The ascitic type is characterized by rapid accumulation of fluid, with accompanying malaise and debility. As the abdomen distends and the diaphragm is pushed upward respiration becomes more difficult and rapid. A certain protrusion of the umbilicus also characterizes many of these cases. Their course is not so febrile, but it may be possible, especially in the early stages, to make out some enlargement of mesenteric nodes, or involvement of the viscera, which will aid in diagnosis. It is most common in children, but it may be met with at any age. In general such a collection of fluid, which cannot be accounted for by recognizable disease of the heart, liver, or kidneys may be suspected to be tuberculous.
Treatment.
—Treatment of tuberculous peritonitis should be surgical when possible. This statement is based partly upon the fact that it is so commonly a secondary condition. Such treatment will depend, in large measure, upon the extent to which it may be possible to remove any exciting foci of the disease; but experience shows that even this is not always necessary to bring about a cure, as in those cases of the ascitic type where it is desirable only to wash out the abdominal cavity and close it again, this simple procedure seeming to suffice.
It is the cases of the ascitic type which seem most benefited by incision and irrigation, usually without drainage, and it is these which are perhaps as hopeless as any under non-operative treatment. It was Van de Warker, of Syracuse, who, in 1883, first recognized the value of simple irrigation in these cases, and while at present we find it impossible to explain the benefit which so often and so rapidly accrues, the measure is universally recognized as that offering the most hope. This, like every other surgical procedure, should be practised early rather than late, preferably so soon as diagnosis is made, or, when this is difficult, it should be made a part of an exploratory operation intended partly for diagnostic purposes. The measure itself is simple. A small opening in the middle line, between the pubis and the umbilicus, permits free escape of all contained fluid, which should be facilitated by changing the position of the patient, thus preventing plugging of the opening by presenting bowel. Every drop which can escape having been removed, the abdomen is then flushed repeatedly with either warm saline solution or a plain watery solution of acetozone, 1 to 1000, or silver lactate or citrate, in the same proportion or a little stronger. My own preference has always been for the latter, and with a silver solution I have obtained a large degree of success. There is no objection to leaving a small amount of either of these fluids in the abdominal cavity—i. e., no more than an ordinary effort to empty it before closing the wound. An incision one inch long, made for this purpose, will serve nearly every indication. Through it the parietal peritoneum, as well as that covering numerous loops of intestine, can be inspected, and through it also a finger may be inserted for exploratory purposes, for the detection of mesenteric nodular disease or of any other focus. Should any serious local condition be revealed which might be benefited by radical measures, this would be the time to practise them.
Before closing the wound margins it would be well to thoroughly disinfect them, for over them has flowed infected fluid, and we sometimes see tuberculous foci develop at this point. This fact explains also the disadvantage obtaining in these cases of making drainage openings. They serve their purpose admirably for a short time, but, becoming thus infected, lead to the establishment of tuberculous fistulas and sinuses, which may call for subsequent operation. Fecal fistula may even be a more remote consequence. As the peritoneum is approached it will be found more or less altered, and there may even be observed bowel or omentum adherent behind it; therefore caution must be observed.
A final caution should also be given in order that we may avoid mistaking that form of ascites which is frequently seen in connection with cancer of the abdominal viscera extended to the peritoneum, and particularly that form spoken of as miliary carcinosis or miliary sarcomatosis, for a tuberculous collection. While surgeons are occasionally deceived, one will usually find much in the history of the case, and in the results of local examination, which may save making this error, if it be so regarded; but, in effect, the opening and the evacuation will give relief, even though this character of the disease makes it less amenable to help from any such source.
CHAPTER XLVII.
INJURIES AND SURGICAL DISEASES OF THE STOMACH.
CONGENITAL MALFORMATIONS OF THE STOMACH.
These malformations are quite rare, at least those raising the question of possible surgical remedy. Transposition does not require relief, nor does a stomach abnormally small allow it. More or less stenosis of the pylorus as a congenital defect has been observed, but it is extremely rare. Along with it is often associated a certain hypertrophy of the stomach muscle. Hour-glass deformity may be of congenital or acquired origin. The latter two conditions permit of easy surgical remedy. Pyloric stenosis may be atoned for by gastro-enterostomy or treated directly by a plastic operation, while the hour-glass stomach permits of an anastomotic rearrangement, either of its dilated portions with each other or with the bowel below.
The acquired malformations are connected with the consequences of ulceration and stricture. They include more or less complete stenosis, either cicatricial or malignant, various forms and types of gastroptosis and gastric dilatation, in which sometimes enormous degrees of distention are produced, with disturbed or practically destroyed stomach digestion. These cases will be considered by themselves a little later, along with their surgical relief.