A practical treatise on medical diagnosis for students and physicians / by John H. Musser.

  • Musser, John Herr, 1856-1912.
Date:
1904
Catalogue details

Licence: Public Domain Mark

Credit: A practical treatise on medical diagnosis for students and physicians / by John H. Musser. Source: Wellcome Collection.

Provider: This material has been provided by the Francis A. Countway Library of Medicine, through the Medical Heritage Library. The original may be consulted at the Francis A. Countway Library of Medicine, Harvard Medical School.

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    eral cavity of the peritoneum. Accordingly the regions of predilection for the development of local or circumscribed peritonitis, with or without perforation, are the same as those that have been indicated as the usual starting-point of general peritonitis. But although the inflammatory focus may be retained by a limiting wall, the process may nevertheless, after suppuration has began, undergo gradual extension and the pus may burrow in various directions. Circumscribed peritonitis in the lower half of the abdomen is due to disease of the vermiform appendix or of the Fallopian tubes; the local signs are, first, those of pain and tenderness ; second, the development of tumor. Subdiaphragmatic Abscess. Subdiaphragmatic or perigastric abscess is a collection of pus walled in by the stomach, spleen, diaphragm, colon, and the abdominal walls, and may be associated with local peritonitis in the upper half of the abdomen. The most common cause is irritation from a gastric ulcer that has nearly or quite perforated and has formed adhesions with the surrounding viscera. This was the cause in 41 out of 52 cases analyzed by Fenwick, while in 6 it was associated with cancer, and in 4 with abscess commencing exter- nally. Pain in the epigastrium was the most prominent symptom ; some of the patients were dyspeptic, and vomiting occurred also; while, singu- larly enough, hsematemesis is mentioned in only 2 cases. Fever is quite marked. Fenwick thinks that in every case of perigastric abscess, except in persons affected with phthisis, cancer, or some other chronic exhausting malady, the first formation of the abscess will be accompanied either by collapse and signs of general peritonitis, or by sudden and severe pain in the epigastrium with indications of local peritonitis. The physical signs are not pronounced; a tumor, according to the same author, is rarely distinguishable except when the condition is caused by cancer. The percussion-note, when a tumor is present, is at first dull but later becomes tympanitic, and the tumor is not movable on inspiration or external pressure; there may, however, be arching outward of the ribs. Palpation is difficult on account of the tension of the abdominal muscles. The degree of displacement of surrounding viscera depends on the size of the abscess and the extent of the adhesions. The breathing is embarrassed by the upward pressure of the diaphragm against the lung and heart, and the dulness may extend as high as the angle of the scapula, simulating a pleural effusion. It should be borne in mind in this connection that the lower limit of the lungs in health corresponds to the eighth or ninth interspace. There may also be dulness in the axillary region; and if the abscess is on the right side, it may simulate an enlarged liver and cause a considerable extension of the hepatic dulness anteriorly, laterally, or posteriorly. If the local peritonitis in the epigastric region is secondary to disease of the pancreas, it may be limited to the lesser peritoneum and cause the physical signs of effusion into that cavity (see Diseases of the Pancreas); while subdiaphragmatic abscess is not limited to the lesser peritoneum and must be recognized by the history of a previous lesion capable of causing perforation and by the general symptoms of abscess. Subphrenic Pyopneumothorax. Sometimes gas is formed in con-