Reprinted from the Cincinnati Lancet-Clinic, October 9, 1897. 
ABDOMINAL INCISION FOR ASCITES.1 
BY 
B. MERRILL RICKETTS, Ph.B., M.D., 
CINCINNATI. 
Mr. Chairman and Gentlemen: 
The object of this paper is to call at- 
tention to a class of pathological condi- 
tions which has from time immemorial 
been treated medicinally, but which the 
writer thinks should be dealt with sur- 
gically, viz., fluid in the abdominal 
cavity abnormal in quality or quantity. 
In fact, all cavities containing fluid 
should be dealt with surgically. But 
this discourse will be limited to the ab- 
dominal cavity. 
The use of the trocar should be 
ignored except for diagnostic purposes, 
for the reason that it is attended with 
many dangers, uncertainty of securing 
a free escape of the fluid, and the num- 
erous adhesions of the viscera to the 
belly wall after multiple punctures; also 
for the reason that it does not afford 
means of inspection of the cavity. It 
must therefore be a very unscientific 
procedure, and must give way to means 
more certain, more efficacious and less 
dangerous. 
Free drainage is desired, and was 
first attempted through the bladder by 
Buchanan (Glasgow Medical Journal, 
1828,1, 195-205). Bennett was success- 
ful in curing a case by establishing a 
fistulous opening in the abdominal wall 
(American Journal Medical Sciences, 
Philadelphia, 1859, N. S. xxxiii, 556). 
This seems to be the first successful case 
with the trocar. However, few cases 
have resulted favorably with this in- 
strument. 
The cause of the ascites is not men- 
tioned in either of these cases, nor is it 
probable that the cause was ever known 
to them. This uncertainty is the most 
potent factor in the abolition of the use 
of the trocar or aspirator. Thus it is 
that modern surgery cannot submit to its 
use except to determine the presence or 
the character of the fluid. 
Reference was not made in the 
author's paper read at the National As- 
sociation of Railway Surgeons ( Chicago, 
September 24, 1895) to the abdominal 
cavity, as he hoped to acquire greater 
experience in dealing with conditions 
found in that cavity before saying any- 
thing further about it, but his experience 
since that time has been of so satisfactory 
a nature that he feels warranted in bring- 
ing it before the profession, which he 
now does. 
Incision (of which no mention can 
be found except in the Wallace paper) 
from two to four inches in length will 
enable a close inspection to be made of 
the liver, spleen, kidneys, pancreas, 
uterus, ovaries, tubes and chyle ducts. 
In fact, almost any part of the perito- 
neum may be subjected to the sense of 
touch or ocular inspection. Then, too, 
the subjection of the peritoneum to the 
atmosphere is many times followed by 
beneficial results. It has been pretty 
well demonstrated that it is the atmos- 
phere, and not the light, which causes 
the so-called capillary or peripheral 
stimulation which follows the opening 
of the peritoneal cavity in disease. Many 
times the effusion is the result of local- 
ized peritonitis, which may be caused 
by abscess, benign or malignant tumor 
growth, adhesions, malformations or 
displacements of organs or viscera. 
i Read before the Mississippi Valley Medical Association, at Louisville, Ky., 
October 5-8, 1897. 2 
ABDOMINAL INCISION FOB ASCITES. 
Wallace {British Medical Journal, 
July 10, 1897, P- 79) suggest the use of 
a tubular speculum for the examination 
of the abdominal viscera. He also 
makes mention of the use of rubber and 
glass tubes for drainage, but the good to 
be derived is not established, as the con- 
tinuous presence causes adhesions of 
such a nature as to preclude the possi- 
bility of free drainage. It would appear 
more rational to drain with gauze, now 
and then detaching the adhesions with 
the finger without local or general 
anesthesia. The sense of touch is most 
desirable in such an event. Double 
incision, one above and one below the 
umbilicus, one or two inches in length, 
should be made in large adults where 
doubt exists as to the location of the 
lesion where the speculum is to be used. 
Indeed, Wallace prefers the low inci- 
sion, although he occasionally makes 
the high one. He does not, however, 
suggest that the two be made simulta- 
neously. 
In punctures ot the legs it is not 
necessary to leave the cannula inserted 
subcutaneously, as practiced by Ewald, 
for its presence is not only painful, but 
many times followed by cutaneous 
necrosis. Daily massage, as a matter of 
course, greatly facilitates the escape of 
fluid, and also tends to keep the punc- 
tures open. 
The writer's experience is limited to 
three cases, two in which constant 
drainage was secured by means of the 
trocar and one (a case of acute Bright's 
disease) in which abdominal section 
was resorted to, together with multiple 
incisions of the lower extremities. 
CASE I. 
Man, aged sixty, heavy drinker of 
alcohol, chronic hepatitis, extensive 
general anasarca with great cyanosis. 
Urine contained 40 per cent, of albumen 
by volume. Constitution such as to 
cause great anxiety as to immediate dis- 
solution. Abdomen tightly distended 
and containing fluid, as shown by the 
exploring needle. Multiple incisions 
were made in genitalia and a large tro- 
car introduced into abdomen above 
pubis. Three and one-half gallons of 
fluid were removed from cavity and one- 
half gallon from genitals. Fluid con- 
tinued to flow through the opening into 
the abdomen for three months, a probe 
being occasionally introduced to prevent 
complete closure of it. The incision 
into the genitals enabled the fluid to 
escape for two weeks. The patient ex- 
perienced instant relief, and continued 
to improve for eighteen months, during 
which time he was able to transact his 
business, such being that of a banker. 
He died in a similar attack at the end of 
the above stated time. 
CASE II. 
Woman, aged forty-nine; cardiac 
dropsy in abdominal cavity, which had 
existed for ten weeks. There was ex- 
tensive infiltration of lower extremities. 
Punctures were made in lower legs, en- 
abling a large amount of fluid to escape, 
aided by massage. Slight improvement 
was manifested at the end of a few days, 
when a large trocar was introduced into 
the abdominal cavity and fifteen pints 
of fluid removed. With the aid of a 
probe the presence of the opening was 
continued for eight weeks, at the end of 
which time there had been great im- 
provement. Her condition remained 
most gratifying for five weeks, when 
she died suddenly. 
case in. 
Man, aged twenty-five, chronic paren- 
chymatous Bright's disease of thirteen 
months' duration. The symptoms were 
well marked, the edema of the face and 
lower extremities, limited at first, 
rapidly becoming general, with transu- 
dation of the fluid into the thoracic and 
abdominal cavities. The amount of 
urine passed per diem was not much 
diminished, but contained a large 
amount of albumen-at least 50 per 
cent, by volume. The effusion into the 
thoracic cavity was small in amount, but 
that into the abdominal cavity steadily 
increased to such an extent as to necessi- 
tate tapping once, and sometimes twice, 
a week, as much as a gallon to a gallon 
and a half of fluid being withdrawn at 
each seance. Despite heroic treatment 
with digitalis, salines, vapor baths, etc., 
reaccumulation of the fluid was rapid, 
and twenty-eight tappings were per- ABDOMINAL INCISION FOR ASCITES 
3 
formed within a period of four months, 
with only temporary relief of the urgent 
dyspnea and cardiac distress. 
As adhesions had formed above the 
site of previous trocar punctures, pre- 
venting the free escape of fluid after 
tapping, and a relief from .the pressure 
symptoms was imperative, it was de- 
cided to make a free incision into the 
abdominal cavity and institute perma- 
nent drainage. This was done. Under 
chloroform anesthesia, an incision three 
inches in length was made in the median 
line midway between the umbilicus and 
symphysis pubis. A large quantity of 
ascitic fluid escaped, and after explor- 
ing the abdominal cavity for morbid 
growths, etc., which were not found, a 
large rubber drainage-tube was carried 
down to the bottom of the pelvic cavity 
and the abdominal wound closed. The 
patient reacted promptly from the oper- 
ation, having borne the chloroform as 
well if not better than one with sound 
lungs, heart and kidneys. The effects 
of the drainage were immediate and 
beneficial, the edema of the lower ex- 
tremities cleared up and the limbs re- 
turned almost to their normal size. The 
improvement in the face and upper ex- 
tremities, while not so great, was well 
marked, and almost all the fluid in the 
chest also disappeared, and the patient 
was much improved in appetite and 
general condition. The drainage-tube 
was removed at the end of the first week, 
as the peritoneum had become intoler- 
ant to it, and drainage was kept up by 
gauze wick until the patient's death. 
Ten weeks after the operation the effu- 
sion in the right pleural cavity became 
purulent, and was removed by open in- 
cision and drainage. The patient rallied 
well from the operation and anesthetic 
(chloroform), but died forty-eight hours 
afterward from gradual failure of the 
vital forces. 
Since writing this paper the author 
has had the opportunity of seeing Dr. 
Edwin Ricketts open an abdomen in 
which tubercular peritonitis was present. 
The cavity was anterior to the intes- 
tines, which formed the cavity wall 
except the anterior portion, which con- 
sisted of the belly wall. Such adhe- 
sions precluded the possibility of using 
the speculum, and it is mentioned for 
that reason. 
Another interesting feature in this 
connection, that of drainage, has been 
presented to the writer by Dr. Ash- 
burn, who, with Dr. Mitchell, saw a 
lady with a large abdominal tumor, 
the contents of which escaped into the 
bladder and through the urethra, thus 
causing complete disappearance of the 
tumor, which, in all probability, was 
an ovarian cyst. The rarity of such an 
occurrence causes me to make mention 
of this case.