The dropsy in these cases is due to obstruction to the passage of blood through the liver, the transudation into the peritoneal sac being an effect of the hydraulic pressure upon the coats of the portal veins caused by the hepatic obstruction. In so large a proportion of cases is hydro-peritoneum dependent on disease of the liver, that the latter is always presumable, assuming that general dropsy does not exist. It is generally considered that enlargement of the spleen may give rise to hydro-peritoneum. There is little or no foundation for this opinion. Enlargement of the spleen occurs in a small proportion of cases of dropsy dependent on cirrhosis of the liver, and, occurring without the latter affection, as, for example, a sequel of intermittent fever, it is not accompanied by peritoneal dropsy. Obstruction of the vena porta by the pressure of a tumor, by the presence of a thrombus, or as a result of adhesive phlebitis, gives rise to peritoneal dropsy in the same way as obstruction due to hepatic lesions, viz., transudation taking place from hydraulic pressure. According to Frerichs, coagula in the portal vein take place, without inflammation, in consequence of weakened force of the circulation, from compression exterior to the liver by swellings or tumors, and in connection with various hepatic affections. Cardiac and renal disease do not give rise to peritoneal, save as an element of general dropsy. Clinical observation shows, in a small proportion only of cases of hydro-peritoneum, occurring as a local affection, evidence of disease either of the heart or kidneys. In the vast majority of cases, the dropsy is dependent on structural lesions of some kind; that is, it occurs very rarely as a functional affection. Of forty-six cases coming under my observation, which I bave analyzed, in one case only was the history consistent with the supposition that the affection was purely functional.

Various causes may co-operate with the morbid conditions upon which peritoneal dropsy is dependent. Disease of the heart, renal disease, anæmia resulting from intermittent fever, lactation, etc., may be mentioned as co-operating causes. It may be doubted, however, if these causes alone ever give rise to the affection. Indirectly they favor its occurrence and determine the epoch when the dropsical effusion takes place.

The effusion of liquid and its accumulation take place usually without pain, tenderness, or any local subjective symptoms. The enlargement first directs attention to the abdomen. In the majority of cases, when this begins it goes on with rapidity, and the abdomen soon becomes considerably or greatly distended. The symptoms referable directly to the dropsy, proceed from the mechanical pressure of the liquid, and, other things being equal, are in proportion to the quantity of effusion. The distension of the abdominal walls by the liquid, and its weight, occasion more or less inconvenience. The functions of the abdominal organs-stomach, liver, kidneysare impaired by compression. Pressure on the veins within the abdomen gives rise to or increases oedema in the lower extremities. The movements of the diaphragm are restrained or arrested, breathing being carried on by the costal muscles, and, if the accumulation be very large, the capacity of the chest is diminished by the upward pressure, and the embarrassment of respiration may be sufficient to destroy life. The appetite is usually more or less impaired. A sense of fulness is frequently felt after taking food in moderate quantity. Vomiting and diarrhoea are occasional symptoms. Hæmatemesis occurs in a certain proportion of cases.

Clinical Treatise on Diseases of the Liver. Sydenham edition, vol. ii. p. 384. For clinical facts on which these and other statements are based, vide paper by the author entitled Clinical Report on Hydro-Peritoneum, based on an Analysis of forty-six Cases, American Journal of Medical Sciences, April, 1863.

Edema of the lower extremities is a pretty constant symptom, the amount of cedema varying much in different cases. The limbs, scrotum, and penis sometimes become enormously swollen. Some oedema of the lower limbs. preceded the enlargement of the abdomen in one-half of the cases (21), among those analyzed by me, the histories of which contained information on this point. An examination of these cases disproved a statement which has been made with respect to the significance of oedema of the lower extremities preceding the abdominal dropsy, viz., that it denotes disease of either the heart or kidneys. Edema of the face and upper extremities does not belong to the clinical history of hydro-peritoneum. If present, it denotes coexisting renal or cardiac disease. In the progress of the affection, emaciation and pallor become marked. The attenuation of the upper part of the body, the distended abdomen and oedematous lower extremities, combine to render the appearance highly characteristic of the affection. Cholæmia or icterus is occasionally present; it occurred in 7 of the 46 cases which I have analyzed.

Febrile movement does not attend the progress of this affection. The pulse may be more or less increased in frequency and proportionately feeble, or it is more or less enfeebled without acceleration. The urine is frequently scanty. Purpurine may be present in the urine, giving rise to an appearance of hæmaturia. The mind is usually intact, but, in a certain proportion of cases, toward the close of life, delirium, convulsions, and coma occur. These symptoms may be due to uræmia or to retention in the blood of the excrementitious principles of the bile (cholesteræmia).

The mode of dying, in the great majority of cases, is by slow asthenia. A rapid and large accumulation of liquid may destroy life by interference with respiration; and apnoea and asthenia are combined when coma precedes death.

The prognosis in most cases is extremely unfavorable. The cases in which a permanent recovery takes place are very few. The morbid conditions on which the affection is dependent are generally incurable, and lead to its return, sooner or later, in most of the cases in which the dropsy disappears or is removed. The duration of the affection is variable. In the fatal cases of those which I have analyzed, the duration varied from six weeks to seventeen months, the average duration being about five months.

The diagnosis of hydro-peritoneum is generally made without difficulty, yet there is a liability to errors which may lead to serious results. A distended bladder has been punctured, the case being supposed to be one of peritoneal dropsy. It is said that John Hunter committed this unfortunate mistake. On careful examination, the tumor formed by the distended bladder may generally be felt through the abdominal walls; but the introduction of the catheter is the diagnostic test. My colleague, Prof. Sayre, was called upon to puncture the abdomen in a case supposed to be one of dropsy. He was struck at once with the unusual appearance of the abdomen, which projected notably in front and was contracted at the sides. A little milky liquid was withdrawn by introducing the catheter and employing suction by means of an India-rubber bag. Death taking place, with the symptoms of uræmia, it was found, after death, that the case was one of sacculated bladder, the saccular appendage being situated above and measuring twenty-eight inches in circumference. Pregnancy, the liquor amnii being unusually abundant, has been mistaken for dropsy and the uterus punctured. Careful examina tion through the abdominal walls and per vaginam, together with the auscul tation of the abdomen, should prevent this error. Great corpulency has led

1 Vide Report, op. cit.

to error and the operation of paracentesis, as in the famous case of "dry tapping" related in the lectures of Sir Astley Cooper. Finally, tympanites, large abdominal tumors, and ovarian cysts are to be discriminated from peritoneal dropsy.

The enlargement of the abdomen from dropsy commences at the lower part, and, if the abdomen be not largely distended, it is more marked below than above when the patient stands or sits. The enlargement on both sides is equal; the abdomen is symmetrical. If the patient lie upon either side, the weight of the liquid causes the depending side to sag. Percussion on one side, the open palm being placed on the opposite side, frequently causes a characteristic shock, called the sense of fluctuation. Sometimes this sensation is more appreciable when the palm is placed near the point at which the percussion is made. The former method of percussion gives rise to what is called diametrical and the latter to peripheral fluctuation. But a more satisfactory application of percussion is to compare the results when the patient is placed in different positions. Percussing first in the sitting or standing posture, tympanitic resonance, from intestinal gas contained in the intestines floating upon the liquid, is usually found at the upper part of the abdomen, extending below for a greater or less distance, and flatness from this point to the pubis. Placing now the patient on the back, the change in the relative situation of the liquid and intestines is shown by the greater extension of the tympanitic resonance toward the pubis. Similar proof of the presence of liquid is obtained by percussing upon one side of the abdomen successively when the body is inclined to that and the opposite side. The exceptional cases in which this test afforded by percussion is not available are those in which the intestines are fixed by morbid adhesions. This is rare in cases of a purely dropsical affection. The several affections simulating dropsy which have been named may generally be excluded by the application of percussion as just described. Ovarian cysts of sufficient size to distend the whole abdomen are the most likely to be confounded with hydro-peritoneum. These are generally, however, distinguishable by the appreciation of the cyst through the abdominal walls, the existence of a tumor on one side before it extended to the whole of the abdomen, the absence of symmetry in the enlargement of the two sides, together with the want of evidence of the presence of liquid in the peritoneal sac afforded by percussion when the body is placed in different positions.

The treatment of hydro-peritoneum relates, first, to the dropsical' effusion, and, second, to the morbid conditions on which the effusion depends. As regards the dropsical effusion, the object is to effect its removal or diminution. For this object, medicinal and surgical measures may be employed. The medicinal means consist of remedies to eliminate water from the blood, and thereby induce absorption of the effused liquid. The elimination of water from the blood is to be accomplished by diuretics and hydragogue cathartics. Diuretics, in most cases, effect but little. It is difficult generally to obtain much diuretic effect from any of the remedies of this class, the difficulty arising from the slowness with which the remedies enter the general circulation, owing to the fact that the morbid conditions giving rise to the dropsy usually involve obstruction to the portal circulation. Of 13 cases treated with diuretic remedies, in 8 no effect upon the dropsy was produced; in 5 more or less diminution of the dropsy followed, but in only 2 cases was the improvement marked and progressive. Little dependence, therefore, is to be placed on diuretics, but inasmuch as, if properly prescribed, they do not cause much disorder or prostration, they should be fairly tried. The saline and vegetable diuretics may be given in succession,

and a diuretic effect is more apt to be produced if several are employed at the same time.

Of

Hydragogue cathartics act more efficiently than diuretics; but clinical observation does not furnish much evidence of success from their use. the different hydragogues, elaterium is the most reliable. I am accustomed to prescribe this remedy in doses of a quarter of a grain repeated at short intervals until abundant liquid evacuations are produced. Afterward the doses may be repeated according to circumstances. Of 17 cases in which this remedy was employed, in 9 no appreciable benefit followed; of the remaining 8 cases, in one case only was the dropsy removed, in the other cases more or less diminution taking place. In all the effect was only temporary. Owing to the disturbance and prostration caused by the prolonged use of hydragogues, they are liable to do harm, and should not enter largely into the treatment.

The apocynum cannabinum, or Indian hemp indigenous in this country, is considered by some an efficient hydragogue in this form of dropsy. From some trial of this remedy in Bellevue Hospital, I have been led to think it is less reliable than the elaterium. The decoction of the root may be employed, or the extract. This remedy is not adapted to cases of cardiac dropsy in consequence of its sedative action upon the heart.1

It is important to bear in mind that, in order to secure the desired effect of diuretics or hydragogue cathartics upon the dropsy, the ingestion of liquids is to be restricted, the patient drinking no more than the wants of the body require.

The surgical method of effecting the removal of the liquid, is tapping. With respect to this operation, the views generally held are, that it is to be resorted to only when the abdominal distension occasions great distress or danger, and not until the indirect means have been thoroughly tried; that the dropsy generally increases more rapidly after the operation, and that the operation involves danger if the system be much prostrated. I have been led to think that these views are erroneous. Tapping effects promptly, without perturbation and without impairing the vital powers, the object for which diuretics and cathartics are employed, measures generally ineffectual, disturbing the digestive functions, and enfeebling the powers of life. The operation is a trivial one, involving little risk of accidents or of peritoneal inflammation. There is no danger from increased rapidity of effusion directly after the operation. The patient is spared not only the inconvenience and distress, but the permanent injury caused by the prolonged pressure of the liquid upon the abdominal and thoracic viscera, and he is in a condition more favorable for other remedies than those which have special reference to the removal or diminution of the dropsy. Clinical experience shows that, in some cases, even when the dropsy is dependent on cirrhosis, the liquid does not accumulate for weeks or months after the operation. In one case which has come under my notice, after two tappings, there was no reac cumulation for six years. It seems to me judicious to resort to tapping so soon as the accumulation of liquid is sufficient to occasion much inconvenience, adopting this direct method in lieu of the indirect means, provided the latter do not prove immediately efficacious, and repeating the operation whenever the abdomen becomes again distended. These views are based on the results of tapping in 20 cases under my observation, the operation in these cases being performed but once in 11 cases, and in the remaining 9 cases being repeated from three to thirty times. The conclusions drawn from the facts

1 Remarks by Dr. Lockwood in Buffalo Medical Journal, Sept. 1864.

2 For details of these cases vide Clinical Report, op. cit., from which the remarks on tapping are borrowed.

contained in the histories of these cases, are as follows: 1. Tapping may be resorted to as a palliative measure, when the condition of the patient is such that only temporary relief is to be expected. 2. In a certain proportion of cases the dropsy returns more or less quickly, and it may be necessary to repeat the operation many times. The repetitions, however, are innocuous. This was illustrated in one case in which it was performed thirty times in 18 months. 3. In some cases the dropsy does not return for a considerable and even a long period. That it will prove a curative measure is not to be expected in the vast majority of cases.

The treatment relating to the morbid conditions on which the dropsy depends embraces, in the first place, measures to prevent an increase of the incurable lesion which exists in the great majority of cases, viz., cirrhosis of the liver. It will be seen, when we come to consider this lesion, that it is generally caused by spirit-drinking. Change of habits, as regards the use of spirits, is, therefore, the most important of the measures coming under this head. In the second place, certain accessory or co-operating causative conditions may be removed, causes which act by impoverishing the blood and impairing the forces which carry on the circulation. This part of the treatment embraces tonic medication with nutritious diet, and other measures to strengthen and invigorate the system. Well-directed treatment for this end, although rarely curative, will often do much to prolong life, and to secure as much improvement of health as is compatible with existing structural lesions.

Scarification of the genital organs, when these become greatly cedematons, is apt to lead to gangrene and sloughing. This has occurred in three cases under my observation.

Mechanical compression of the abdomen, after tapping, by means of a swathe or a laced supporter, is a measure of importance as not only affording comfort, but tending to prevent a renewal of the dropsical effusion.

CHAPTER XI.

DISEASES AFFECTING THE COLLATITIOUS OR SOLID VISCERA OF THE ABDOMEN.

Acute, Diffuse Hepatitis-Anatomical Characters-Clinical History-Pathological Character -Causation-Diagnosis-Prognosis-Treatment-Circumscribed, Suppurative HepatitisSuppurative, Portal Phlebitis-Cirrhosis of the Liver.

I

Or the affections of the solid or collatitious abdominal viscera, the greater number by far, and the more important, are seated in the liver. These will be considered, and afterward the affections of the spleen and pancreas. shall first consider the hepatic diseases which are undoubtedly inflammatory; next, structural lesions of the liver; and, lastly, functional affections of this Acute inflammation of the liver, or hepatitis, is presented in two forms, viz., diffuse hepatitis, that is, the inflammation extending over the whole or a greater part of the organ, and circumscribed, suppurative hepatitis, or hepatic abscess. These two forms claim separate consideration. Suppurative inflammation of the portal vein, portal phlebitis, will be considered in this connection. Subacute or chronic hepatitis is generally supposed to be the essential pathological condition in the affection known as cirrhosis of