OPERATIVE TREATMENT OF CIRRHOSIS OF THE LIVER.
DR. CHARLES H. FRAZIER read a paper with the above title, for which see page 715.
DR. JOHN B. DE_kVER said that he had seen a cure following simple tapping in the case of a man who had every indication of cirrhosis ; he was frightfully distended. He could not breathe lying down, had been sitting up in his chair for several nights previous to the tapping. The man never had a recurrence after his tap and lived three or four years. He has since died, but did not die of any symptoms referable to the liver. He was an alco holic as well as a specific case.
DR. WHARTON said that some years ago he did an abdominal section in a case of cirrhosis of the liver for Dr. Pepper, simply opening the abdomen and draining away the fluid ; and this case improved very much for a time. He lived six or eight months, but finally died. He was very comfortable, and did not require tapping after the incision.
DR. JOHN B. ROBERTS said that he had two patients under care for sometime upon whom he expected to perform this opera tion. He had waited because both cases had cirrhotic kidneys as well as cirrhotic liver, and had not been in good condition. One had evidences of cedema of the lungs, and appeared to be on the verge of delirium tremens when he first saw him. The jaundice was quite marked. In both cases the urine has been scanty in amount. He intended to simply make an incision big enough to get one or two fingers into the abdomen, smooth out the omentum, and with a long curved needle make sutures through the skin and muscles, and tie the catgut sutures on the outside. It seemed to him that the rapidity with which this operation could be finished. and the fact that one only needs a small incision, would enable one to do away with general anaesthesia. Cocaine infiltration of the site of incision would be sufficient. General anmsthesia is rather risky in cases of cirrhosis of liver and kidneys, hence this method would be desirable.
[Since the discussion, Dr. Roberts has operated upon the two cases mentioned by the small incision and cocaine anwsthe sia.] DR. FRAZIER said that he had hesitated writing up this case for publication when but thirteen months had elapsed since the operation had been performed, fearing that one might advance the criticism that the results obtained were those of operation per se. He thought, however, that the results had been such as to warrant one in attributing them to the nature of the operation itself. As to the technique, this is in every sense of the word sim ple, once the operator has decided upon his plan of procedure. He must decide, first, whether he will confine his operation to the immediate neighborhood of the wound ; secondly, whether he will extend his operative field to the diaphragm, liver, and spleen, and, thirdly, whether he will employ drainage. Some operators scarify not only the peritoneal surface of the abdominal wall on either side of the wound, but in addition the adjacent surface of the liver and diaphragm and of the spleen and diaphragm, thereby exciting the formation of a greater number of adhesions.
He had been loath to carry out such an extensive operation in this that is, an operation which subjected such an exten sive surface of the delicate peritoneum to traumatism. He there fore omitted so much of the operation as has to do with liver, spleen, and diaphragm. In almost all cases hitherto reported a drainage tube has been inserted through an additional wound in the suprapubic region, and this has not been removed until there has been no further accumulation of fluid. He was convinced that this step in the operation should be omitted ; that it in no way contributes to the result, and furnishes an additional risk, for there is constant danger of the peritoneal cavity becoming infected along the drainage-tube tract. He much preferred to resort to paracentesis, should the occasion demand it, during the period in which the collateral circulation is being established.