A NEW INSTRUMENT FOR THE READY AND 
EFFECTIVE USE OF THE DOUBLE CURRENT 
IN THE TREATMENT OF SUPPURATING 
CAVITIES AND PELVIC DRAINAGE. 
GEO. H. BIXBY, M. D., 
OB' BOSTON. 
[Reprinted from The Boston Medical and Surgical Journal, November IS, 1875. ] 
CAMBRIDGE 
printed at tl)c CiiteMfcc 
1875. A NEW INSTRUMENT FOR THE READY AND EFFECTIVE 
USE OF THE DOUBLE CURRENT IN THE TREATMENT 
OF SUPPURATING CAVITIES AND IN PELVIC DRAINAGE. 
BY GEORGE H. BIXBT, 31. D., OF BOSTON, 
Surgeon to St. Elizabeth’s Hospital for Women. 
In the course of a somewhat extended experience in the treatment 
of the surgical diseases of women, an unusually large number of cases 
of pelvic abscesses, retro-uterine hsematocele, and intra-uterine tumors 
have come under my observation. In a review of the clinical history 
of the two first-mentioned affections and of the means employed in their 
treatment, I find that while in a few instances a single evacuation by 
aspiration or otherwise was sufficient to obliterate the suppurating cav- 
ity, the majority of cases required the use of stimulating and disinfect- 
ant injections. The employment of the different forms of double cath- 
eters and drainage tubes hitherto in use was most unsatisfactory, in my 
hands at least, the treatment being in some cases unsuccessful and in 
others unnecessarily prolonged. Among the difficulties encountered I 
will mention, first, the liability to displacement, and, owing to the lax 
condition and the change in the relations of the tissues, the extreme 
difficulty attending reposition, attempts to restore the instrument not 
unfrequently proving unsuccessful, even after prolonged and tedious 
manipulations, thus necessitating the establishment of a new opening; 
second, the tax upon the strength of the patient and the demand upon 
the time and patience of the surgeon. I recall the histories of several 
cases in which, from a tardy recognition of the disease, surgical inter- 
ference was delayed, and the poisonous effects of the discharge were so 
marked that the interruption of the treatment, even for a few hours, was 
followed by grave symptoms of septic poisoning; and notwithstanding 
the imperfect appliances at my disposal, upon vigorous resumption of the 
treatment an amelioration of the symptoms took place immediately. It 
is evident from these facts that the displacement of any appliance for 
maintaining a patent aperture, the subsequent closure of the aperture, 
and the interruption of the treatment, even for a short time, become 
under all circumstances serious affairs. In view of these difficulties, 
and encouraged by the recent discussions and by the acceptance on the 
part of the profession of the theory that blood-poisoning is the most fre- 
quent cause of death after abdominal and pelvic operations, as well as a 2 
A New Instrument for Pelvic Drainage. 
possible cause of the so-called puerperal fever, I have been led to the 
suggestion of a new instrument for the application of an old but most 
useful surgical principle in the treatment of such affections. The in- 
strument, which I shall denominate the double trocar, consists of a can- 
ula ten inches long and one fourth of an inch or less in diameter, straight 
or curved according to its particular use. A horizontal septum divides 
its cavity into two equal chambers, the inferior extremity of each being 
fenestrated to the extent of an inch. Superiorly each chamber is con- 
nected by a branch, the afferent and the efferent, with rings and guard 
for retention. Into this double canula there fits a flexible double tro- 
car attached to a common handle, and answering for both the curved 
and the straight canula. When the trocar is inserted and forced home, 
the two extremities come together in sufficiently close apposition to form 
a single point. A piece of rubber tubing two or three inches in length 
attached to the afferent branch forms a convenient coupling for the noz- 
zle of the syringe, and the efferent is lengthened to the desired extent 
by the same means. The copious and uninterrupted current and the 
CODMAN & SHURTLEIV 
BOSTON. 
A. Canula. 
B. Efferent branch. 
C. Afferent branch. 
D. Guard. 
E. Probe point. 
E E. Fenestras. 
G. Double trocar. 
H J. Efferent and afferent stoppers. 
I. Central stopper. 
absolute immunity from the admission of air, obtained by the use of the 
fountain syringe, render that instrument, or an apparatus constructed 
upon the same principle, absolutely indispensable to the use of the double 
canula. 
It is claimed for the double trocar that, while it has all the advan- 
tages of the single instrument, it possesses the additional advantage of 
establishing at the same time a complete appliance for the double current. 
It is claimed also, that from the copiousness of the current obtained by 
means of this instrument it has all the advantages of a large opening, 
without the dangers of haemorrhage, and with less risk of self-inocu- 
lation. 
This Instrument is recommended in the following conditions: A New Instrument for Pelvic Drainage. 
3 
With straight trocar and canula : 
I. Pelvic abscess. 
11. Retro-uterine hasmatocele. 
With straight canula alone and blunt point 
111. Pelvic abscess and hasmatocele, when a free opening is preferred 
and when there is a multiple sac. 
With the curved instrument: 
IV. Pelvic drainage after ovariotomy and abdominal operations. 
With straight canula alone ; 
V. The uterine cavity after the removal of intra-uterine and inter- 
stitial uterine fibroids. 
VI. The uterine cavity in acute puerperal endometritis, offensive 
post-partum vaginal discharges, for the application of cold and of astrin- 
gents in post-partum haemorrhage, and for the treatment of the female 
bladder. 
I. Pelvic Abscess. At the opening of this paper I stated that with 
rare exceptions a single evacuation, by whatever means, was not suffi- 
cient to destroy the pyogenic membrane of a pelvic abscess ; therefore 
the existence of pus in the pelvic cavity was an indication for the im- 
mediate commencement of the protracted treatment. 
Pelvic abscesses are most often unilocular; cases with multiple sacs, 
however, do occur. In case of doubt as to whether we have to do 
with a unilocular or a multiple abscess, by evacuating completely with 
the aspirator the subsequent presence or absence of fluctuation is easily 
determined by a careful examination. 
The method of operating now considered, being a substitute for the 
free opening, does not differ materially from that laid down in the text- 
books ; but at the risk of being prolix I shall describe it in detail, with 
some modifications. The patient, etherized and with a bandage passed 
around the waist, is placed upon the left side across a bed or upon a table ; 
the right limb sharply flexed, or, if preferred, in the lithotomy position. 
The uterus, if not anteverted, which is more often the case, should be so 
placed, if it be possible ; if necessary it should be held in that position 
with a sound.1 The diagnosis is then confirmed with an aspirator, the 
depth required to reach the fluid being carefully noted. 
Since a complete or even a partial evacuation in a unilocular cyst 
would cause it to become flaccid, and would render further operative in- 
terference exceedingly difficult if not dangerous, the least possible amount 
of fluid drawn the better. The most prominent part of the tumor hav- 
ing been ascertained, and the seat of the pulsation of large vessels 
avoided, the trocar, with concealed point and armed with the guard and 
with both rubber tubes in place (the afferent closed with a stopper, the 
i During the past year I saw a case of pelvic abscess in which the uterus was retroverted 
and bound down by adhesions. I have no doubt that the inflammation and subsequent 
suppuration were due to efforts employed to separate them. 4 
A New Instrument for Pelvic Drainage. 
efferent tied in a single knot), is introduced into the vagina upon the 
finger of the left hand and placed firmly against the tumor. With the 
left hand in the vagina, controlling the extremity of the trocar, the 
puncture is made in downward direction with a firm but steady force. 
The peculiar impression imparted as the instrument passes into the cav- 
ity is quite unmistakable. The previous arrangement of the tubes pre- 
vents a sudden escape of the fluid. The trocar is now withdrawn suffi- 
ciently to conceal its point, the guard secured against the vulva, and 
the tapes for retention applied. The last step is best effected by pass- 
ing them through the staple, around the limb, under the bandage around 
the waist, and finally tying or, what is better, buckling the extremities 
together in front. The patient being on the left side, the right tape of 
course is first applied, and will serve to retain the instrument until she 
is turned upon the back, when the other is adjusted. If the oper- 
ation is performed with, the patient on her back, of course both tapes 
are put in position at once. The patient' is now placed upon the back, 
near the edge of the bed, and the left tape adjusted. We may evac- 
uate the abscess at once, but the better plan is to attach to the afferent 
branch the tube of a fountain syringe charged with a disinfecting solu- 
tion, and suspended or held six feet above the bed, at the same time un- 
tying the knot in the efferent branch and placing its extremity in a 
vessel on the floor beside the bed. The trocar is now withdrawn with- 
out fear of displacement, the central opening of the canula is closed with 
a stopper, the stop of the syringe is opened, and the contents of the 
abscess are forced out by the strong current. 
We have now in position a convenient and ever ready appliance for 
the use of the double current, with little risk of displacement, of easy 
application by the most inexperienced attendant, and with slight annoy- 
ance to the patient. The frequency of the application should depend 
upon the nature of the discharge and its effect upon the system. I have 
usually commenced the treatment with three daily applications and one 
at midnight. Under all circumstances the application should be copious. 
The efferent current should be frequently interrupted, the cavity thus 
filled, and contact with every part of it secured. After a fair trial of 
the usual disinfectants I have returned to the use of a five per cent, 
solution of carbolic acid (four drachms to sixteen ounces of glycerine, 
soap, and water) as by far the most efficacious. 
11. Retro-Uterine Hcematoeele. Since the investigations of M. Nd- 
laton the surgical treatment of this affection has been confined to those 
urgent cases in which the life of the patient was imperiled from a 
distention that threatened rupture into the peritoneal cavity. The 
cases under my observation were of this character. In all, the treat- 
ment was by a primary free opening, followed by disinfecting injec- 
tions. The discharge, at first sero-sanguinolent, became putrid, de- A New Instrument for Pelvic Drainage, 
5 
mantling protracted and unremitting attention. Owing to the great 
tendency to close in spite of repeated dilatations, the method of treat- 
ment was reduced virtually to an opening of the size made by a 
large trocar. The patients recovered, but not until many weeks had 
elapsed, the most alarming symptoms of blood-poisoning frequently oc- 
curring. Notwithstanding the recommendation by most authorities of 
a free opening in the treatment of this affection, I am disposed to attach 
much importance to the method above suggested in connection with the 
treatment of pelvic abscess, for the reason that, as the aspirator indi- 
cated in all my cases, the contents of the cyst are composed, even in 
the late stages, not only of coagula but of a large amount of sero-san- 
guinolent fluid. After what seemed to be a complete evacuation after 
the free opening, the cavity continued to secrete for weeks a purulent, 
offensive discharge, as if from a pyogenic membrane. lam convinced 
that the entrance of air through such an opening was sufficient to break 
down and liquefy the coagula. That this process was materially expe- 
dited by the copious double current there can be no doubt. 
111. In Pelvic Abscess and Hoematocele, after free opening, the use of 
the straight canula with probe-point in connection with the fountain 
syringe, in the manner to be described when the treatment of the uter- 
ine cavity is discussed, will be found to render invaluable service. 
IV. Pelvic Drainage after Ovariotomy. When the operation has 
reached the stage prior to that of the closure of the wound, after applying 
a bandage around the body, the surgeon passes the left hand into the 
pelvis along the pedicle until it reaches a point in the reflexion of the 
peritoneum opposite Douglas’s fossa, and with the right hand introduces 
the trocar into the vagina, armed with its guard, its afferent and effer- 
ent tubes adjusted, and its point concealed. With bimanual manipula- 
tion the extremity of the instrument is placed against Douglas’s cul-de- 
sac, as low as possible below the uterine connection, without impinging 
upon the rectum, and held firmly in position. An assistant pushes the 
trocar through the vaginal septum, its passage being guarded and con- 
trolled by the operator’s left hand, still in the pelvis. This done, the 
point of the trocar is concealed by a slight withdrawal, the instrument 
tilted upward and forward, and the extremity of the canula protected 
by a probe-point.1 The guard and tapes are adjusted as in pelvic ab- 
scess, and the trocar is entirely removed,2 Of the use of the double cur- 
rent in pelvic drainage, special mention will be made later. 
For the conception of the idea of drainage in the after-treatment of 
ovariotomy, and its first application, the profession is indebted to the 
1 After introduction, Dr. Kimball reverses the curved canula. 
2 The straight canula Avith probe point introduced through the wound into the pelvis at 
the time of the operation, and reposed in the angle of the wound, would, it seems to me, ad- 
mirably carry out Professor Peaslee’s method of drainage, having also the additional advan- 
tage of the double current. 6 
A New Instrument for Pelvic Drainage. 
genius of Prof. E. R. Peaslee of New York, who first employed it 
through Douglas’s fossa. For the further development and perfection 
of this method, the credit belongs to Dr. Gilman Kimball of Lowell. 
This, I think, is fully substantiated by the following brief history. In 
1846, Dr. Handyside, of Edinburgh, after tying the pedicle, passed the 
ligatures through Douglas’s fossa into the vagina. In 1849, Dr. March, 
of Albany, suggested the idea. Professor Peaslee, not aware of this, did 
the same in 1854. The object of this procedure, as in the above cases, 
was simply to dispose of the ligatures. In 1855, in a case of ascites com- 
plicated with an ovarian cyst, Professor Peaslee passed an elastic cath- 
eter from the vagina up into Douglas's cul-de-sac, expressly for purpose of 
drainage. The method of passing the ligatures through the cul-de-sac of 
Douglas, as inaugurated by Dr. Handyside, was employed again in 1866 
by Dr. J. F. Miner, of Buffalo, by Dr. Gilman Kimball in 1867, and still 
later (I believe in 1871) by Dr. William Warren Greene, of Portland. 
The object of the operation in the three last cases was to establish drainage. 
In 1868, Dr. Kimball modified the operation by lodging the ligatures in 
a canula introduced per vaginam into Douglas’s cul-de-sac. More recently 
he again modified it, bringing the ligature outside of the wound (except 
when the clamp was used) passing the canula into Douglas’s fossa and 
allowing it to remain as long as it served to conduct off any matter that 
had accumulated in the pelvic cavity. Pelvic drainage has been fre- 
quently employed since, and the subject has been discussed by able 
authorities at home and abroad.1 A complete history of this impor- 
tant subject would far exceed the scope of this paper. I cannot, how- 
ever, resist the opportunity to vary somewhat its descriptive character, 
by submitting without comment the condensed histories of a few cases 
from the literature of the subject (confining myself to three authorities), 
as illustrative of the primary and secondary indications and applications, 
and of the results of pelvic drainage after ovariotomy. 
The following is the first case on record of primary drainage through 
Douglas’s cul-de-sac, by Prof. E. R. Peaslee, of New York.2 “ This was 
a case of ovarian tumor complicated with ascites, one hundred and six 
pounds of fluid withdrawn by a previous tapping. In anticipation of con- 
tinued secretion from the distended peritoneum, after operation a gum- 
1 Prof. E. R. Peaslee: Diseases of the Ovaries, pages 437, 438; American Journal of 
Obstetrics, August, 1870, pages 509, 510; American Journal of the Medical Sciences, 
January, 1856. Dr. Gilman Kimball ; Boston Medical and Surgical Journal, May 28, June 
11, August 6, 13, September 17, 1874. Mr. Spencer Wells : Diseases of the Ovaries, 1865, 
page 393, 1873. Dr. Skene, Brooklyn : New York Medical Record, October 1, 1873. Dr. J. 
Marion Sims : New York Medical Journal, December, 1872, April, 1873. Dr. W. W. 
Greene, Boston Medical and Surgical Journal, Ixxxiv. 137. Mr. Thomas Keith: Transac- 
tions of the London Obstetrical Society, v. 62 ; also his cases Nos. 36,39, 59, 81, 101, 
and 103. Dr. J. F. Miner : Buffalo Medical and Surgical Journal, June, 1866, September, 
1866. ,i 
2 Ovarian Tumors, pages 510-518. American Journal of Obstetrics, August, 1870. A New Instrument for Pelvic Drainage. 
7 
elastic catheter was passed by the vagina through Douglas’s cul-de-sac 
into the peritoneal cavity, and tightly corked. Patient did well until fifth 
day, when symptoms of septicaemia appeared, and on removing the cork a 
small amount of foetid fluid escaped. Injected a quart of luke-warm water 
through the tube into peritoneal cavity, and allowed as much to flow 
back. On repeating this, the patient remarked, ‘ I feel as refreshed as 
if I had taken a bath,’ and became bright and natural. Septicsemic symp- 
toms would, however, return in eight or twelve hours. Injections of ar- 
tificial serum composed of one or two drachms of common salt to the pint 
of pure water ; later, solution of the liquor sodte chlorinatse, from one to 
two drachms to the pint of water, alternately with the salt and water, 
was employed two or three times daily for seven days, when, there being 
no longer any odor of decomposition in the fluid obtained through the 
tube, the latter was removed.” Result, recovery.1 
The following are abstracts of Dr. Kimball’s cases from 1867 to 1875, 
giving the indications for application and results of primary drainage ; 
these include the first cases in which the ligature was lodged in a canula 
o O 
and also the first cases in which the canula was used alone. 
Case I. Single ovary. Complications: chronic adhesions, anteriorly, 
parietal, omental, and colon; laceration of peritoneum ; escape of con- 
tents into peritoneal cavity. Pedicle: short and thick ; tied in two 
parts; cut close ; dropped into pelvis. Method of drainage: ligatures 
passed through posterior uterine cul-de-sac and out by the vagina. 
Symptoms: excessive vomiting, relieved upon escape of putrid dis- 
charge from vagina ; no further interruption to convalescence. Result, 
recovery. 
Case 11. Single ovary. Complications : ascitic fluid, chronic ad- 
hesions, parietal and omental. Pedicle : slender, ligated. Drainage: 
ligature passed through Douglas’s fossa. Symptoms : third day, pain 
in abdomen ; vomiting ; quickened pulse ; prostration. The same day 
free offensive discharge per vaginam. Result, recovery. 
Case 111. Single ovary. Complications : ascitic fluid ; adhesions 
anteriorly, parietal and omental. Separation followed by free haemor- 
rhage, ligature required ; several slu’eds of peritoneum and omentum 
ligated and removed. Pedicle: short, slender, ligated. Drainage: 
O 7 7 o © 
ligatures passed out through vaginal cul-de-sac. Symptoms: favor- 
able till eleventh day, when signs of tetanus appeared; abundant 
flow of bloody serum immediately after operation, and continued to a 
greater or less extent throughout; was offensive and foetid on the 
second day. The fact that there were no signs of septicaemia proved 
the value and success of the drainage, and without the accidental com- 
1 Professor Peaslee has used drainage in every case of ovariotomy since 1855, in which 
there was anything to drain from the peritoneal cavity after that operation ; but he has always, 
since then, preferred to drain through the abdominal wound, and not by the cul-de-sac. 8 
A New Instrument for Pelvic Drainage. 
plication, recovery would have very likely resulted. Result, death 
from tetanus, twentieth day. 
Case IV. Single ovary. No pedicle ; tumor attached and identi- 
fied with entire broad ligament, and portion of the fundus uteri; 
breadth of mass, six inches ; division into six parts, each embraced in a 
separate ligature, uterus cut through, its centre having .been trans- 
fixed by strong ligatures and tied separately. Drainage: passage of 
the latter ligatures through canula in vaginal cul-de-sac. Symptoms : 
indications of peritonitis after twenty-four hours, namely, vomiting, 
tympany, continuing three days, when a free flow of bloody serum be- 
gan from the canula. Immediate cessation of above symptoms. Later, 
discharge offensive, nature' improved by the use of disinfecting injec- 
tions through the canula. Canula removed after eight days ; discharge 
continued, but gradually diminished and ceased at the end of ten days. 
Result, recovery. 
Case V. Single ovary. Complications: tapping previous to oper- 
ation ; ascitic fluid ; rupture of the cyst; prolonged operation ; adhe- 
sions parietal and omental, portions of omentum removed. Pedicle : 
tied in two parts, dropped back. Drainage: ligatures passed through 
Douglas’s fossa through a canula. Symptoms : first day, pulse 130- 
140, abdomen somewhat distended, slight pain. Third day, pulse 180, 
no pain, no tympany; p. m., pulse 140, dark discharge from vagina, 
the first since operation. Fourth day, morning, pulse 132, no vaginal 
discharge; six a. m., vaginal discharge returned ; twelve m., discharge 
continued; two p. m., tired and nervous, slight discharge from the 
vagina, bowels distended, clammy sweat, cold feet. Fifth day, a. m., 
discharge from wound slight, distention continued, return of heat to 
extremities; p. m., two ounces of foetid discharge from vagina. 
Eighth day, discharge more abundant, pulse 130. Tenth day, ten 
ounces sero-purulent, dark-colored, offensive fluid from peritoneal cavity, 
symptoms more alarming. Twelfth day, pulse 110, offensive discharge 
continued from abdomen and vagina, incision not inclined to heal 
soundly- Fifteenth day, pulse 100, discharge from abdomen dimin- 
ished and less offensive, vaginal discharge continued. Result, recov- 
ery, after protracted convalescence. 
Case VI. Single ovary. Complications: tapping previous to 
operation; adhesions parietal and omental; profuse haemorrhage from 
the same ; portions of omentum cut away and stump reposed in incis- 
ion ; escape of fluid into cavity. Pedicle: tied in two parts ; dropped. 
Drainage : ligature passed by a canula through Douglas’s fossa. Symp- 
toms : two days after operation, discharge of bloody serum ; ceased 
on the third and did not return ; symptoms favorable up to fourth day ; 
then became alarming, such as pain, distention, nausea, vomiting, and 
quickened pulse. In absence of surgeon, nurse passed a female cathe- A New Instrument for Pelvic Drainage. 
9 
ter into left iliac fossa and removed ten ounces of foetid fluid ; imme- 
diate relief. Result, rapid disappearance of threatening symptoms, 
speedy recovery. 
Case YII. Both ovaries. Complications : burst cyst; escape of 
contents into peritoneal cavity; adhesions general and to viscera. Ped- 
icles : both slender, short; cut close to tumor ; dropped back. Drain- 
age : ligatures twisted together, passed, through Douglas’s fossa, 
through a canula. Symptoms : first day, a. m., slight pain in abdo- 
men ; vomiting occasionally as before operation. Second day, nausea; 
pulse 110 ; no discharge through canula. Third day, slight discharge. 
Sixth day, pulse 112 ; vomiting continues ; slight distention ; discharge 
from vagina abundant and offensive. Later, escape of discharge through 
incision, that from vagina in no way diminished; antiseptic injections 
through canula and into abdominal cavity produced no favorable effect 
upon the quantity or quality of the discharge; continues unabated. 
Result, death from septicemia, twelfth day. 
Case YIII. Single ovary. Complications : ascitic fluid; none es- 
caped into cavity. Pedicle : broad, thick ; clamp. Drainage : angle 
of wound, and ligature passed through vaginal cul-de-sac through can- 
ula. Symptoms: first day after operation, bloody serum passing 
freely from canula. Fourth day, pain in the bladder; discharge from 
canula ceased. Sixth day, free discharge of offensive matter forced 
through the incision ; injection through angle of the wound every few 
hours. Symptoms favorable. Convalescence interrupted by an attack 
of diarrhoea, lasting four days. Result, recovery. 
The following are notes of other cases of Dr. Kimball, that came 
more or less under my observation : 
Case I. Large cyst. One ovary. Complications: adhesions, pari- 
etal, omental; profuse hmmorrhage ; walls everted. Pedicle : ligated, 
drawn up and reposed in the angle of the wound. Drainage : sin- 
gle curved trocar; cul-de-sac. Symptoms: escape of bloody serum 
twelve hours after operation. Third day, passage of rectal injection 
through canula, and later, fgecal matter. Canula removed. Pain, dis- 
tention, restlessness, evidence of impaction of fasces, relieved by oil 
and afterward copious soap and water enema. Result, subsequently 
rapid recovery. 
Case 11. Both ovaries, in a patient aged* seventy. Complications : 
enormous distention ; fifty inches; extensive adhesions to parietes, 
omentum, intestines, pelvis. Operation protracted; large portions of 
peritoneum and omentum ligated and removed ; escape of fluid into 
cavity ; tumor and contents weighed one hundred and fifty pounds. 
Pedicle : clamp and ligature ; the last reposed in angle of wound. 
Drainage : canula through Douglas’s fossa. Symptoms : bloody se- 
rum first two days; displacement of canula fourth day. No further 10 
A New Instrument for Pelvic Drainage. 
discharge, no untoward symptoms. Result, slow but complete re- 
covery. 
Case 111. One ovary. Complications: oedema of extremities; 
great distention intensified by respiration ; infiltration of walls of abdo- 
men ; burst cyst. After closure of the wound ascitic fluid welled up 
through angle of wound. Drainage : canula, cul-de-sac. Symptoms : 
abundant flow of serum for several days. No serious symptoms. Re- 
sult, recovery rather slow but complete. 
Mr. Spencer Wells’s cases, showing secondary indication for drain- 
age, are as follows : 
Case I. Single ovary. Complications : tumor in connection ; ex- 
tensive adhesions to omentum and bladder. Pedicle: lio-ated and re- 
turned. Symptoms: third day, sharp pain, relieved after uterine 
discharge, resembling menstruation ; -continued well until ninth day. 
Later, sleepless night from pain and flatulence ; typhus symptoms ; dry 
tongue, dilated pupils, flushed face, drowsiness. An accumulation of 
fluid detected in pelvis per vaginam. Puncture with trocar, five ounces 
dark, bloody serum, ammoniacal odor, removed. Tenth day, pulse 112, 
95, 92. Typhus condition aggravated, as discharge from vagina had 
ceased ; examination revealed fluid still present in vaginal space. Punct- 
ure again resulted in removal of ten ounces of fluid ; more putrid than 
that of the day before, and containing pus. Chassaignac’s drainage tube 
passed through the two punctures forming a loop. Free discharge 
through tube for several days; rapid improvement. Tube removed 
twenty-eighth day; thirty-fourth day sat up; forty-second day left for 
home ; one month later was in perfect health. 
Case 11. Single ovary ; no adhesions. Pedicle : clamped. Symp- 
toms ; second day, flatulent distention of abdomen ; removal of clamp 
necessary ; pulse 130. Fifth day, free dischai’ge of dark, bloody serum 
from wound. Sixth day, discharge free, pulse 116. On ninth day, 
also on tenth and eleventh, discharge still foetid, but more purulent. 
Twelfth day, patient very low ; a soft swelling found behind the uterus. 
This Avas punctured through the cul-de-sac, giving escape to a pint of 
serum with blood and some pus. Thirteenth day, free suppuration from 
wound ;p. m., a free discharge of foetid pus by the vagina. She gradu- 
ally sank, and died on the twenty-sixth day. 
Post-Mortem. No signs of general peritonitis ; bottom of Douglas’s 
fossa and cavity holding three or four ounces of pus. The opening 
through Douglas’s fossa made with trocar was quite closed. It is to he 
regretted that a freer opening was not 'made and left open. 
Case 111. One ovary. Complications : adhesions, parietal, pel- 
vic. Pedicle : ligated. Symptoms : forty-seven hours after operation 
stitches removed, wound seemed firmly united ; nine p. m., attack of 
vomiting, escape of reddish serum from angle of wound. Fifth day, A New Instrument for Pelvic Drainage. 
11 
pulse 140, abdomen tympanitic, evidently containing fluid. Evidence 
of fluid high up behind the uterus. Vomiting with prostration contin- 
ued, and ou sixth day pulse 160 ; a half-ounce of reddish grumous fluid 
from open angle of the wound. At midnight wound commenced dis- 
charging, and then the symptoms became more favorable. Seventh day, 
evidence of foecal impaction ; relieved ; pulse fell at once from 160 to 
1B0; discharge of curdy fluid. Eighth day, free discharge from the 
wound. Evidence of fluid behind the uterus still existing; a trocar 
passed into Douglas’s fossa gave vent to three and a half pints of black, 
foetid, tarry fluid. Sixteenth day, trocar again introduced, and one 
pint of fluid discharged. Seventeenth day, canula replaced and more 
fluid escaped and continued to do so all night. On twenty-first day, 
discharge free, foetid, yellow, and purulent; pulse 140. Twenty-fifth 
day, discharge continues ; canula withdrawn ; the flow ceased the next 
day. By probing the cavity one ounce of fluid removed. Result, death 
on twenty-ninth day. 
Post-Mortem. Recto-vaginal pouch empty ; utero-vesical pouch filled 
with creamy pus ; pus found incarcerated between the coils of intestines, 
forming a large number of abscesses. 
We come now to the consideration of the use of the double current 
in connection with drainage. As we have seen, the cessation of the 
discharge, which was invariably followed by alarming symptoms, was 
due to the obstruction of the canula. This was constantly proved, from 
the fact of its return after free injection. Upon examination of the can- 
ulas that had been obstructed shortly after the operation, I found the 
closure to be due to hardened coagula, that required considerable force 
to detach. When the obstruction took place some days later, it was evi- 
dently caused by an accumulation of thick, tenacious, sero-purulent or 
ichorous matter, exceedingly difficult to dissolve and wash away with 
a single current. 
From a careful study of the foregoing cases, we venture to offer the 
following suggestions. The canula in position as above described, as in 
pelvic abscess, the hose is attached to the afferent branch and the effer- 
ent tube is placed in a vessel beside the bed. The first few hours a sero- 
sanguinolent discharge usually flows of its own accord, but this being 
the usual stage for the formation of coagula, at least as soon as six hours 
after the operation a current of tepid water, slightly carbolized, should 
be allowed to make the circuit of the instrument, merely for the sake of 
insuring patency. If at the end of four or five days the fluid escapes 
in the same condition as when it entered, and there are no untoward 
symptoms present, in all probability the necessity for drainage , has 
ceased, and the canula may be removed with impunity. Leaving the 
instrument in position a longer or shorter period, even after this stage 
its presence being, in my opinion, indifferent, must depend upon the 12 
A New Instrument for Pelvic Drainage. 
judgment of the surgeon. If, on the other hand, early after the opera- 
tion, or even a few days later, we discover local or general signs of pu- 
trid accumulation, the injection should be copious, frequent, and highly 
disinfectant, and the case treated precisely as one of abscess in any 
other part. I see no reason why, by cutting off the efferent current 
the entire abdominal cavity may not be thoroughly washed out. 
Y. Treatmevit of the Uterine Cavity after the Removal of Intra- 
Uterine and Interstitial Fibroids.—lf there be great danger from 
o “ 
blood-poisoning, when the exciting cause is situated in the cellular 
tissue, how much greater must he the tendency when the nidus of in- 
fection is located in the cavity of an organ so rich in vessels and nerves 
as the uterus. The uterus in patients enfeebled by years of constant 
metrorrhagia tolerates most astonishingly the violent and protracted 
manipulation often necessary in the enucleation of intra-mural fibroids, 
but death results in a comparatively short time from the confinement 
within its walls or cavity of the smallest quantity of putrid matter. 
The cases are by no means rare in which death has taken place from 
septicaemia, incident to a degenerating fibroid, and for want of a perfect 
drainage for the removal of purulent and putrid matter, following the 
removal of such growth by operation. 
For the prevention of such unfortunate occurrences, from personal 
experience the use of this instrument is most earnestly recommended. 
The method of its application is as follows: The patient being on the 
edge of the left side of the bed, the surgeon seats himself a little below 
the pelvis. A No. 4 fountain syringe, previously charged with a dis- 
infecting fluid, is suspended or held six feet above the bed. The hose 
is coupled with the afferent branch of the canula. The canula is now 
introduced into the patulous os, and held in position with the left hand ; 
this done, the nurse arranges the bed-pan and places the afferent tube 
(four inches long) of the canula in it. The suction extremity of a 
Davidson’s syringe is placed in the bed-pan, the other in a vessel at the 
surgeon’s feet. Everything being in readiness, the stop of the hose is 
opened. As the fluid begins to enter the pan, having made the cir- 
cuit of the canula and the uterine cavity, the surgeon simultaneously 
commences with the Davidson’s syringe to pump the fluid into the 
vessel at his feet. In this manner any amount of the fluid can be em- 
ployed without once overflowing the pan and wetting the patient, an 
accident most annoying, not to say dangerous, since it necessitates an 
immediate change of clothing. As in pelvic abscess, during the passage 
of the fluid the current should be frequently interrupted, in order to 
secure its contact with every part of the suppurating surface. In a 
large and patulous uterus no danger need for a moment be feared. In 
my cases this procedure occasioned a sense of fullness, but not the 
slightest pain or discomfort. This treatment was employed in one of A New Instrument for Pelvic Drainage. 
13 
my cases (twice daily by myself, and at midnight an injection through 
the drainage tube by the nurse) for eighteen days, the occurrence of 
menstruation being no contraindication. The quantity used was always 
profuse, not less than two and three quarts. Again I have to say that 
I relied mainly upon the employment of a solution of carbolic acid, four 
drachms to sixteen ounces of glycerine, soap, and water. Though the 
tumor enucleated was six inches in diameter, its removal leaving an 
enormous suppurating surface, from one end of the treatment to the 
other there was not the slightest evidence of septic poisoning, and the 
patient made a rapid recovery. 
VI. The Treatment of the Uterine Cavity in Acute Puerperal En- 
dometritis and in Offensive Post-Partum Vaginal Discharges. For 
a clear and comprehensive view of the relations of puerperal fever 
to the infective diseases and pyaemia, I would in this connection call 
attention to the recent exhaustive discussions upon the subject at the 
instance of Mr. T. Spencer Wells, by the Obstetrical Society of Lon- 
don.1 The editor of the Obstetrical Journal of Great Britain thus 
closes a short review of this memorable scientific contest: 2 “ Now the 
profession may know what are the latest and most mature thoughts of 
the best obstetrical authorities in England,3 upon a disease in which 
few indeed are not gravely interested. Every particle of evidence re- 
lating to it has* been resifted and retested. The very term puerperal 
fever has had a struggle for its existence, and although the time does 
not seem to have arrived for its abolition, its right to exist is strongly 
denied by several. On many points there still remains much obscurity 
and difference of opinion. On others, again, there is a happy unanim- 
ity. All agree that the puerperal condition of a woman is one which 
renders her liable to be affected by influences which at another time 
might produce no serious mischief. A large majority of the Fellows 
believe that puerperal fever is, caused by septicaemia, autogenetic or 
communicated. The very soul and strength of the discussion rests in 
this thought. Here is the idea which cannot be too vividly impressed 
upon the minds of all obstetricians and midwives. Upon its entire 
acceptance and proper apprehension depends the safety of the mother. 
An offensive post-partum vaginal discharge must not be permitted. It 
must be prevented by skillful management of the third stage of labor, 
by insuring efficient Jochial drainage, and, if necessary, by washing out 
the utero-vaginal canal with antiseptic fluid. No one now doubts the 
communicability of the poison which exists in putrid lochia, or that the 
most minute quantity of it conveyed to a healthy puerperal woman 
1 Obstetrical Journal of Great Britain, May, June, July, August, 1875. 
2 Idem, September, 1874, pages 392, 393. 
3 The editor should have said also “America,” since Prof. Fordyce Barker, of New York, 
took an active part in the discussion. 14 
A New Instrument for Pelvic Drainage. 
may produce in her a fatal complaint. A responsibility of a most seri- 
ous nature attaches itself to all those who have in any capacity to deal 
with lying-in cases. A mystery hangs over the nature of this pyogenic 
fluid, h'ut the laws which relate to its origin and propagation are suffi- 
ciently well known to enable us to do much toward checkiyig its genera- 
tion and preventing the extensio7i of its maligyiant action ivhen begotten.” 
Notwithstanding their able opponents, so far as my experience goes 
I am disposed to place myself with the majority of the Fellows in regard- 
ing septicaemia, autogenetic or communicated, as the cause of so-called 
puerperal fever ; hence it has been my habit for years to employ dis- 
infecting vaginal injections after every case of labor. 
Again, as a further evidence of a growing interest in the subject, Dr. 
Griinewald, of St. Petersburg, details the measures which were adopted 
at the lying-in asylum in that city to prevent infection.1 “Acting on 
the theory that some wound or laceration of the parts concerned in 
labor presented a nidus for the reception of the disease, attention has 
been directed toward these points, and the result has been happy. The 
most common starting-point was held to be the vagina or the os uteri. 
At these points the poison was absorbed, and the disease traveled on- 
ward along the planes of connective tissue. The rule observed was to 
examine every woman by the aid of a speculum immediately after labor. 
Every laceration or abrasion was then carefully attended to, and as 
soon as a morbid appearance, such as diphtheritic deposit or the 
like was noticed, a solution of carbolic acid and water (one part to 
twelve) was applied, or the sesquichloride of iron in a similar propor- 
tion. If the disease advanced and there were signs of endometritis, 
injections were practiced by means of a double catheter. The indica- 
tions for intra-uterine injections were (1) retention of membranes, (2) 
retention and decomposition of coagulated blood, (3) lochiometra, (4) 
in any form of .endometritis, and (5) in secondary haemorrhage. In 
fact, it was customary to use a weak solution of carbolic acid (one part 
to four hundred) as an intra-uterine injection, in all cases, immediately 
after labor, by way of prophylaxis. 
The necessity-for the most thorough application of disinfecting meas- 
ures at the slightest evidence of an offensive post-partum vaginal dis- 
charge being placed beyond question, the double canula and fountain 
syringe will be found an invaluable means for the accomplishment of 
this end. The method of application is the same as that employed 
in treatment of the uterine cavity after removal of fibroids. 
VII. The method of application in the use of cold and astringents 
in post-partum hoemorrhage, being the same, does not require a separate 
mention. 
VIII. In the treatment of chronic cystitis in the female, the canula 
1 American Practitioner, October, 1875, page 337. A New Instrument for Pelvic Drainage. 
15 
is employed, with long efferent tube, as in pelvic abscess after simple 
puncture.1 
Originality is here claimed for the double trocar only ; for the double 
canula is mainly an improvement upon those hitherto in use. The 
compactness of the instruments, available for so many different and 
important ends, renders it useful as well to the general as to the 
special practitioner. The double trocar is manufactured by Messrs. 
Codraan and Shurtleff, of Boston, for whose patience and painstaking 
I desire to express my sincere obligations. 
1 The curved canula with probe point admirably answers the purpose of a double male 
catheter.