A system of practical medicine. By American authors. Vol. 2

by Unknown

Bristowe has seen no cures from either sudorifics, diuretics, or purgatives. I have seen one or more from each of those agents, all cirrhotic. He "has seen cures occasionally from mercury, iodide and bromide of potash, copaiba, and a combination of fresh squills and crude mercury." I agree with him in his statement that counter-irritants are useless, making exception for chronic peritonitis and the early stage of the tubercular variety. He thinks quinia, iron, and cod-liver oil are useful.

Paracentesis in almost every case will at length become necessary, and the question comes whether it should be practised early or late. If it be delayed till the oppression of the breathing makes it imperative, the walls of the abdomen will be so stretched as to present little resistance to the reaccumulation of the fluid, and a second tapping will be required in fifteen to twenty-five days. A bandage is a poor substitute for muscular contraction. If, on the other hand, the fluid is withdrawn before the muscularity is not stretched out of the muscles, then accumulation will be less rapid and the patient will be spared the suffering which large accumulations cause. But tapping is not always an innocent operation. It is sometimes followed by acute peritonitis. By the early tapping this risk is oftener taken. Reginald Smith suggests the use of a small canula by which only ten or twenty ounces of the fluid can escape each hour. This mode, he thinks, removes the danger of syncope and makes the bandage needless.

Hemorrhagic Effusion

in the peritoneum is a topic on which there is little to be said. A primary effusion of this kind probably does not occur. In hæmatophilia, where the mucous membrane of the nose and wounds bleed dangerously, there is no record of spontaneous bleeding into the peritoneal cavity. The same thing can be said of that very rare disease which has been called bloody sweat. An unmarried lady applied to me fifteen years ago with this disorder. The blood would ooze out at hundreds of points on the inner face of the arm; these would run together and drop off the arm, or the same thing would occur on the chest and in the bend of the knee. This would continue for two or three minutes, and then cease of itself, but to recur in one or more, rarely several, places. For years this habit continued. There was no irregularity of the menses. I could find no visceral disease; there was no nose-bleed. She lost strength, but only moderately. This kind of bleeding continued for several years. She is now approaching fifty years of age, and for the last two or three years has had no recurrence of the bleeding. There was never anything in this case to lead to the suspicion of peritoneal or other serous hemorrhage. In the few similar cases on record there is the same absence of all evidence of internal bleeding.

It has already been said that a certain amount of blood, as shown by its corpuscles, is to be expected in cancerous ascites, and with less uniformity in tubercular ascites, and not unfrequently in hepatic dropsy, as well as in acute peritonitis. This may not deserve to be called hemorrhage, on account of the moderate quantity of blood that is effused; but aside from that which results from rupture of blood-vessels it is about the only kind of it with which we are familiar.

Scurvy, and conditions of the blood analogous to those produced by that disease, make it almost certain that if pleurisy or pericarditis occurs while these conditions exist, it will be hemorrhagic. I am not, personally, acquainted with a single instance in which peritonitis in this condition has occurred. Copeland, however, says that hemorrhage in peritonitis has been noticed by Broussais and others. The blood is mixed with the serum and stains the surface of the false membrane, as in hemorrhagic pleurisy and pericarditis, and the disease is of an asthenic type, "occurring in the hemorrhagic diathesis." "The symptoms are inflammatory from the beginning, and rapidly pass into those indicating great depression; the pulse becomes rapid, small, and soft, death quickly supervening, with convulsions, cold and damp extremities and surface," etc.

Copeland has himself not seen a case, and regards its occurrence as very rare. Delafield states that "Friedreich describes two cases occurring in patients with ascites who had been frequently tapped. He says that both the parietal and visceral peritoneum was covered with a continuous membrane of a diffuse, yellowish-brown color, mottled with small and large extravasations of blood. The membrane was thickest over the anterior abdominal wall. It could be separated into a number of layers. These layers were composed of blood-vessels, masses of pigment, branching cells, and fibrillated basement substance. In many places the extravasated blood was coagulated in the shape of round, hard, black nodules. The new membrane could be readily stripped off from the peritoneum, and there were no adhesions between the visceral and parietal portions of the peritoneum."

The erosions of abdominal cancer sometimes open vessels of considerable size, causing large hemorrhage into this cavity and sudden death.

When aneurisms of the abdominal aorta rupture, they sometimes flood the abdominal cavity; oftener they open into the structures under the peritoneum on the left side, and make a large flat tumor extending from the point of rupture downward to the brim of the pelvis, and even beyond it.

A gentleman whose health was usually good, thirty-five years of age, felt an unwonted exhaustion and feebleness creeping over him. His countenance became pale, his pulse rapid, growing smaller and smaller. It seemed certain that there was hemorrhage somewhere, but until it was noticed that the bowels were growing tumid and hard there was nothing to guide us to its seat. Even then we were left to conjecture regarding the bleeding vessel. This sinking continued for thirty-six hours. After death it was found that a small aneurism had been formed on one of the vessels of the omentum, not larger than a small walnut, and had ruptured by a very small opening, and that it was by this small opening that life had oozed away.