THE TREATMENT OF ASCITES BY DRAINAGE INTO THE SUBCUTANEOUS TISSUES OF THE ABDOMEN
1273 ceased and no plug was required. The growth was L-shaped, I consisting of nasal and naso-pharyngeal limbs measuring respectively 2 inches and 2 inches in length. The attachment was mainly to an area about the left choanal margin, i but partly also to the roof of the naso-pharynx. Healing was rapid, and up to the present time (six months after the operation) there has been no recurrence. ' The method employed in these two cases is essentially that advocated by Brady, with the difference
... the bony anterior nasal aperture is widened through an intranasal instead of an external incision. The operation would probably be suitable for all cases of naso-pharyngeal fibroma excepting, perhaps, those which have, before coming under observation, attained a great size with numerous offshoots in neighbouring cavities, for which some form of osteoplastic resection of the upper jaw may be required. The operation is, moreover, comparatively free from danger, involves no scarring or deformity, and permits of at least as complete a removal as any other method. Liverpool. a method of treating spina bifida by establishing a drain, composed of silk threads, between the subdural space and the subcutaneous tissues of the scalp. This is a modification of a somewhat similar method I have been using for draining the peritoneal cavity in cases of ascites. In this condition a drain composed of strands of material, such as silk, would not answer the purpose, as the end of the drain which projected into the peritoneal cavity would soon become encapsulated and so rendered useless. For this situation I employ a glass drain of such a shape that it will not slip into the peritoneal cavity. These drains or buttons are of various sizes, so that a suitable one can be chosen for each case. The buttons consist of a perforated glass cylinder expanded into a flange at each end. (Fig. 1 .) The largest FiG. 1. size measures one inch across the flanges, three-quarters of an inch between the flange6, and has a canal one-twelfth of an inch wide. (Fig. 2 .) The flange itself has a thickness of about one-sixteenth of an inch. The diameter of the flanges I and the width of the canal may be the same in the various sizes ; but it is essential that the cylindrical part should vary in length, as this part has to pass through the thickness of the abdominal muscles, and as this thickness varies in different individuals so also must the length of this part of the button. In practice I have found it a convenience to have variations in the size of the flanges also, but this is not nearly so important as having gradations in the length of the cylinder. Care must be taken to have all the edges and corners rounded and that every part is perfectly smooth. The operation is a simple one. An incision, about three inches long, is made in the middle line below the umbilicus, and the peritoneal cavity is opened in the line of the incision. If the abdomen has not been previously tapped the greater part of the ascitic fluid escapes at this stage. The omentum is now drawn down and removed at a level well above the point where the drain is to be placed, because, if left, it very soon passes into the opening in the drain and completely blocks it. The first case I did was a failure owing to my having neglected this precaution. The subcutaneous tissues are now dissected outwards, on one side, till the semilunar line is exposed, and through this an opening is made into the peritoneal cavity. This opening should just be large enough to permit the button being placed in position. The drain may be passed either from the peritoneal or subcutaneous side, but if from the latter care must be taken to avoid stripping the peritoneum from the edge of the opening when inserting the tube, or the flange may come to lie between the peritoneum and the subperitoneal tissues. By slipping one flange edgeways through the opening there is no difficulty in placing the button in position. When a suitable size has been chosen one flange should lie flat on the peritoneum and one on the abdominal aponeurosis, without any pressure being exercised on the intervening tissues. If too long, the apparatus would project into the peritoneal cavity, and the intestines might get nipped between the flange and the abdominal wall; while if too short, the button would tend to cut its way through the thickness of the tissues in its grasp. If the opening for the drain has been made too large and the edges do not grip the button firmly, a pursestring suture should be placed close to the button on the aponeurotic side, so that when tightened the soft tissues are brought into close contact with the groove in the drain. The subcutaneous tissues are next closely stitched by a continuous suture to the anterior layer of the sheath of the rectus. This suture is placed about one inch from the margin of the primary incision and parallel with it. By this means the superficial end of the drain is shut off in a compartment of its own, and the fluid, as it escapes from the peritoneal cavity, is prevented from throwing too much strain on the suture closing the skin incision. The primary wound is sutured in the usual manner, the skin being closely stitched by a buttonhole suture to prevent any leakage. A collodion dressing applied to the wound gives additional support. This dressing is reapplied as often as required till the skin wound is firmly healed. For one or two days afterwards the patients usually complain of pain round the neighbourhood of the button, but when this has passed off no further discomfort is experienced. If the quantity of peritoneal exudate be considerable a fluctuant swelling, almost of the size of the fist, forms within 24 hours in the subcutaneous tissues round the drain; but as absorption becomes established in the superficial vessels the swelling diminishes, till only a slight cedema remains to show that fluid is still escaping. When the exudate is small in quantity the swelling does not pass beyond the stage of oedema. It might be supposed that the intestines would adhere to the peritoneum round the edge of the button and thus shut it off from the peritoneal cavity, but in two cases which died several weeks after the operation, and in which a postmortem examination was made, no adhesions were found and the peritoneum was quite smooth up to the edge of the opening ; nor was I able to find, even after microscopical examination, any evidence of what might be possible, the peritoneum growing round the edges of the opening to the outer aspect of the drain and so encysting it. I have performed this operation in several cases of ascites secondary to malignant disease, and also in cases of cirrhosis of the liver, with marked diminution of the abdominal distension, and to the great relief of the patients. Glasgow.