a course of a few days. Bearing these facts 
in mind, I find no evidence that abdominal section has been performed 
for lymphatic peritonitis in any considerable number of cases. The 
reports of coeliotomies for puerperal peritonitis with which I am most 
familiar show that the operations have been^me in general after the 
end of the first week ; in other words, at a time in which women the 
subjects of lymphatic peritonitis have either died, or have begun to 
recover. As supporting this inference I find that among my corres- 
pondents only four-Drs. Boldt, Polk, Carstens and Etheridge-have 
performed cceliotomy for general peritonitis within seven days after 
labor, and only four-Drs. Smith, Etheridge, Polk and Baldy-have 
operated for localized peritonitis within the same limit of time. Seven- 
teen of them have operated for puerperal peritonitis later than the 
seventh day of the puerperal period. 
Lymphatic puerperal peritonitis is not amenable to treatment by 
cceliotomy. I know of nothing, either in my own experience or in 
the literature, which gives the least encouragement for operating 
upon this class of cases. All that have been operated upon have died. 
It is not difficult to understand why operation done for lymphatic 
peritonitis should accomplish so little. A simple cceliotomy, with 
washing out of the peritoneal cavity, does not influence the principal 
seat of trouble, which is in the uterus and pelvic lymphatics, and ne- 
cessarily it can not influence the multiplication of germs which already 
may have entered into the general circulation. The more radical op- 
eration of hysterectomy offers but little in these cases, as by the time 
peritonitis has become a marked feature, either the patient is so re- 
duced as to be unable to withstand the shock of a serious operation, 
or she is already suffering from well marked general septicaemia. These 
cases should be operated upon at a much earlier stage, before the de- 
velopment of peritonitis or marked general septicaemia. Cases of 
puerperal peritonitis in which the septic element is less marked are 
more amenable to treatment by operation. Polk and Outerbridge 
have reported successful cases of cceliotomy for localized peritonitis 
done within the first week after labor, and many cases are on record 
in which cceliotomy has been performed for localized peritonitis at a 
later period. I have nothing new to offer concerning the indications 
for operation in puerperal peritonitis. So far as I know patients op- Coeliotomy for Puerperal Septicemia and Peritonitis. 
5 
erated upon for general peritonitis have died; hence, excepting the 
hope that the diagnosis maybe wrong, one would hardly be justified 
in recommending operation with such a diagnosis. In cases of localized 
peritonitis, during the first few days of the attack, coeliotomy should 
be done if the attack be a severe one which does not yield promptly to 
treatment. In cases presenting well-marked local lesions, to be made 
out by a bimanual examination, the indication for operation is more 
urgent than in those in which nothing can be determined by examina- 
tion. In my judgement such cases should be carefully studied, and 
operation be elected or rejected because of the conditions present-the 
symptoms and the general course of the case-rather than in accord 
with any rules applied to such cases in general. Coeliotomy is cer- 
tainly indicated if the attack of peritonitis be a severe one, which does 
not yield promptly to medicial treatment. Also, later in the course of 
puerperal peritonitis, operation is indicated if the patient fails to im 
prove, and is demanded should the case take an unfavorable course. 
In such cases, however, it should not be forgotten that bimanual ex- 
amination will usually disclose marked local lesions. 
'At the present time it is safe to conclude that the prognosis of 
coeliotomy done for general puerperal peritonitis is fatal. In cases 
of localized peritonitis it is best in those cases in which the inflamma- 
tory process has become well localized, and in which sepsis is absent, 
the case having resolved itself into one of pyosalpinx, abscess of the 
■ovary or pelvic abscess of puerperal origin. The prognosis is fairly 
good in cases of circumscribed peritonitis operated upon promptly, 
that is within two or three days. Cases which have gone from bad to 
worse, and in which the operation is done as a last resort, usually ter- 
minate fatally. 
We have still to deal with cases of infection of the birth-canal, in 
which the progress of the disease is from bad to worse, in spite of 
irrigation and curettement of the utero vaginal canal. In these cases 
septic intoxication, or beginning septicaemia, are marked features, ab- 
sorption of ptomaines or of micro organisms taking place from the 
uterus or vagina. In these cases peritonitis, cellulitis, or lymphangitis, 
are either absent or in their incipiency-the infected uterus is the 
nidus of the morbid process.' Some years ago such a case would have 
been treated by a continuance of the irrigation and by internal medi- 
cation. Under this method of treatment undoubtedly a few cases 
have recovered, but in the great majority, when, in spite of curette- 
ment and through irrigation of the uterus, the septic process in- 
creases instead of diminishing in intensity, the issue is a fatal one. 
The proposition to perform hysterectomy in such cases, and thus to 6 
Charles P. Noble, M. D. 
remove the seat of the disease, has the merit of being logical. This 
proposition has been carried into effect by Kelly and Smith with a 
favorable result, and by Montgomery with a fatal issue. I have read 
of another successful casein the hands of of a German operator, but am 
unable to find the reference. In these cases abdominal hysterectomy 
was preformed. In Kelly's case there was a beginning lymphangitis, 
in Smith's a beginning peritonitis, and in Montgomery's pus was found 
in the uterine sinuses. 
At the present time I am prepared to advocate the performance 
of hysterectomy for infection of the uterus, when, in spite of thorough 
curettement, followed by copious irrigation of the utero-vaginal canal, 
and the use of an iodoform suppository and gauze within the uterus, 
the septic symptoms increase in severity. In general, the less radical 
measures of treatment should be employed for twenty-four or forty- 
eight hours, this time limit to be varied according to the severity of 
the septic symptoms. In such cases, not only should the uterus be 
curetted and douched, but the patient should be well purged with 
salines. The use of quinine, baths and anodynes should not be neg- 
lected. In all such cases, the general condition of the patient, includ- 
ing the pulse, temperature, stomach and morale, is the best guide in 
deciding for or against the immediate resort to hysterectomy. 
At this time the great success which has been achieved in hysterec- 
tomy, done by way of vagina, for non-puerperal conditions, in the hands 
of the French school of surgeons, raises the question whether or not 
this method of operating should not be selected in puerperal cases. 
Experience alone must determine this question. This is one of the 
problems of the future, as only a small number of cases have as yet 
been operated upon by the lower route. Upon theoretical grounds, I 
am not inclined to advocate hysterectomy by the vagina for puerperal 
infection, as when it is employed we are precluded from inspecting, ir- 
rigating and widely draining the peritoneal cavity. This method would 
best fulfill the indications when employed very early in the course 
of the disease, when the chances of peritonitis would be small and 
the necessity for extensive drainage of the peritoneal cavity absent. 
Because of the time saved, the use of the method of forci-pressure 
instead of the ligature is indicated. 
The advocates of the vaginal route for removing the diseased struct- 
ures from the pelvis will undoubtedly take issue with the general posi- 
tion, that abdominal section is the operation indicated to deal with the 
various consequences of puerperal septic inflammation. I am pre- 
pared to agree with them that large pus accumulations can be more 
safely dealt with by way of the vagina than by operation from above. Cceliotomy for Puerperal Scplictzmia and Peritonitis. 
7 
but with this exception, from my point of view, the preferable method 
of operating for puerperal septic inflammation and its results is by 
coeliotomy. 
The present status of the subject of coeliotomy for puerperal septic- 
aemia and peritonitis may be summed up as follows; 
Cases may be divided into two classes- 
(«) Those having morbid conditions in the pelvis antedating labor 
such as tumors, pus tubes, or other septic accumulations, the bruising 
or rupture of which during labor leads to peritonitis or septicaemia. 
Prompt operation in these cases has given good results. 
(b) Those having normal pelvic structures at* the onset of labor- 
The infectious process may spread through the lymphatics to the per- 
itonaeum, and give rise to peritonitis, to cellulitis, and to septicaemia. 
It may spread by the way of the Fallopian tubes to the peritonaeum, 
setting up peritonitis. Or it may be limited to the utero-vaginal canal. 
Coeliotomy is not indicated in lymphatic peritonitis, as the morbid pro- 
cess is to widespread to be reached by operation. Coeliotomy has been 
followed by a fatal result in cases of general peiitonitis. The only 
ground for advising operations with such a diagonsis is the possibility 
of a mistaken diagnosis. The prognosis is best when coeliotomy is 
done for localized peritonitis, when the process has become well cir- 
cumscribed and the element of sepsis eliminated ; in other words, when 
the case has resolved itself into one of pyosalpinx, abscess of the ovary, 
or pelvic abscess of puerperal origin. The prognosis is good when 
cases of localized peritonitis are operated upon promptly, that is with- 
in two or three days. Cases which have gone from bad to worse, and 
in which the operation is done as a last resort, usually terminate fatally. 
Hysterectomy is indicated for those cases in which the infection is 
limited to the utero-vaginal canal, when, in spite of thorough curette- 
ment of the uterus, together with copious irrigation of the utero-vaginal 
canal, and the employment of proper systemic treatment, the infectious 
process increases in severity. 
In dealing with the results of puerperal septicaemia by operation, coe- 
liotomy affords the opportunity for satisfaction diagnosis and adequate 
treatment. The organs involved may be palpated or inspected, and 
when necessary the operation may be completed by thorough irrigation 
and satisfactory drainage. The vaginal route for operation is indicat- 
ed for large pus accumulations which are found late in the puerperium. 8 
Charles P. Noble, M. D. 
Literature. 
Shoemaker, George E.: Puerperal Septicaemia. Am. Joum. Obstetrics, November, 1889. 
Davis, W. E. B : Surgical Treatment of Puerperal Peritonitis. Atlanta Med. and Surg. 
Journal, 1892-'93, lx, 257-262. 
Montgomery, E. E. : Complications in the Puerperal State. Am. Gynrec. Journal. 
Toledo. 1892, ii, 554-559- 
Noble, C. P. : Salpingitis considered in its Relation to Pregnancy and the Puerperal 
State. Trans. Am. Gynrec. Society, 1891, xvi, 480. 
Hirst, B. C. : Position of Abdominal Section in the Treatment of Puerperal Peritonitis 
Trans. Am. Gynaec. Society, 1891, xvi, 248. 
Maury, R. B.: The Indications for Laparotomy in the Treatment of the Puerperal Fev- 
ers. Trans. Am. Gynrec. Society, 1891, xvi, 248. 
Goldsborough, B. W.: Hysterectomy done Five Days after Labor for Puerperal Metri- 
tis. New York Med. Journ., 1893, Ivii, 195. 
Teichelmann, E.: Puerperal Peritonitis; Ruptured Old Pyosalpinx; Section; Recovery; 
Operation on the Fourteenth Day. Lancet, London, 1891, ii, 1276. 
Pryor, W. R.: Left Hydrosalpinx and Right Salpingitis in a Case of General Acute 
Peritonitis from a Neglected Abortion. New York Journ. Gynrec. and Obstet., March, 1892. 
Outerbridge, P. : Operation. Puerperal Fever. Two Cases. New York Journ. Gynrec. 
and Obstet., 1892, ii, 331-336. 
Parish, W. H.: Coeliotomy after Labor. Am. Journ. Obstet., New York, 1892, xxvi, 48. 
Davis, E. P. ; Irrigation of the Peritoneal Cavity in Puerperal Sepsis. Ann. Gynrec. and 
Pred., 1891-'92, v, 604-609. 
Davis, E. P.: C<eliotomy in the Treatment of Puerperal Sepsis. Am Joum. Obstetrics, 
New York, February, 1895. 
Grandin E. H.: Treatment of Purulent Puerperal Peritonitis. Am. Journ. Obstet., 
1893, xxvii, 427. * 
Maury, R. B. : Suggestions, etc.: Puerperal Fever. Memphis Medical Monthly, 1893, 
xiii, 97-103. 
Noble, Charles P. : Acute Puerperal Cellulitis and True Pelvic Abscess. Am. Journ. 
Obstet., New York, xxix, No. 4, 1894. 
Noble, Charles P. : Puerperal Cellulitis and Puerperal Peritonitis. Am. Gynrec. and 
Obstet. Journ., January, 1895.