ASCITES.
The treatment of ascites in the first instance must be directed to the removal of the primary cause, and this will obviously consist in the exhibi tion of the remedies suitable to the management of the different diseases which will be enumerated under their separate headings. Failure generally is the result of such efforts, especially in cirrhosis of the liver, and the same can be said of counter-irritation and the local and mouth administration of so-called " absorbent agents." The injection subcutaneously of a quantity of the ascitic fluid to produce an increased diuresis is as ineffi cient as the stereotyped diuretics; little is to be expected from saline purgatives or the withholding of liquids or salt from the diet.
Failing these, there is nothing left but the operation of tapping when the accumulation is large enough to cause discomfort or threatens to render breathing difficult. By evacuating the fluid life will be prolonged in the worst cases, and in a few instances early and repeated tappings have been known to permanently relieve cirrhosis of the liver.
The patient, if weak, may have the operation performed in bed, but it is more satisfactory to place him in a chair after the contents of the bladder have been voided or removed by catheterisation. A broad binder having been loosely applied to the abdomen with the view of exerting pressure by traction on its ends during the withdrawal of the fluid, the surgeon having percussed the middle line and found complete dulness between the umbilicus and pubes makes a minute incision into the sterilised skin midway between these points, through which he thrusts a trochar and canula. On withdrawal of the trochar, the fluid is permitted to flow, pressure on the walls being made by drawing on the ends of the bandage. There is no advantage in using a large instrument, and some operators prefer a minute tube of the Southey type with rubber attached, through which the fluid may he allowed to slowly flow into a basin as the patient lies on his back or either side in bed.
After the peritoneal sac has emptied itself, the opening is closed by a little lint soaked in Friar's Balsam, and kept in its place with a strip of plaster. A dry diet will usually considerably delay the return of the accumulation.
When, after repeated tappings, the speedy reaccumulations of the fluid prove that there is nothing more to be hoped for than palliation of the condition, the surgeon may be requisitioned to perform a radical opera tion. This is obviously only admissible when the primary disease is not of a malignant nature, and it has afforded permanent relief in many cases of hepatic cirrhosis when undertaken in the early stages of the disease before the patient's peritoneum has lost its absorptive powers by the supervention of inflammatory thickening. It consists in establishing
an artificial anastornosis between the general circulation and the portal system IS recommended by "Palma and carried out by Morrison. A small incision should open the abdomen above the umbilicus, and after the fluid has been entirely evacuated, a portion of the omentum is drawn up and sutured to the parietal peritoneum and recti muscles. It is necessary to insure thorough drainage in order to permit of as complete union as possible between the omentum and abdominal parietes.: Some operators at the same time rub forcibly the surface of the liver and the adjoining internal surface of the abdominal wall and stitch them together, in order to encourage the formation of adhesions, in which new vessels will form and still further assist the anastomosis. Cutting the portal vein and suturing its distal end to the vena cava has also been performed.
After tapping through a large incision, Mauclaire fixed a T-tube, the long end of which dipped into the pelvis, whilst the short arms were buried in the subcutaneous fatty tissue at the wound, with the view of draining the ascitic fluid into the connective tissue spaces. The results were, however, very disappointing, and the same may be said of the heroic attempts to establish anastomosis between the vena cava and porta 1 vein or between the vena cava and superior mesenteric vein. A few successes have followed the Ruotte method of cutting the saphenous vein at the saphenous opening, tying the distal end and drawing up the proximal extremity and leaving it free in the pelvic fluid. Mcnill intro duced silk strands through a trochar wound and drained into the connec tive tissue. Nash inserts a bone bobbin in the right femoral canal through an abdominal incision.
Chylous ascites can only be palliated by repeated tappings, and these should be delayed as long as the patient's sense of discomfort is not seriously drawn upon. Obviously there is little to be expected from the Talma-Morrison operation in such cases, or where the condition is due to syphilitic gummata, which often may be made to yield to large doses of Iodides and short courses of Mercury.
In the ascites accompanying abdominal tuberculosis most satisfactory results have followed abdominal section.