The diagnostic use of artificial pneumoperitoneum.

Artificial pneumoperitoneum is a procedure with which doctors are familiar, particularly in respect to its therapeutic application in pulmonary tuberculosis and chronic diffuse pulmonary emphysema. Diagnostic use of the procedure in lesions of or near the diaphragm is well known to chest physicians and surgeons, yet some general practitioners, surgeons and radiologists have remained hesitant to utilize pneumoperitoneum as a part of their diagnostic armamentarium. This is no doubt due to relative unfamiliarity with the technic of the procedure and overemphasis in the medical literature of the dangers, contraindications, and complications of induced pneumoperitoneum. As chest physicians for whom the induction of pneumoperitoneum holds little fear, we are in a position to acquaint our fellow practitioners in other specialties with the relative benignancy of the procedure as well as its wide applicability in a variety of clinical situations. It is our aim to review herein briefly some of these applications. Jacobaeus,1 in 1913, first suggested the use of pneumoperitoneum to provide contrast for roentgen visualization of the abdominal viscera, and Orndoff,2 in 1919, reported his experience with this method in more than 100 cases with lesions of the upper abdominal viscera. It has been used with success in suspected subdiaphragmatic abscess. Sante,8 four years later, reported the case of a young man with perinephric abscess complicated in the postoperative period by right pleural empyema, in whom hiccup and abdominal pain appeared. The right diaphragm was seen to be elevated on chest x-ray inspection and a strong clinical suspicion of right subdiaphragmatic abscess was entertained. Artificial pneumoperitoneum was induced, after which roentgenograms revealed a completely free space, containing air, between the liver and the right diaphragm. Thus, this procedure satisfactorily ruled out subdiaphragmatic abscess, abdominal exploration was avoided, and right thoracotomy was performed for the empyema, resulting in cure. In this same paper, Sante advocated utilizing pneumoperitoneum in distinguishing cardiospasm from malignancy of the lower esophagus or cardiac portion of the stomach. He stated that, in cardiospasm, esophageal constriction occurs at the level of the diaphragm with a dilated sac above, and no involvement of the region between the diaphragm and cardiac orifice of the stomach, this being well seen with the aid of pneumoperitoneum. In carcinoma of the esophagus or cardiac stomach a constriction and irregularity may be seen with barium meal, but the extent of the