cancerous peritonitis, and the inspection its lesions, that a treatise
on the subject is hardly called for. It often happens that cancerous
antecedents in the patient or his relatives will lend an aid to the
diagnosis, which this case did not present. To distinguish this disease
from tubercular peritonitis no question can arise except in its
dropsical form, and then the lungs in every case of the latter that I
have met with have the physical signs of tubercles, though not always
the rational indications. The pulse is much more accelerated in the
tuberculous variety. I omitted to state that the temperature of this
patient was often taken, and till the closing scene was never found
more than one or two degrees above the healthy standard, and the
morning and evening heat did not materially vary; the opposite of both,
then, would be expected in a tuberculous case. The existence of
meteorism is much more common in the tubercular disease; indeed, in the
cancerous case recited there was none of it. The duration of the two is
different--that of the cancerous kind is recorded in months, while the
tuberculous variety may continue two years. The cancerous is more
likely to be attended by alarming accidents, like the complete
obstruction of the bowels, large hemorrhages, and a sudden lighting up
of acute peritonitis. Finally, in the light of the case here recorded,
it seems probable that the examination of the abdominal fluid will
become of great importance. I have never carefully examined the fluid
of tubercular dropsy, but it does not seem probable that it will have
the syrupy {1172} appearance, the large amount of albumen, the
abundance of fibrin-fibres, and the granular large cells with nuclei
only perceptibly less in size than the cells themselves, that were
repeatedly found in this case--found by two observers, and at every
tapping after the first.
TREATMENT cannot be curative; it therefore consists of such
administrations as will relieve pain, give sleep, improve the appetite,
increase the flow of urine if it be scanty, and relieve the bowels if
there is a tendency to constipation. It is as much the duty of the
physician to put off the fatal day, when he can, in incurable
affections as it is to cure those that will yield to his prescription
and advice. In the case just narrated opium or an opiate alone produced
such unpleasant after-effects that she was unwilling to take it, but
when the extract of belladonna was given with it she slept pleasantly,
and could take her food the next day.
Infantile Peritonitis, or Peritonitis of Childhood.
Bauer, in _Ziemssen's Cyclopædia of Practice of Medicine_, and Wardell,
in _Reynolds's System of Medicine_, have each devoted a chapter to this
form of disease. They refer to the fact that the foetus may have
peritonitis before birth or be born with it, or may have it when a few
days old. They say that this form of the disease occurs most frequently
in lying-in asylums or foundling hospitals, and that it has been
supposed to depend on a syphilitic taint. They say, too, that it
follows erysipelas, scarlet fever, measles, etc. I do not perceive that
the description of either of these authors makes any marked distinction
between this and the same disease in adults, except what may arise from
the inability of the infant to describe its sensations, and the more
rapid course of the disease to a fatal result--in some cases
twenty-four hours. Having myself had no obstetrical practice, or next
to none, I have nothing to add to their statements, and can from my own
knowledge abate nothing. I therefore refer the reader to these
chapters, and to the references given by the first of these authors,
for a fuller knowledge of the matter.
Regarding the comparative exemption of children, after the first few
weeks of life, from spontaneous peritonitis, referred to by one of
these authors, I can fully confirm his statement. Though I have
assisted in the treatment of many children suffering from peritonitis,
I have difficulty in recalling to mind a single case in which the
disease was not caused by perforation of the intestine or vermiform
appendix of the cæcum, and in much the greatest frequency perforation
of the appendix.
B. F. Dawson,[11] after reciting a case in which the liver had
undergone a peculiar degeneration and was attended by peritonitis
before birth, states that Sir J. Y. Simpson observed nine cases in his
own practice "and notes more than a dozen from different sources."
These cases seemed to have been caused by the ill-health of the mother
during gestation, or excessive labor, injuries, venereal disease, and
were mostly attended by grave disease; the viscera often, the liver;
but sometimes the mother was perfectly healthy, and the peritonitis was
the primary disease. Death almost always occurred in utero or shortly
after birth. In one instance the child recovered.
[Footnote 11: _N.Y. Med. Journ._, Dec., 1882.]
{1173} The _Med. Record_ takes the following from _Schmidt's
Jahrbucher_ for Jan. 7, 1883: "Dr. Oscar Silbermann recognizes two
varieties of peritonitis in the new-born. The non-septic or chronic is
developed usually in the first third of foetal life, and is generally
syphilitic in origin. If the peritoneum covering the intestines be
involved, as well as that over the liver and spleen, various forms of
intestinal obstruction may result. Most frequently there is occlusion
of the anus, less often stenosis or complete stricture of the small
intestine. Of a number of cases of congenital occlusion of the
intestine collected by the author, all ended fatally, only one living
beyond twelve days.
"The second, acute or septic, form of peritonitis in the new-born the
author divides into two varieties, according as the peritonitis is only
a part of general infection or is the sole manifestation of the septic
poison. In either case the point of entrance of the poison is always
the navel wound. The symptoms, which need not all be present in a given
case, are vomiting, watery stools, meteorism, ascites, abdominal
tenderness, icterus, etc. The pulse and temperature may vary in degree
in different cases. A cure of the septic form is possible; therefore
the treatment should be carefully considered. The navel wound should be
cleansed, and the child is to be isolated from its mother. To control
the fever quinine may be given. Priessnitz's sheet is of value;
vomiting may be checked by chloral (one-half to one grain in water).
The strength should of course be maintained by stimulants if
necessary."
Ascites.
The accumulation of fluid indicated by this name has already been
referred to in its relations to several causes. There are, however,
conditions producing it which have not been considered or only
considered partially.
The most prolific source of abdominal dropsy is obstruction of the
portal circulation on its way to or through the liver. Condensation of
the liver structure in cirrhosis, with destruction of many of the
portal capillaries and compression of many more, is prominent in this
connection. The compression of the liver caused by an adventitious
external covering, referred to under the head of Local Peritonitis,
acts similarly, whether it compresses the vein at its entrance into the
liver or not, although it is not known to produce any destruction of
the portal capillaries. Some enlargements of the organ are attended by
the same result, but they are always associated with a hardening of its
structure. The disease lately called waxy liver, now often denominated
lardaceous, belongs to this class, as does that condition in which the
organ is enlarged, hardened, and fissured, regarded as syphilitic
liver. That both these diseases may have a syphilitic and mercurial
origin is not a point now under consideration. They both harden the
hepatic structure and obstruct the portal circulation, while they may
not in equal degree hinder the progress of arterial blood. This is
explained when we remember the diminished force that propels the portal
blood. Neither of these diseases produces dropsy early in its progress,
but, as I have seen it, always before it reaches its fatal termination.
Fatty liver has not, in my observation, produced dropsy, {1174}
although I have seen livers made very large by that disease, and the
absence of dropsy when the liver has been large has aided me in
distinguishing it from the waxy disease. Cancer of the liver in some
instances does, and in others does not, produce dropsy of the bowels.
It is only certain to have this result when a tumor is in position to
press upon and obstruct the portal. Hypertrophy of the liver, caused by
mitral regurgitation or other disease of the heart, does not generally
produce dropsy, but, aided by anæmia or watery condition of the blood,
such a result is possible. In children, however, it is not very rare to
see the bowels distended by dropsy, and to discover that the liver is
enlarged at the same time. It is common in such cases that the dropsy
and the hypertrophy disappear after a few weeks of treatment. This may
occur in a child that is anæmic, but without any disease of the heart.
Such a case was brought to me two or three months ago, and after four
weeks of treatment by tonics and diuretics the health was
re-established. There is one point in these cases of some importance.
When the child lies on his back, if the abdomen is much distended, the
liver cannot be felt. It has sunk away into the fluid, and in this
position ordinary percussion cannot ascertain its dimensions. In the
July number (1840) of a quarterly journal edited by Swett and Watson, I
published an article in which I reported the conjoined labors of the
late Camman and myself on a new method of combining auscultation and
percussion, with its results, under the heading "Auscultatory
Percussion." By the method described in that article--viz. by placing a
solid stethoscope, or for that Laennec's first stethoscope, a rolled-up
pamphlet, on the chest at a point where the liver has not fallen away
from its walls, and percussing on the abdomen from below upward--a
point is reached whence the percussion sound is brought sharply to the
ear, while half an inch below the sound is dull and distant. The lower
edge of the liver is thus easily recognized, and its upper boundary is
found in a similar manner or by ordinary percussion, so the difficulty
of measurement disappears.
In such case, when the dropsy disappears and the liver recovers its
natural dimensions at the same time, the inference is that the
hypertrophy caused the dropsy, and that the hypertrophy was of the kind
called simple. The nutmeg liver is thought to have an agency in
producing dropsy, but as it is for the most part associated with
diseases that have been called dropsy-producing, its bearing on this
effusion may yet be regarded as uncertain.
It is common to speak of heart dropsy in such a way as to imply that
disease of the heart alone can produce abdominal effusion. I doubt it.
I even doubt whether the heart alone can cause the anasarca that is so
often attributed to it. In following a great multitude of heart
diseases from the time they were recognized to their termination, I
have been struck with the ease with which the patients attend to their
business, sometimes even laborious business, for years--in one instance
fifty years--with almost no complaint, and how rapidly their condition
changes as soon as albumen and casts appear in the urine. I have been
compelled by these observations to ascribe the anasarca and oedema that
makes this last stage of heart disease so distressing to the kidneys,
and not to the heart. Double pleuritic effusion is not uncommon under
these circumstances, but every physician must have noticed the rareness
of troublesome abdominal {1175} dropsy, while there is
sometimes--perhaps often--a little effusion; and when in the
exceptional cases there has been much, it was almost always accounted
for by a dropsy-producing change in the abdominal organs, not, perhaps,
discovered during life; so that for me, while they produce overwhelming
effusions in other parts of the system, they are minor agents in the
production of ascites. Phthisis is occasionally attended, toward its
close, by oedematous legs and albuminous urine, but I cannot report any
important relation between these and peritoneal effusion. I can say the
same of chronic bronchitis. I record this negative testimony regarding
the two last-named diseases, because I find them enumerated among the
causes of abdominal dropsy.
Cancer may invade the portal vein, tumors of adjacent parts other than
those of the liver, or an aneurism may compress it and cause dropsy.
Hydatid tumors may do this. Diseases of the pelvic organs, both acute
and chronic, may produce it, but then the disease would fall into the
class of those produced by chronic or subacute peritonitis.
DaCosta thinks he has lately had a case of chronic peritonitis attended
by ascites. It was in a woman thirty years of age, who had been thrown
with force upon the frame of an iron bedstead, striking the lower part
of the bowels. Pain and tenderness followed. These were not confined to
the injured part, but extended to the whole abdomen; and there was
menorrhagia. After a time there was fluid effusion in the peritoneal
cavity, which slowly increased till her state demanded relief from
tapping. The fluid after this operation did not return. The pain and
tenderness were constant symptoms all through. She slowly improved, and
at the time the case was reported it was believed that she would soon
be discharged from the hospital. The only doubt which DaCosta finds
regarding the diagnosis is in the facts that the liver was diminished
in size and that the spleen was moderately enlarged, and he admits the
possibility that an adventitious capsule of the liver may have caused
the ascites, but believes that it was dependent on chronic peritonitis.
Acute peritonitis subsiding into chronic, with increase of fluid
effusion, as I have already said, I am not familiar with. That
occurring in cancerous and tuberculous peritonitis has already been
considered. But in relation to these some facts regarding frequency of
occurrence, collected by Bristowe, are worth quoting. He says that in
48 cases of tubercular peritonitis, dropsy was found in 12, and that in
22 of peritoneal cancer, 12 had more or less ascites. He further adds,
regarding cirrhosis, that of 46 cases observed post-mortem, there was
dropsy in only 20. This is not surprising, as in all the diseased
conditions of the liver that produce dropsy the anatomical changes must
reach the point at which there is considerable portal obstruction
before the effusion will occur.
The amount of fluid found in ascites varies greatly. In some it may
remain for a long time stationary at four or five quarts; in others the
suffering caused by an accumulation of nine or ten quarts will demand
its removal; and in a few cases twenty quarts have been removed in one
operation. It is in cirrhosis that the largest quantity is found, and
it is in this disease and in cancerous peritonitis that the most
frequent tappings are required. The quality of the fluid also varies
markedly: from being almost as clear and thin as spring-water it may be
almost ropy, or in color greenish or yellowish or slightly red; it is
very likely to contain {1176} albumen; and it is probable that a
further study of its microscopic elements may enable us to resolve
doubts regarding the cause of the effusion. It very often contains
blood-corpuscles.
Bristowe finds from hospital records that ascites occurs in about equal
frequency in males and females, but, as everybody has noticed, that
hepatic dropsy is much more frequent in men than in women. Ascites, he
says, is most frequent between the ages of thirty and fifty, and next
between twenty and thirty and between fifty and sixty, but is not
uncommon above the latter age; and it occurs in children.
SYMPTOMS.--In general, ascites is easily recognized by the swollen
state of the bowels: a well-rounded swelling when the patient stands or
sits, but spread out in the flanks when he lies on his back; the
fulness of the side on which the patient may be lying, and the
flattened condition of the opposite side,--belong to this disease, and
as a group to no other. The results of percussion are significant in
the movement it causes in the fluid, and for the resonance or flatness
it produces. When the patient lies on his back, tapping with the
finger-ends on one side of the abdomen sends a wave of the fluid across
to the other side, where it is perceived as a gentle blow by the
applied fingers of the other hand. If the abdomen is not full, this
wave will be produced at the upper level of the fluid, but not above
that. If this wave cannot be sent across the body, it may be found on
either side by percussing above and feeling for it below; percussion
also teaches where the fluid is, and where it is not, by the dull sound
it produces. It is rare in ascites that the intestines do not float on
the surface of the fluid, at least from the umbilicus upward, and there
give a loud percussion sound, while toward the back, and often toward
the pelvis, it is dull, or even flat; changing the position of the
body, the resonance will be uppermost and the dulness in the most
dependent part. Then the softness or impressibility of the abdomen till
the tension becomes great is noticeable. The changed position of the
fluid as the body is turned from side to side is important. A very
small quantity of fluid can be detected in this manner. The patient is
placed on his right side and percussion is made in the right flank:
there is dulness, while in the left flank there is resonance. The
patient turns on to the left side: dulness now changes position, and is
on the left, and on the right resonance. If it is feared that some
undetected fluid remains in the pelvic cavity, the pelvis may be raised
by pillows and the same examination repeated, or he may be placed in
the knee-and-elbow position referred to by Bristowe, and the percussion
will then be made upward in the umbilical region. In some cases the
contraction of the mesentery will not allow the intestines to rise
through a large amount of fluid and float on it; but such cases are
almost confined to the cancerous and the tuberculous varieties of the
disease; and as in these the symptoms are grave, the physician will
probably have visited his patient many times before this contraction
will embarrass him. Besides, when mesenteric contraction occurs there
is a very strong probability that the omentum will also be contracted,
be rolled up, and lumpy; as this can almost always be felt above the
level of the umbilicus, he has in it an explanation of the absence of
resonance on the fluid. It has happened that oedema of the abdominal
walls or fatty accumulations there have given a delusive though feeble
fluctuation on percussion. In such cases, if the patient make moderate
pressure with the back of a small book in {1177} the course of the
median line, that kind of wave will be broken, while a wave in the
abdominal cavity will not be prevented. When there is considerable
distension of the abdomen by fluid, weak spots in the abdominal wall
often yield and make a tumor. This is very common at the umbilicus,
where a little bladder is lifted half an inch or more above the general
curve of the abdomen. The fluid frequently follows the track of
hernias. In females it has been known to press the anterior wall of the
vagina backward and downward, so as to make it protrude at the vulva.
It has, in one of my own cases, by downward pressure caused complete
prolapse of the uterus. It is very often attended by oedema of the
lower limbs. This is accounted for by the pressure of the abdominal
fluid on the veins that return the blood from these parts, or in
cirrhosis by contraction of the ring or notch through which the vena
cava passes in the liver. If there is general oedema, the cause will
probably be found in disease of the kidneys; or if in one limb, in
pressure or thrombosis of one iliac vein. As the disease advances the
accumulating fluid forces the diaphragm upward, diminishes the
breathing room, and threatens the life still more. Then the patient
cannot lie down in bed, but spends his nights as well as days in an
easy-chair, and sleeps leaning forward on a support for his forehead.
The veins on the abdominal surface will fix attention. With almost any
large tumor in the cavity they become more or less enlarged. But in
cirrhotic dropsy this becomes more striking than in any other
affection. The enlargement is attended by a reversion of the
blood-current on the lower half of the abdomen. This is early shown by
emptying an inch or two of a vein with the finger, drawing it either
upward or downward, and noticing from which direction it is refilled
when the pressure is removed. The pelvic veins do not readily discharge
their blood by the natural channels, and by anastomosing branches it is
forced over the surface of the abdomen and into the thoracic veins,
these latter becoming in turn greatly enlarged. The appetite is
commonly poor, the digestion flatulent, the pulse accelerated.
Emaciation is gradual or rapid. The urine is commonly scanty, and in
cirrhosis of a reddish hue. The skin is apt to be dry, particularly so
in simple chronic peritonitis. The tongue has no characteristic fur,
and is often, almost always toward the close, dry. The mind is not
affected till near the end; then often the patient is delirious,
commonly mildly. Diarrhoea is not uncommon, and even dysentery has been
observed. The result is almost always unfavorable, or, as has been
said, lethal.
The diagnosis is not often difficult. When, as in chronic peritonitis
and in tuberculous peritonitis, the fluid is confined in a sac or sacs,
each particular pool will be yielding to pressure, but elastic, and
will give the percussion wave, though it may extend but a short
distance. To distinguish ovarian dropsy--ovarian cysts, as it is now
called--from ascites may require a few words. Ovarian tumors of all
kinds are found to be more prominent on one side when they rise from
the pelvis than on the other. This is not the case with ascites. The
uterus and its appendages lie in front of the pelvic intestine, and
when any of them ascend above the pelvis they must occupy the same
relative position. In other words, a large ovarian cyst must lie in
front of the intestines, while intestinal resonance should be found
behind and in the sides. But if the ovarian cyst does not occupy the
whole height of the bowels, intestinal resonance {1178} may exist above
it, and the dulness may be found below, bounded by a portion of a
circle, and sometimes the cyst walls are resisting enough to allow its
boundaries to be ascertained by the fingers. This cyst can also be felt
in the vagina; and the uterus, instead of being pressed down, is
sometimes lifted upward, so that it cannot be reached in the vagina,
but can be felt through the abdominal walls just above the pelvic
bones. A condition more troublesome than this is when ovarian cyst and
ascites occur together. Then the posterior or lateral resonance is lost
when the patient lies on her back, but can be found on one side when
she lies on the other. In that concurrence, in dorsal decubitus it is
possible by pressure or a little blow to send a wave of the ascitic
fluid over the front of the cyst. This can be seen as well as felt.
Should the patient take the knee-and-elbow position, the intestinal
resonance may be restored in both flanks.
TREATMENT.--In opening the chapter on the treatment of ascites it is
usually said, Give principal consideration to the diseased conditions
that have caused the dropsy; in other words, cure cirrhosis, cancerous
peritonitis, tubercular peritonitis, heart disease, and the secondary
affections of the abdominal organs, release the liver from the
dangerous compression to which it is subjected, and all will go well.
But they do not inform us how these impossibilities--at least in most
cases impossibilities--are to be achieved. It is true that the
physician would not shrink hopelessly from the treatment of simple
chronic peritonitis. But this is one of the rarest causes of ascites. A
physician in a long lifetime may not have seen a case. It is true,
ascites is a symptom, always a secondary, or even a tertiary,
affection; and theoretically there can be no better advice, but
practically it cannot amount to much. Then, if the cause cannot be
removed, it remains to do our best to relieve the patient of his load
and strive to prolong his life to its utmost possible limit. In doing
this the physician will often find himself able to give gratifying
relief, and once in a great while to rejoice in a cure.