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Essays on clinical medicine online

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with what occurred after simple incision in cases of tuberculous peri-
tonitis allowed one to question whether the relief of ascites in cirrhosis
of the liver which followed the radical operation was brought about
by the development and growth of vascular anastomoses. This view
of McBurney's seems to approximate that of Dr. Osborne, of New
Haven, and of Dr. Cheadle, already cited.

On the other hand, Packard and Le Conte 4 claim that " one of the
ways by which repeated tappings may aid in the recovery of cases of
cirrhosis of the liver is through the formation of adhesions similar to
those aimed at in the operative procedure, but to a less degree." Be
these views as they may, I cordially assent to their previous state-
ment, 5 that " these cases of advanced cirrhosis of the liver, operated
on or not, die with evidence of progressive toxaemia and gradual failure
of all the organs to do their proper work."

i Quoted by Brown (p. 11). 2 Page 16.

3 New York Medical Record, January 28, 1899, p. 143.

4 The American Journal of the Medical Sciences, March, 1901. 6 Ibid., p. 257.


Despite these views, they state in their conclusions, as their opinion,
" that where the diagnosis of pure portal cirrhosis of the liver can be
made, and where persistent and well-directed medical treatment is
productive of insignificant results, the operation should be strongly

Here, it seems to me, the great difficulty lies in this precise diagnosis
at the present time ; for do we not know that constantly our autopsies
show that concomitant lesions exist which render nugatory all radical
op3ration3 — i. e., other kinds of cirrhosis, chronic peritonitis, advanced
degeneration of other organs, like the heart and kidneys, etc. ?

There can be little doubt that in very many cases of hepatic cir-
rhosis it is important to do what we can medicinally and otherwise to
keep the heart in a vigorous state. Once it becomes inefficient func-
tioually, either because of simple dynamic weakness or owing to struc-
tural changes, the development of the ascites is certainly more rapid
and more apt to recur. We recognize in this way that the obstructed
portal circulation due to fibrosis is also heightened notably by venous
stagnation caused directly by impaired heart power. ' No doubt the
explanation of instances of early effusion in hypertrophic cirrhosis is
thus often satisfactorily given. If such a view be admitted it can be
readily understood why we can obtain good effects from suitable treat-
ment in just such cases. An important part of this treatment must be
the maintenance of sufficient cardiac power if it be possible to prevent
venous stagnation in the liver.

In instances where venous stagnation occurs of cardiac origin the hepa-
tic veins at the centre of the lobules are especially affected, and it is also
true in these instances that here is likely to be formed the fine fibrous
deposit which, as we have seen, characterizes hypertrophic cirrhosis.
Not always is the cardiac inefficiency shown by evident physical signs,
nor, indeed, by the presence of ascites ; still, in hypertrophic cirrhosis
or simple engorged liver it is a safe plan to give, for a while at least,
small, repeated doses of digitalis, and note its obvious effects either on
the size of the liver directly or some of the suggestive symptoms con-
nected therewith.

Appended are histories of cases of " omental anastomosis."

Case I. — Case of cirrhosis of the liver in which radical operation
was performed by Dr. F. H. Markoe. J. S., aged fifty years, married ;
hotel steward ; born in the United States ; admitted to St. Luke's
Hospital June 30, 1898. Alcoholic history ; suffering from ascites.
Liver probably enlarged ; rough and nodular. Abdomen much dis-
tended ; evidences of fluid ; superficial veins enlarged.

First Aspiration. Three days after admission, 125 ounces obtained ;
second : eleven days later 128 ounces obtained.

Treatment nil. Left hospital July 22, 1898 ; re-entered, December
6, 1898.



Abdominal fluid increased in quantity as compared with quantity
before the last tapping, July, 1898.

Third Aspiration. Two days after admission, 370 ounces obtained ;
fourth : five weeks after admission, 400 ounces obtained ; fifth : seven
and a half weeks after admission 440 ounces obtained ; sixth : ten and
a half weeks after admission, 475 ounces obtained.

Treatment. Digitalis, iodide of potash, theobromine, copaiba, etc.
Left hospital March 1, 1899, and readmitted two weeks later; abdo-
men greatly distended.

Seventh Aspiration. Day after admission ; 390 ounces obtained.
Left hospital, and readmitted April 17, 1899.

Eighth Aspiration. Day admitted ; 426 ounces obtained.

May 13th. Ninth : 390 ounces obtained.

Jane 14:th. Tenth : 450 ounces obtained.

July 10th. Eleventh : 330 ounces obtained.

August 12th. Twelfth : 452 ounces obtained.

October 1th. Thirteenth : 520 ounces obtained.

November lMh. Fourteenth : 510 ounces obtained.

Treatment. Codeine for cough.

January 22, 1900, Dr. F. H. Markoe performed upon the patient the
operation of " omental anastomosis," and 500 ounces of light yellowish
fluid slowly evacuated from the abdomen. On palpation, the liver
was found large ; also some abdominal adhesions. Vomiting of green
fluid off and on for six days following operation.

Fourteenth Aspiration. Six weeks after operation ; 138 ounces ob-

Subsequently, up to November, 1901 (twenty-two months later),
patient has been aspirated about fifteen to seventeen times, which, with
those performed before operation, make about thirty in all.

November, 1901. He is now confined to bed, and is unable to leave
it by reason of asthenia. 1

Case II. — A second case of " omental anastomosis " for cirrhosis of
the liver was performed by Dr. F. H. Markoe at St. Luke's Hospital,
April 27, 1901. The patient had marked ascites ; was a boy, aged thir-
teen years, and had been quite a drinker. Subsequent to the operation
the patient was tapped once before he left the hospital, on May 21,
1901. Since that date he has returned about every six weeks to have
the fluid removed from the abdominal cavity. The patient's general
condition is about the same as before the operation. The ascites is
probably somewhat less.

Case III.— The following case of " omental anastomosis " is one in
which Dr. F. W. Murray operated.

History. P. A. B., married, aged forty-eight years; no specific dis-
ease ; excessive alcoholic habits.

Four months before admission to St. Luke's Hospital patient noticed
yellow conjunctivae and loss of flesh and strength. His abdomen
increased by eight inches in size. This increase subsided for a time
under calomel and salines, but soon returned. April 2, 1900, entered
hospital ; 328 ounces of fluid removed by tapping ; largely reaccumu-
lated in two or three days. Transferred to surgical service April 18th.

Abdomen measured 44£ inches at a point three and a half inches

1 Patient died December 15, 1901, from heart failure.


above the umbilicus ; percussion flat over the whole abdomen. Opera-
tion April 19th, by Dr. Murray. Incision four inches long at the
left of the umbilicus ; 3} gallons of fluid removed ; omentum thick-
ened and vessels injected ; sutured to parietal peritoneum by five inter-
rupted sutures of No. 1 catgut ; stood operation well. Urine acid ;
specific gravity, 1020; slight trace of albumin; no sugar; few hyaline

Aspirated April 23, and 64 ounces of fluid obtained. April 30th,
circumference 39 inches. May 2d, primary union of wounds. May
12th, oedema of feet ; stuporous ; pulse rapid ; coryza marked ;
erythema over nose, diagnosed as erysipelas. May 13th, temperature
between 98.3° and 99° F. Pulse varies from 90 to 100. Respiration,
24. Died. (Above history furnished by Dr. Martin.)

Note. — Since writing the foregoing paper a valuable contribution
from the pen of Dr. George E. Brewer, on " The Surgical Treatment
of Ascites Due to Cirrhosis of the Liver," has been published. From
it we take the report of " 5 personal cases and analyses in tabular form
from about 50 more from the literature." From reviewing these statis-
tics Brewer finds at least 6 patients who have been cured of ascites by
this procedure — i e., Talma-Morrison operation — and who have re-
mained well for two years or more ; 6 others have died, with relief of
this symptom from two to six months before death, or who had not
been under observation long enough to demonstrate a permanent cure.
Another patient suffering from hemorrhage of the alimentary canal
was promptly cured by this operation. Many others have been mate-
rially benefited ; 38 have recovered from the operation ; and, consid-
ering that the great majority of these were within a few weeks of
inevitable death, he thinks that it should encourage us to suggest
operation at an earlier and more favorable stage of the disease. If
this suggestion is followed he believes that statistics will show a great
improvement over those he is able at this time to present. 1

In a later contribution on this subject Dr. W. Murrell, of Westmin-
ster, writes 2 that " much depends on careful selection, and the best
results would probably be obtained in the pre-ascitic stage when the
diagnosis rests on the alcoholic history, with haematemesis and enlarge-
ment of the liver and spleen."

1 Journal of the American Medical Association, February 22, 1902, p. 135.

2 Lancet, June 7, 1902, p. 1604.

C'OVj. I.

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