[Reprinted from the American Gynaecological and Obstetrical Journal 
for March, 1896.] 
DRAINAGE IN PERITONEAL SURGERY.* 
Bv Henry T. Byford, M. D., Chicago. 
In answer to the invitation to discuss drainage in abdominal and 
vaginal section, I will briefly give the impressions I have gained from 
personal experience. 
Drainage in peritoneal surgery is for the purpose of removing from 
the peritoneal cavity or neighboring wounded tissues irritating or 
septic matter that has been introduced at the time of the operation 
or that finds lodgment there subsequently. When it is possible to 
prevent the introduction or accumulation of such matter, drainage is 
of course unnecessary. When such prevention is impossible, it be- 
comes a question of judgment as to whether the irritating or septic 
matter will in a given case cause only slight symptoms or give rise to 
serious consequences. 
There is danger in leaving irritating matter, such as bloody effu- 
sion from raw surfaces, and there is sometimes danger in draining. 
When the nursing after the operation is not absolutely reliable, most 
surgeons would prefer to allow the peritonaeum to take care of a mod- 
erate amount of effusion. When good nursing and personal supervi- 
sion follow the operation, drainage is preferable if there is any doubt 
as to the ability of the peritonaeum to absorb the fluid. When exten- 
sive oozing surfaces are left, and septic germs can not with certainty 
be excluded or removed, the surgeon who does not drain assumes a 
great responsibility. 
The chief hindrance to a just appreciation of drainage is the fact 
that either the appropriate and best methods are not always employed 
or understood, or else not properly carried out. 
In the first place, the drainage must be adequate. It must afford 
a ready exit to the offending material. 
In the second place, it must include means for the prevention of 
infection by way of the drainage-tube or material. 
* Read before the Chicago Gynaecological Society, January 17, 1896. 
Copyright, 1896, by J. D. Emmet, M. D. Henry 7\ By ford, M. D. 
In abdominal operations it is not always sufficient to drain the cul- 
de-sac of Douglas or the lumbar regions. It must be determined where 
the effusion will accumulate, and the tube or gauze must reach these 
places. In one case I used three drainage-tubes with success. In 
others I have used both a drainage-tube and gauze. In nearly all 
cases I find it advisable to administer salines as soon after the opera- 
tion as the stomach will tolerate them for the purpose of causing peri- 
stalsis, and thus of preventing adhesions of the irritated peritoneal 
surfaces to each other and to the raw surfaces. In this way pocketing 
of effusion is prevented, and its flow toward the drainage-tube or 
material is facilitated. 
After transperitoneal nephrectomy, drainage by gauze strips 
through a puncture in the lumbar region is preferable, although after 
large tumors the capsule can sometimes be stitched into the abdom- 
inal wound and drained, the wound being then extraperitoneal. 
Transperitoneal tubular drainage has, however, proved practical in my 
experience. After operations upon the intestines and abdominal vis- 
cera, drainage through the abdominal walls must be employed. 
After operations upon the pelvic viscera, either abdominal or 
vaginal drainage may be made use of. 
Operations involving trauma high up in the pelvis should ordina- 
rily be drained by the glass tube extending from the lower portion of 
the incision down to the bottom of the pelvis. If, however, there is 
excessive oozing, or a large septic surface left in the pelvis, the gauze 
packing or Mikulicz drain is better, for it acts as a tampon, as a drain, 
and as an isolator of the infected or inflamed area. The danger of 
paralysis or obstruction of the intestines from adhesion of the lat- 
ter about the gauze gives it dangers that do not belong to the tube, 
and should restrict its use in such cases to those absolutely requiring it. 
When pelvic-bound tumors are removed, leaving the bottom of the 
pelvis almost entirely denuded of peritonaeum, drainage into the vagina 
by means of the gauze tampon is often necessary to keep the intestines 
out of the wounded area and the fluids from contact with the general 
peritoneal cavity. A judicious use of vaginal drainage is the enucle- 
ation of the worst forms of pelvic-bound tumors, and in papillomatous, 
tuberculous, and malignant tumors adds greatly to our success in 
abdominal sections for such conditions, and enables us to operate 
upon cases that would otherwise be unfit for operation. 
It may even become necessary to remove the uterus to facilitate 
vaginal drainage. When growths of this kind are of moderate size it 
is sometimes safe to remove the uterus by way of the vagina, enucleate Drainage in Peritoneal Surgery. 
3 
or disintegrate the tumors through the space thus provided, and then 
practically shut off the peritoneal cavity from above by the gauze 
tampon and drain. When vaginal section is performed, either gauze 
or a rubber tube may be used. 
In cases of removal of the uterine appendages through an incision 
in the posterior vaginal fornix, a short rubber tube, whose lumen is 
about one third of an inch in diameter, is all that is necessary in most 
cases. The act of vomiting and other motion of the body force the 
effused fluid through the tube into the gauze which envelops the 
external end within the vagina. After thirty-six hours the tube should 
be drawn out by means of a string previously attached. I have em- 
ployed this kind of drainage in a large number of such cases with 
good results. 
In quite a proportion of the cases in which drainage is necessary 
the oozing is so free that a gauze packing is better. This of course 
makes it necessary to leave quite a large vaginal opening to contract 
gradually. 
When the uterus is removed per vaginam the gauze drain is, I think, 
preferable, and should project only as far as the stumps and oozing 
surfaces; never up among the intestines. 
The second requisite of successful drainage—viz., the prevention 
of infection—can usually be attained, and when attained, the chief ob- 
jection to drainage disappears. 
The glass tube for abdominal drainage should be too small to 
admit a lead pencil. When I see some of the drainage-tubes used 
I am always reminded of stove pipes that are made to let a draught of 
air through them. Their contents should be drawn every hour or two, 
never at longer intervals, and this by means of a sucker, not by a swab, 
as the latter tends to force some of the liquid back into the peritoneal 
cavity. A strip of gauze should be kept in the tube between the 
dressings. The tube should be removed in from thirty to forty 
hours. The wound should not then be closed by a suture, but a 
narrow strip of gauze should be passed into it through the abdominal 
walls with a probe and be left for four or five hours. If the tube is 
slim enough, and the wound has been tightly sewed around it, the 
parts will come together about the gauze, which dries the surfaces and 
secures a primary union after its removal. The drainage site should 
afterward be washed off with a i-to-2,000 solution of corrosive mer- 
curic chloride twice daily. 
When the Mikulicz drain is used, about one quarter or one fifth 
should be removed each day, and while the strip is being pulled out 4 
Henry T. Byford, M. D. 
all of the blackish bloody fluid that appears at the surface should be 
soaked off with sterile absorbent cotton. After the tampon is all out 
a little fresh sterile gauze should be introduced every three or four 
hours for two or three times to keep the wound dry, provided there is 
still space for it. 
When a large gauze packing is left in the pelvis and brought out 
from below, it should be removed in a gradual manner. When but 
little projects into the peritoneal cavity, as is usual after vaginal hys- 
terectomy for carcinoma or small fibroids, it should be left for about 
four days and then be removed all at once, and be followed in a few 
hours by mild antiseptic douches. 
The vulvar dressings should consist of an abundance of sterilized 
absorbent material and be changed every three or four hours. All 
manipulations of tubes or gauze drains should be by sterile hands 
with sterile materials. 
In conclusion, I wish to emphasize the fact that I do not believe 
in drainage when it can be avoided. At the same time I have no fear 
of drainage when I have one of my trained nurses to take care of the 
tube. I should therefore consider myself culpable if I were to add to 
the dangers of an operation by unduly prolonging it for the checking 
of moderate oozing. Neither should I feel justified in taking any risk 
in leaving either blood or material that might be septic without pro- 
viding for adequate drainage