650 DISEASES OF THE PERITONAEUM. 



to the vessels of the peritonaeum. As this can only occur from an ob- 

 struction of the portal vein, it is evident that ascites occurring alone, 

 without dropsy of any other part, accompanies diseases of the liver 

 and its blood-vessels. 



3. Lastly, ascites not unfrequently accompanies extensive degenera- 

 tion of the peritonaeum, such as carcinomatous or tuberculous. Of the 

 various forms of carcinoma, however, the alveolar carcinoma of the 

 peritonaeum alone appears to be accompanied by extensive ascites. 



ANATOMICAL APPEARANCES. The amount of serum found in the 

 abdomen varies. In some cases it is only a few pounds, in others it is 

 forty or more. The fluid is sometimes clear, sometimes slightly cloudy, 

 from containing cast-off and fatty epithelium. It is usually bright yellow, 

 rich in albumen and salts, and only rarely contains flocculi of coagulated 

 fibrin. In the fluid which is poured into the abdomen, particularly in de- 

 generation of the peritonaeum, precipitates of " late coagulating fibrin " 

 (fibrin spa'tergerinnung) form after it stands awhile in the air. 



The peritonaeum itself is usually dull and whitish ; the superficial 

 layers of the liver and spleen are slightly discolored. Under the pres- 

 sure of large effusions, the liver, spleen, and kidneys may become 

 bloodless and smaller. Lastly, the diaphragm is occasionally pressed 

 upward, to the third or second rib, by the fluid. 



SYMPTOMS AND COURSE. It is scarcely possible to give a descrip- 

 tion of ascites, as it is never an independent disease, and as its symp- 

 toms can only be artificially separated from those of the original af- 

 fection. 



If ascites occur during general dropsy, the subjective symptoms of 

 the new disease, when compared with the other troubles of the patient, 

 are usually too unimportant at first to direct attention to the ascites. 

 Then the physical examination, induced by the suspicion that there 

 may be ascites, gives the first certain knowledge of its existence. The 

 case is different in the ascites accompanying disturbance of the portal 

 circulation or degeneration of the peritonaeum. When cirrhosis of the 

 liver or cancer of the peritonaeum occurs latently, the gradually in- 

 creasing troubles caused by the ascites may be the first anomalies 

 noticed, and may first excite a suspicion of the original disease. As 

 long as the abdomen is moderately filled with fluid, the patients only 

 complain of a feeling of fulness, and are inconvenienced by the tight- 

 ness of clothes which were previously comfortable. They also notice 

 slight difficulty on deep inspiration. If the fulness of the abdomen 

 increase, the sensation of fulness becomes painful, and the slight diffi- 

 culty of breathing increases to severe dyspnoea. The pressure of the 

 fluid on the rectum may cause constipation, and the flatulence induced 



