Cancerous Peritonitis

Benign tumors of the abdomen are not frequently the cause of general peritonitis, and when they are, the grade of the disease is acute rather than chronic. They very often provoke local inflammation and become adherent to the neighboring structures. The same is true of malignant growths in the abdominal cavity, except that the adhesions are earlier formed and more likely to occur. Localized cancer, of whatever variety, is not very prone to produce general peritonitis, even though there be multiple developments of it. But when the disease takes the disseminated form, and is sprinkled over the whole extent of the peritoneum, then inflammation is almost certain to occur—not of high grade, and yet deserving the name subacute rather than chronic. A case which illustrates this statement has come under my observation within the last year. I will recite it with sufficient detail to make it intelligible.

A lady about forty years of age had, up to the summer of 1881, enjoyed very good health, though she was never robust. At that time she felt her strength abating and her stomach disordered. She sought health in various places, and took professional advice in September. It availed her little; the bowels were gradually swelling and fluctuation could be felt. She was losing strength and flesh. There was not a cachectic countenance, but the features were growing sharp. She had suffered but little from pain till October. At that time she was at the family country home. Then she began to suffer from a severe pain in the left thigh; and this, it was noticed, increased as the accumulation in the bowels increased, and at length her physician felt compelled to tap her—not so much on account of great distension of the bowel as in the hope of relieving the pain. He drew off nine quarts of gluey, viscid fluid, and her pain was wholly relieved. Twelve or fifteen days after this she was brought to her city home, and her city physician, seeing that her case was a grave one, sought the aid of a distinguished gynæcologist. She was then again tapped to give him a more satisfactory examination. He found the ovaries considerably enlarged and hard. They could not, however, be felt by pressing the fingers into the pelvis from above—only by the vagina. I saw her on the 10th of November. The fluid had again made considerable tumefaction of the bowels, and she was again suffering great pain in the region of the right kidney and in the leg of the same side, together with cramps. The relief given by the first tapping induced us to propose its repetition. It was, however, delayed till the 14th, that the physician who had tapped her before might be present and assist. The quantity of water drawn was again nine quarts, and again the pains and spasms were quieted. The examination of the abdominal fluid was interesting. It was nearly clear, reddish, of syrupy flow and consistence, and so viscid that while a portion of it had remained on the slide of the microscope long enough for the examination of its constituents the thin cover became so firmly attached to the slide that it could not be removed without breaking or long maceration. The albumen was so abundant that the fluid was completely consolidated on boiling. Fibrinous threads were running through it in great numbers, and here and there was a cell of large size, round, granular, but not plumped up with granules, with a nucleus barely less in size than the cell itself; its outer border within, but only just within, the boundary or wall of the cell. It was the nucleus that was granular, for there was little room for granules between the nucleus and the cell wall. The vial containing the fluid had been standing three or four hours for a sediment. This in a vial four inches high occupied the lower half, and gave nothing to the dropping-tube till the sedimentary matter was drawn into it by suction. This matter consisted of fibrillated fibrin in large quantity; a great number of the cells just described, some grouped, but most separate or single. There were pus-cells in moderate quantity, each having the amoeboid movements, and a considerable number of red blood-corpuscles, some of natural form, some crenate.

Immediately after the tapping the flaccid condition of the abdominal walls admitted an examination. A solid, hard mass was found running across the upper part of the bowels, a nodule of which was lying on the stomach at the point of the ensiform cartilage. A harder mass of irregular shape was also found just above the pelvis on the right side, extending upward and to the right. This was in extent two by three inches. The ovary, however, could not be detected by pressure from above downward. The diagnosis up to this time was hardly doubtful, but these revelations made it complete, and crushed any lingering hope of the patient's recovery.

While the pain and spasm ceased after the tapping, the oedema of the left leg, which came on some time before the last tapping, did not diminish. The hard spot near the right iliac fossa was tender on pressure, but otherwise hardly painful. While the fluid did not exceed six quarts or so, she had little pain anywhere. There were no external glandular swellings. Her appetite was poor, and she took but little food. She vomited very little till the end was approaching. The urine contained a few globules of pus, some pigment matter, two or three hyaline casts, but no trace of albumen. For sixteen days following November 14th the patient was comfortable, but the fluid was slowly filling the bowels again. At that time the pains already referred to began to return. On December 5th they required another tapping, and preparations were made for it, but vomiting, rather severe, led to its postponement to the next day. The quantity of fluid drawn was nine and a half quarts. It was of the same syrupy consistence as that previously drawn, and under the microscope showed exactly the same constituents and gave the same quantity of albumen. The next day stercoraceous vomiting commenced, with no movement of the bowels, except what was produced by 10 grains of calomel given on the second day of this vomiting. That acted well and produced a temporary relief. She after this took no food by the mouth, but milk and beef-tea were injected into the rectum. Still, the fecal vomiting returned, and she died on the 15th.

The post-mortem examination was made on the 17th by William H. Welch. I could not attend it. His report is complete as to the main features of the case, though it does not furnish an explanation of the spasms and the oedema of the left leg, regarding which Welch was not informed. The pain and spasm were doubtless due to backward pressure of a diseased part on a nerve or nerves, and the oedema to a narrowing of the iliac vein by pressure or constriction by fibro-cancerous matter on its outer sides. "The peritoneal cavity," he says, "contained somewhat over a gallon of clear, yellow serum. Both the visceral and parietal layers of the peritoneum were thickened, in some places more than in others; this was especially marked on the anterior of the stomach and on the lower part of the ileum and in the left iliac region. The omentum was greatly thickened and retracted into a firm mass (or roll), which extended somewhat obliquely across the body, more to the left than to the right. The mesentery was much thickened and contracted, drawing the intestines backward. In a few places only was the peritoneal surface coated with fibrin, and the intestines were mostly free from adhesions. The coils of the lower part of the ileum, however, were firmly matted together by organized connective tissue in such a way that they were twisted, often at a sharp angle, so as greatly to constrict the calibre of the gut. The serous and muscular layers of the intestine at this point were greatly thickened. By these causes there appeared to be a complete obstruction at a point about six inches above the ileo-cæcal valve. By careful dissection these coils were straightened out, so as to remove the main cause of obstruction. The peritoneal covering of the liver was adherent to the parietal layer.

"The surface of both the visceral and parietal peritoneum was studded over with hundreds of small, firm, whitish nodules, generally not larger than a pea, and often not larger than a pin's head. In some places they had coalesced and made firm patches an inch in extent. This same material was found in the contracted omentum in considerable quantity. In a few places, particularly on the uterus, a blackish pigmented deposit appeared.

"The ovaries were not adherent, but both were enlarged to the size of a hen's egg. The outer surface of each was rough and corrugated. The new growth was deposited on the exterior and penetrated each a quarter to half an inch. It was of uniform white color and of firm consistence.

"The stomach wall was thickened nearly throughout its extent, but particularly in the anterior part, where it amounted to thrice the normal thickness. This consisted wholly of hypertrophy of the muscular coat and increase of fibrous tissue in the peritoneal layer. This new growth was traced, in the interlacing bands, from the surface into the muscular coat. In the outer layer of the stomach were found three small white nodules. The mucous membrane of the organ was healthy or a little pale.

"The retro-peritoneal glands along the aorta were enlarged, soft, and of a reddish-gray color. A nodule was found in the wall of the duodenum outside the mucous membrane, and one in the Fallopian tube."

Every organ in the abdomen and chest was examined, but nothing important found except what is here recorded. Welch concludes his record with the following diagnosis: "Primary scirrhous carcinoma of the ovaries. Secondary deposits in the peritoneum, in the outer layer of the right Fallopian tube, of the stomach and duodenum, and in the retro-peritoneal glands. Chronic peritonitis, intestinal obstruction."

This case presents to the reader so accurately the usual course of cancerous peritonitis, and the inspection its lesions, that a treatise on the subject is hardly called for. It often happens that cancerous antecedents in the patient or his relatives will lend an aid to the diagnosis, which this case did not present. To distinguish this disease from tubercular peritonitis no question can arise except in its dropsical form, and then the lungs in every case of the latter that I have met with have the physical signs of tubercles, though not always the rational indications. The pulse is much more accelerated in the tuberculous variety. I omitted to state that the temperature of this patient was often taken, and till the closing scene was never found more than one or two degrees above the healthy standard, and the morning and evening heat did not materially vary; the opposite of both, then, would be expected in a tuberculous case. The existence of meteorism is much more common in the tubercular disease; indeed, in the cancerous case recited there was none of it. The duration of the two is different—that of the cancerous kind is recorded in months, while the tuberculous variety may continue two years. The cancerous is more likely to be attended by alarming accidents, like the complete obstruction of the bowels, large hemorrhages, and a sudden lighting up of acute peritonitis. Finally, in the light of the case here recorded, it seems probable that the examination of the abdominal fluid will become of great importance. I have never carefully examined the fluid of tubercular dropsy, but it does not seem probable that it will have the syrupy appearance, the large amount of albumen, the abundance of fibrin-fibres, and the granular large cells with nuclei only perceptibly less in size than the cells themselves, that were repeatedly found in this case—found by two observers, and at every tapping after the first.

TREATMENT cannot be curative; it therefore consists of such administrations as will relieve pain, give sleep, improve the appetite, increase the flow of urine if it be scanty, and relieve the bowels if there is a tendency to constipation. It is as much the duty of the physician to put off the fatal day, when he can, in incurable affections as it is to cure those that will yield to his prescription and advice. In the case just narrated opium or an opiate alone produced such unpleasant after-effects that she was unwilling to take it, but when the extract of belladonna was given with it she slept pleasantly, and could take her food the next day.