QUIT-SHOT, AM) OTHER W OUXDSOE T1 IE PERITONEUM, JIY HUNTER McGUIRE, M.D., Richmond, Virginia, Crofrtsor of Surgery, Mrdicat College of Virginia.) lioiir. J. Marion Sims, republished in the Richmond and Louis- ville Medical Journal, February, 1873, it is very well shown, by the seven pust-mortem examinations made by Dr. Sims, and the 26 post-mortems in the eases occurring in the practice of Mr. Wells, that the cause of death was due to the presence of pent-up colored acrid serum in the perito- neal cavity. The writer says that death may be due to shock, or exhaustion, or hemorrhage, or heart-clot, but these are of rare occurrence; and in 37 out of the 39 cases examined, death was “clearly traceable to the poison- ous fluids effused in the peritoneal cavity.” lie proposes to prevent this col- lection by inserting a drainage tube through the Douglass cul-de-sac into the cavity of the peritoneum, and drain oir the septic fluid as rapidly as it is formed. He has employed the drainage tube for this purpose in four cases, and ascribes the recovery of two of bis patients to its use. I was convinced, after reading this paper, of the correctness of the author’s views in regard to the necessity for drainage after Ovariotomy, and determined to use it in the next ease I operated on. The following cases are reported as bearing upon this subject of drainage after wounds of the peritoneum, and not be- cause they have any special interest as simple cases of Ovariotomy: Miss S. W., act. 48 years, single, from Prince Edward county, Va., has enjoyed good health until six years ago, when she noticed some enlargement of the abdomen, and some uneasiness and hardness in the right groin. Upon examination, a tumor about the size of a turkey egg was discovered. It in- creased very slowly, if at all, until February 15th, 1873, when it began to grow rapidly. Between the 15th of February and the 15th of April, the measurement around her abdomen at the umbilicus increased five inches. When the tumor began to grow, but before it had increased very much, she consulted the eminent surgeon, Dr. Mettauer, of this State, who advised against any surgical interference. She was so completely disabled by the tumor in May, that Dr. J. L. White, of Farmville, her family physician, sent her to me. She was much emaciated, her stomach and bowels in an ex- ceedingly irritable state. The tumor was still growing, and her general health rapidly declining. Had never been tapped. She measured 45 inches around the largest part of the abdomen. Diagnosis—Multilocular ovarian cyst of the right side. May 27th.—Chloroform was administered by Dr. Taliaferro, and, assisted bv Drs. Thomas, Upshur and Ross, of this city, and Drs. Dunn and Leigh, of Petersburg, I performed Ovariotomy. There was nothing unusual in the 6 operation. The large, thick-walled single cyst was attached to the anterior abdominal wall by adhesions which readily gave way, except at the upper and right portion, where they were so thick and strong that I was obliged to use the scissors and knife. There were no adhesions on its posterior sur- face. The pedicle was secured in a clamp, and the blood, amounting to one or two ounces, which had escaped from the torn and cut adhesions, carefully sponged from the cavity. The cyst weighed three pounds, and contained forty-three pints of fluid, a little darker but very much like healthy urine in appearance. Having determined to use the drainage tube suggested by Sims, I passed a large trocar through Douglass’ cul-de-sac into the recto-vaginal pouch of the peritoneum. Withdrawing the stylet, a piece of gum-tubing which I supposed had been properly prepared, was carried through the canula. One end of this tube projected several inches beyond the vulva, and the other was carried through the pelvic and peritoneal cavity, and was intended to have been fastened at the lower angle of the abdominal incision, but I found the gentleman to whom I entrusted the preparation of the tube had misunderstood my intention in regard to it. He had punched holes in it throughout its entire length. Not having an- other tube at hand, I withdrew the one which had been inserted, and closed the wound in the ordinary way with silver sutures. A solution of per-sul- phate of iron was applied to the stump of the pedicle, and cotton-batting laid on the belly and held down with a flannel roller. The operation lasted thirty-five minutes. She recovered slowly from the effects of the chloro- form, and did not re-act well for several hours. In twenty-four hours the nausea from chloroform had passed off, and she was quiet and hopeful. Has slept some, has no pain, and takes with some relish champagne or but- ter-milk in very small quantities. At the end of the second day, or forty- eight hours after the operation, nausea and vomiting became almost inces- sant. She was anxious and restless; pulse 130; temperature 102°, I left her that night, thinking she would die in twenty-four hours. The next morning I was surprised to find her much better; pulse 98 ; tempera- ture 99° ; nausea gone; spirits cheerful. I was entirely at a loss to account, for the change, until on examining the wound, I found the folded sheet which had been placed under her hips saturated with bloody serum, which had escaped from the vagina through the opening made into the Douglass cul- de-sac. More than half a pint had been discharged in this way, and con- tinued to escape for hours afterwards. Dr. Taliaferro, the physician at the Infirmary, who used the catheter for this patient, informed me that the dis- 7 charge was acrid and very offensive, and he found it necessary to use soap and water and disinfectants freely, to rid his hands of the odor left by the discharge. She told me afterwards that she knew exactly when the dis- charge took place. From that moment she began to improve. The clamp came off on the twelfth day. The wound closed and she was out of bed some time during the fourth week. I am very well satisfied that this lady owes her life to the puncture made through the vagina into the peritoneal cavity and the drainage which took place through it. In a letter just received from her, she says she is in bet- ter health than she has been for years. M rs. M., let. 4”), wife of a prominent physician of this State, naturally of good constitution, robust, witjfc obese tendency, weighing when well, 190 lbs. Has had eight children, the youngest now seventeen years old. About one year after the birth of the last child, she was supposed to be again preg- nant, and at the end of nine months discharged .a large hydatiform mole, the birth of which was attended with violent and protracted pain, and fol- lowed by profuse and almost fatal hemorrhage. lias had occasional attacks of pain and tenderness in the left ovarian region since that time. Seven months ago, she discovered a tumor there, which apparently remained sta- tionary for two months, and then began to grow rapidly. During the last three months, has had repeated and violent attacks of pain in the abdomen, attended with fever. She measures around the abdomen at the umbilicus forty-seven inches, and from the ensiform cartilage to the pubis twenty inches. The uterus is central, slightly prolapsed and fixed ; its cavity mea- sures three and a quarter inches. She has nausea, occasional vomiting, dyspnoea, and attacks of faintness which are very alarming. The functions of nearly all of the abdominal organs are obstructed by the size of the tu- mor. The urine i< scanty, loaded with lithates, and albumen frequently but not constantly present. No casts have been found in it. I saw this patient for the first, time August 5th, 1873; and a day or two afterwards, for the sake of temporary relief, tapped her, and succeeded, after much trouble, in drawing off about a gallon of dark reddish albuminous fluid. The more urgent symptoms were immediately relieved by this; her appetite returned, and she rapidly improved in strength. In fifteen days, how- ever, the fluid re-accumulated, and the abdomen regained its former dimen- sions. As the weather was very warm, and her general condition still un- favorable, I would have repeated the tapping, in order to gain time, if I could have found a cyst large enough to afford relief by paracentesis. As I 8 could not discover this, and the symptoms were urgent, I decided to operate at once. Diagnosis—Multilocular ovarian tumor. Prognosis—Unfavorable. August 30th.—Assisted by Professors McCaw, Cunningham and Wellford, and Drs. Thomas, Taliaferro and Skelton, I performed Ovariotomy. A mix- ture of chloroform, ether and alcohol was used as an anaesthetic. An inci- sion five inches long was made between the umbilicus and pubis through the skin and a layer of fat more than two inches thick. The tumor had numer- ous attachments, principally parietal, many of them slight and easily broken down, but some of them strong, thick, fleshy bands, which were separated with difficulty. The pedicle was long and narrow, and twisted twice upon itself, showing that the tumor had undergone spontaneous rotation during some period of its course. Atlee’s clamp was used to secure the pedicle, and the abdominal cavity thoroughly cleared of blood which had oozed from the torn adhesions. For the purposes of drainage, a large trocar was passed through the Douglass cul-de-sac into the peritoneal cavity. The abdominal wound was closed with deep and superficial silk sutures, the former includ- ing the peritoneum. The abdomen was padded with cotton-batting, a flan- nel bandage placed around it, and the patient removed to the bed. As soon as she recovered from the effects of the anaesthetic, one-third of a grain of morphia was administered hypodermically. August 31st, 5 A. M —Pulse 120; temperature 101°. Had several nours of refreshing sleep during the night. Complains of slight abdominal sore- ness. Catheter used, and one-fourth of a grain of morphia given. Asked for sweet milk, and has taken it in small quantities. 8 A. M.—Some nausea; vomited once for the first time since the opera- tion. Iced champagne in teaspoonful doses given. No drainage. 9 A. M.—Pulse 120; temperature 102°; is quiet; nausea gone. Has taken one pint of milk in the last twenty-four hours. Napkin stained with red serous discharge from the vagina. September 1st, A. M.—Slept the greater part of last night; pulse 104; temperature IOO20; the napkin showed slight colored discharge from the vagina. From this period no particular event occurred until September 10th, when the clamp came away. The pulse varied from 104 to 112, and the temperature from 99.5° to 102°. The patient was nourished almost exclu- sively with milk, and kept moderately under the influence of morphia. In consequence, doubtless, of the presence of the large quantity of adipose 9 tissue, free suppuration took place about all of the sutures. Around the deep sutures large collections of matter formed, and continued to be dis- charged for some days after the stitches were removed. The cplored dis- charge from the vagina ceased about the fifth day, and was followed by a free discharge of pus, which lasted for three or four days and then gradu- ally stopped. September 11th.—Bowels moved for the first time since the operation. Complains of some pain in the rectum and irritable bladder. From this date she continued slowly to improve; the irritability of her bladder and rectum passed off; her appetite and strength gradually returned as the pulse and temperature diminished. She is now (Nov. 1st) well and going about. Mrs. M. M., a‘t. 49 years, had one child 11 years ago; was admitted into the College Infirmary September 30th, 1873. About seven years since, she had a dull pain in the right iliac region, and soon afterwards noticed some in- crease in the size of the abdomen. At this time, she believed herself to be pregnant, and did not become convinced of the mistake until nine mouths had passed. Has suffered occasional attacks of pain in her back and lower part of the abdomen ; but until a few months ago these attacks have not prevented her from attending to her ordinary duties. About two years after the pain and swelling commenced, her bladder began to trouble her; micturition be- came difficult and frequent. This has gradually increased, and is now the source of her greatest distress. She has a large cystocele protruding from the vulva, and is unable to empty the bladder unless she pushes the tumor back into the vagina and presses forcibly upon it with her fingers. Pain in the abdomen has lately become constant, sometimes excessive. She represents it as beginning in the right side and extending up as far as the shoulder. The recumbent posture increases the pain. She sleeps very little, and chiefly in a sitting position. Her appetite is tolerably good; pulse about 90; tongue clean and bowels regular. The abdomen measures in circumference at the umbilicus 441 inches; from eusiform cartilage to pubis 19 inches; from anterior superior spinous process of the right side to umbilicus 11 if inches; from anterior superior spinous process of left side to umbilicus 101 inches. The uterus is movable, not displaced; cavity four inches long. Diagnosis—Multilocular ovarian tumor of the right side. Prognosis—Favorable. 10 October 2d, 1873.—Her bowels having been well emptied by a dose of castor oil administered the evening before, she was placed upon a table, and a mixture of chloroform, ether and alcohol given by Dr. Talia- ferro. The following gentlemen were present and assisted in the operation: Professors Cunningham, Wellford and Manson, and Drs. Thomas, Ross, Watkins and Upshur. After making an incision down to the cyst and separating some of its ad- hesions, which I accomplished with much difficulty (so intimately were they blended together), I removed by the trocar about three gallons of dark, por- ter-colored fluid, and then attempted to turn out the empty cyst. I found it, however, closely adherent to the abdominal walls and viscera. By a thin layer of organized lymph, the cyst wall was sealed to everything it touched. After much difficulty I succeeded in separating all of its adhesions, both parietal and visceral; and turning the tumor out, secured the pedicle, which was large and thick, in Atlee’s new clamp. There wras free oozing of blood from the torn adhesions, but it gradually ceased on exposing the parts to the air. No ligature was required. The cavity of the abdomen was thoroughly cleansed of blood, and for the purposes of drainage a trocar was carried, as in the preceding cases, from Douglass’ cul-de-sac into the peritoneal pouch between the vagina and rectum. The abdominal wound was closed with deep and superficial silk sutures. She recovered slowly from the effects of the auiesthetic. When conscious- ness returned, she became restless and complained of great pain in the abdo- men. She had nausea, with occasional attacks of vomiting, cold extremi- ties, feeble pulse, and gradually sunk and died from exhaustion thirty hours after the operation. As her friends were anxious to remove her body at once, a post-mortem examination could not be obtained; but Dr. Taliaferro, in removing the clamp, cut the sutures and exposed a portion of the abdominal cavity. There had been no hemorrhage. I shall never again be willing to trust to drainage effected in this way after Ovariotomy. The openings made by the trocar are too small and too easily choked by a clot of blood, or obstructed by a fold of the vagina, or in some way closed and rendered unfit for drainage. I think it will be bet- ter, just before closing the abdominal incision, to make an opening with a sharp bistoury from Douglass’ cul-de-sac into the peritoneal cavity, and touch the edges of this outlet with per-sulphate of iron to prevent immediate union of the cut surfaces. This opening should be shaped like a horse-shoe, and 11 large enough to admit the point of the finger. A double thread should be pa>sed through the top of tlfb flap, the convex portion of which should look towards the uterus, and the ends of the thread extend beyond the vulva. This would serve as a guide to the finger or an instrument if closure was threatened. The opening thus made would add nothing to the danger of Ovariotomy, and spontaneous union would take place soon after the thread was withdrawn. If for any reason a ligature instead of the clamp was used, the ends of the ligature could be brought through this opening into the vagina and out of the vulva. The cases recorded show, as far as they go, that the peritoneo-vaginal outlet, if large enough, is sufficient to effect drainage, and there is no neces- sity for the drainage tube. Indeed, the same objection that applies to the ligature threads, when the pedicle is secured in that way, might be used with even greater force against the drainage tube. Wells says, “ I think the ligature threads act as a sort of seton in the peritoneal cavity, set up in- flammation, and excite the formation of the serum, for which they are said to provide the outlet.” The same author informs us: “Where bad symptoms follow ovariotomy, the surgeon should suspect that some fluid, either serum, blood or pus, is collecting in the peritoneal cavity. It may collect in such quantity as to give rise to sensible fluctuation from one side of the abdomen to the other.” He advises the evacuation of this fluid as soon as it is detected, and his ex- perience is “that the benefit of the evacuation of fluid is often very marked; and that any danger arises from too early closing of the opening, not from the opening having been made.” I can see no good reason why this outlet should not be made when the Ovariotomy is performed, sis it adds, at the time, nothing to the danger of the operation. To defer it for a few days is to subject the patient to the hazard of septicaemia from a quantity of serum too small to be detected by fluctuation, or to incur the risk of being obliged to drain it after blood- poisoning has probably commenced, and when the patient is in no condition to bear additional surgical interference, however trifling. Cannot drainage also be procured after gun-shot, and other penetrating wounds of the abdomen, with or without visceral injury; or shall we con- tinue what Dr. Otis calls the “Ostrich plan,” of giving opium and making the patient as comfortable as possible until death relieves him? Dr. Otis, who has had unusual opportunities, and who has investigated this subject with the same care and ability that has characterized all of his writings, 12 says, in Circular No. 3, Surgeon General’s Reports, 1871, page 87: “The general mortality in these cases is so very Mrge as to furnish additional argument in behalf of M. Legouest’s proposition to incise the abdominal walls and explore the track of the projectile in certain gun-shot penetrating or perforating wounds of that cavity. Thus only can the patient exchange the probability of inevitable death for the possibility of recovery.” He believes that prejudices against this operation, as at one time against Ovari- otomy, will be dispelled before many years have elapsed. Of the truth of this statement I have no doubt; and when the abdominal wall is opened, the track of the bullet explored, internal hemorrhage arrested, or foecal ex- travasation prevented, the chances of recovery will be still further increased by making a free outlet for the red serum, which traumatic peritonitis pro- duces, and which kills by septictemia. The bottom of the peritoneal cavity in woman is the recto-vaginal pouch. In man, the bottom of the cavity is the fold between the bladder and rectum. An outlet here into the rectum would drain the whole cavity, and could be made without any difficulty be- fore the abdominal incision was closed. If the wound is a perforating one, without visceral injury, and one of the openings can be made dependent, it should be kept open and drainage effected through it. If the wound is a simple penetrating one, without visceral injury or internal hemorrhage, and no abdominal incision necessary, under the influ- ence of an anesthetic, the fingers and half of the hand may be introduced into the rectum, as suggested and practised by Prof. Simon, the position of the bladder precisely determined, and the puncture made from the rectum into the cul-de-sac between that organ and the bladder, or.the operation might be performed with a speculum analogous to that devised by Dr. Sims. The suggestion made by Dr. Sims that gun-shot wounds of the pelvis are less fatal than similar injuries of the abdomen, will be confirmed by the ex- perience of nearly every military surgeon. The diminished mortality in these cases is due, doubtless, to the drainage which the nature of the wound frequently permits. Among my cases of stone, I have found two following gun-shot wounds of the pelvis. One of the calculi has as a nucleus a couoidal pistol ball; the other has in its centre a piece of bone torn from the os pubis and left by the bullet in the bladder.* Each case recovered from the gun-shot wound and the subsequent operation for stone. ♦These calculi are in the “Army Medical Museum,” Washington, D. C.