Vol. 60, 1909 - University of North Carolina at Chapel Hill

ORIGINAL COMMUNICATIONS. 383
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designed for the relief of ascites, its most etes. By some otliers, the omentum is imdistressing
result. Hence, we shall not at- planted within the rectus sheath,
tempt to set forth a classification of cirr- Of the various modifications, the one prachosis,
which varies numerically with the ticed by Narath, from its rational simplicity,
number of authorities consulted, nor with seems deserving of especial attentioi). He
the theories of etiology. makes a small incision, rulls out theomen-
The operation is designed to offer me- turn and stitches it to the areola tissue just
chanical relief by establishing a collateral beneath the skin. He then closes the wound
venous anastomosis between the portal and around the artificial epiplocele tight enough
systemic vessels around, instead of through, to avoid hernia and not too tight for conthe
liver, presupposing that the ascites is striction. He claims that the collateral
due to mechanical failure of the normal circulation is best established through the
blood channels. When we chase back our superficial veins, and states that a very evimemories
and recall the broken derelicts dent enlargement of these veins can be
whom we have tapped from time to time noted within five days. Its advantages are
till death claimed them; when we remem- that it can be quickly done under cocaine
ber that such men are actually or prema- anesthesia, with little or no shock, either
turely old; that the conditions producing one or both sides of the median line at one
cirrhosis have also crippled their kidneys, or at two sittings. Its disadvantage is the
hearts and blood vessels; and that tempo- possibility of hernia through the imperfectly
rary recovery would only mean one more closed fascia.
plunge into dissipation, the field seems far
from promising, and we naturally ask the
The after-treatment of these cases is com-
paratively simple. The pelvic drain used
question, "Is it worth while?" by Morrison has been abandoned by most
A closer study of the subject will answer operators. The abdomen is bandaged tightly
this definitely in the affirmative, for it will
be found that many men with years of usefulness
before them, women with no alcofrom
chest to hips. The diet is dry with as
little fluid as possible. The bowels are kept
open with saline laxatives. Usually, from
holic history at all, and children faroftener one to three subsequent tappings are needed
than one would suppose, are subject to cirr- before the collateral circulation is properly
hosis of the liver.
The jirognosis, in the light of statistics.
established.
Case.—E. S., white, aged 18, works in a
also far from encouraging. The mor- tobacco factor>' as packer of boxes. Her
tality varies greatly with the groups of cases father died of heart disease and paralysis;
collected by different investigators. A fair mother living and healthy. She is the
summary, in the words of one writer, isthat youngest of three children. The first died
one-third die within a month, one-third are suddenly at the age of five months; the seegreatly
benefited and one-third are slightly ond is 24 years of age, normal in every way,
improved or unaffected. The immediate is married and has three healthy children,
mortality, which was very high in the early She was a large, healthy baby, but had a
cases, has been greatly reduced and will rather full abdomen. She developed norunquestionably
be still further improved by mally up to the age of three or four when
abetter selection of cases for operation and growth and development seemed retarded.
a wiser selection of operative procedures to She went through the diseases of infancy,
suit the individual case.
Operations.—The operation as originally
but was never seriously ill. She attended
school up to the age of 12, and was bright,
described by Talma and popularized by quick and capable. She had one scanty
Morrison and Drummond, consisted in a menstrual period at 15, but has not menlinear
incision near the median line begin- strualed since, though she has had backning
a little below the ensiform cartilage, ache and pelvic pains at times.
Through this the abdomen was mopped dry In 1906, three years ago, she stopped
of fluid and the anterior surface of the liver work on account of feeling tired and badly,
and spleen scarified with gauze by rubbing, and went to visit relatives in the country.
The omentum was then stitched to the
parietal peritoneum of the anterior abdo-
She soon noticed that her waist was enlarg-
ing and that she became tired and even exminal
wall and the wound closed. This hausted from slight exertion; also that her
procedure has been variously, modified by lips and fingers were blue. There was some
other operators. Schiassi fixed the omen- swelling of the feet and ankles at this time.
turn between the peritoneum and overlying She was treated by Dr. W. H. Parker and
muscles, and sutures the sjjleen to the pari- was soon able to return to work,
etal peritoneum. Von luselberg fixes the In May, 1907, she was .seen by Ur. Harry
gall-bladder to the anterior abdominal wall. Baker who says that she had at this time a
Ito and Omi leave in gauze drains or plugs, marked dyspnea upon the least exertion.
causing the intestines to adhere to the pari- Her lips were purple and her face and body