PSEUDOASCITES At this juncture I will discuss a symptom-complex which has fre quently been mistaken for tuberculous peritonitis, and which was first described by Tifbler, under the name of pseucloascites, as a deuteropathic condition of ehronic nephritis.
The manifestations of free aseites do not differ in childhood from those in adults, the two decisive symptoms being the movable area of dulness with change of position, and fluetuation. These two symptoms, however, can under certain circumstances be simulated in juvenile age by fluid intestinal contents. Tobler has seen five cases which had been diagnosed as tuberculous aseites, and where after laparotomy the surgeon (Czerny, Lossen) did not find a trace of effusion in the abdomen.
Schmidt (Basle) has reported one such case; Allaria (Turin), two. I also know of two cases which went to laparotomy with the diagnosis of tuberculous ascites and where no effusion was found. Occurrences of this kind do not seem to be very rare.
According to Tabler, the abdomen in these eases is distended as in asches, the umbilicus indented or bulging. Venous tracts can be dis tinguished. At different times the distention is somewhat slighter in the same patient and the abdominal wall somewhat more relaxed. When the body is in motion, the abdomen drops pendulously to either side.
The fluctuation may be so characteristically' pronounced that it cannot be distinguished from that of true ascites. Repeated examine tions, however, may disclose less distinct conditions which would justify doubts as to their significance.
Percussion may reveal an area of dulness which does not differ from that of a free effusion, and is rapidly and completely movable when the patient's position is changed, forming a horizontal surface.
If children with this condition are examined on several successive days, it is surprising to observe hon- the demarcation and nature of the dulness undergo changes, being one day higher on the left and another day higher on the right side, or forming a horizontal surface in the same way as free aseites. When in digital pereussion the finger that serves as a pleximeter penetrates deeply and gradually, it is sometimes possible to push the fluid intestinal contents away and obtain a tympanitic sound.
In doubtful eases, evacuation of the intestine by laxatives and injec tions should never be omitted.
All children with this symptom-complex have suffered for years front obstinate diarrInpa, are underfed, may show retarded growth and have a pendulous abdomen. The suspicion of tuberculosis is often justified. The age of these patients is from three to nine years.
Figs. 64 and 63 show beautifully the symptom-complex of pseudo aseites and at the same time the type recently established by Herter (New York) for "intestinal infantilism." J. G., six and one-half years old. Weight at birth, 3000 Gm. Was fed on mother's milk for five months and continued healthy until one year old. At that age there was vomiting and diarrhoea; two months later inflammation of the lungs and suppuration of the ears. Since the occurrence of vomiting and diarrlava there were chronic digestive dis turbances, usually two or three mucous, evil-smelling stools daily. Good and bad periods alternated. The abdomen became distended and the mother notieed retarded growth.
Present condition: Height only 82 etn. Weight 10,900 Gm. Pale, weak, but intellectually well developed. Considerable arrest of growth. Teeth nearly all carious. Slight systolic sound over all the valves of the heart. Light diffuse catarrh over the lungs. Abdomen: Distended, circumference 59 cm.; markedly pendulous when standing. No indura tions arc palpable. Complete dulness over the lower part of tlae abdomen.
Demarcation upward slightly concave and bilaterally symmetrical. On changing position the abdomen falls entirely over on one side and the dulness is rapidly shifted. Fluctuation pronounced. Liver not enlarged, spleen palpable. Stools formed. Urine free from albumin.
Considerable anmmia; hmmoglobin 30 per cent. Blood picture of secondary anmmia. Pirquet's reaction negative in several examinations. Wassermann negative.
During several months' stay at the hospital the dulness changed in a surprising way from one day to the next. The child is a veritable conundrum, and all physicians to whom she was shown were struck by the variable findings. Figs. 66 to 69 will illustrate the various positions of dulness on several days.
According to my observations I agree with TRler in suggesting the following pathogenesis: After many years of intestinal catarrh a tympanitic distention of the abdomen will result in the course of time together with a relaxation of the abdominal walls and the development of a pendulous abdomen. The parts of the distended intestinal loops which are filled with timid contents sag down, drawing the mesentery with them. The latter fact could be verified by Tabler at some autopsy findings, and Allaria con firmed the same in all respects based upon the findings of another case which came to autopsy. Allaria found a very long mesentery with a veritable prolapse of intestinal coils which glided into the deepest parts of the abdominal cavity.