Ascites.
Synonyms:—Abdominal dropsy; dropsy of the peritoneum; hydrops peritonei.
Definition:—A condition in which serum accumulates in the peritoneal sac.
Etiology:—This condition is supposed to depend upon a stasis from obstruction of the portal vein. It is an accompaniment of cirrhosis of the liver, various diseases of the heart and tubercular peritonitis. It may also accompany chronic lung disease, and especially chronic bronchitis. It occurs with Bright's disease during the progress of severe malarial disorder, and also with chlorosis and anemia. The presence of foreign bodies in the abdominal cavity which will compress the trunks of the large veins, retarding the passage of blood, results in ascites. Direct obstruction of the thoracic duct, which may result from external pressure, from constriction from wounds, from thrombosis, or from malignant or tubercular invasion or parasites, will cause this condition.
The fluid is ordinarily of a light straw color; it contains a large quantity of albumin, but does not coagulate. There are rare cases in which the serum is lactescent or milk-like in color, the cause of which has not been explained, except where fat cells are found freely distributed through it. The quantity of fluid varies from a few pints to several gallons. There is also considerable variation in its specific gravity. It may be quite thin at times and watery, or at other times viscid and dense. It may be tinged with blood or it may contain pus.
Symptomatology:—There may be considerable fluid in the peritoneal sac without marked evidences of its pressee. When the quantity exceeds one and a half or two pints, however, its presence produces discomfort, fulness, weight, and in rare cases some pain. These symptoms increase as the quantity of fluid increases; soon the sensation of weight becomes a dragging pain; there is difficulty of breathing, due to some compression of the lungs, which will be found to increase upon exertion or if the patient lies down. The heart becomes irregular and rapid in its movement and palpitation is not uncommon. Men are especiailly liable to experience difficulty in breathing. There is dizziness and faintness often amounting to syncope; usually there is nausea and other gastro-intestinal disturbance with constipation. Pressure upon the bladder produces frequent urination, and because of material change in the blood pressure in the kidneys, the urine is occasionally highly albuminous. Percussion over the abdominal wall will elicit dulness, which is generally uniform, but when there is but small quantity of fluid in the abdomen the dulness will change as the position of the patient is changed, always occupying the dependent portions of the sac. Above the dulness there may be considerable resonance or tympany.
A symptom, pathognomonic of abdominal dropsy, is fluctuation of the fluid in the cavity. This may be felt by placing one hand on the side of the abdomen and gently striking the other side with the free hand. As the condition continues, emaciation is apt to follow with a progressive loss of strength. If serious disease of the liver, kidneys or heart be present, the evidences of grave constitutional disorder develop rapidly; the patient is unable to lie down, but little food can be taken, and a general sense of discomfort is most pronounced.
Diagnosis:—It would seem that ascites could be easily diagnosed. It may readily be mistaken in a female for ovarian cyst, or vice versa. With the ovarian cyst, although it may produce as much enlargement as an extreme case of ascites, the enlargement is somewhat irregular, especially in its early development, and there is disturbance of the menstrual function. These patients are not as likely to have kidney or heart complications. When there is but little enlargement, if the patient may be placed in a knee-chest position, the fluid will gravitate to the region of the umbilicus where it may be distinctly detected. The fact that dulness on percussion changes on changes of position, and the fluctuation, are pathognomonic evidences of fluid in the peritoneal sac.
Prognosis:—In early cases, not seriously complicated, where the cause is at all amenable to treatment, the prognosis is good. In protracted cases which depend upon serious organic lesion or other intractable cause, the prognosis as to permanent recovery is not good. Where valvular disease or Bright's disease are present, the prognosis is bad.
Treatment:—In our vegetable materia medica we have recourse to a reliable class of remedies for the removal of dropsical conditions, and for the relief of the direct causes which induce them, that are certainly not found elsewhere. In the selection of remedies for this purpose attention must be paid to other conditions and to the general strength of the patient. Irritation of the intestinal tract by powerful hydragog cathartics will soon result in derangement of digestion, which greatly curtails the absorption of nutrition. When the kidneys are diseased, irritating diuretics must be avoided. On the other hand, when the dropsy depends upon disease of the heart, we have remedies which may be specifically adapted with reference either to their direct influence upon the heart or to their diuretic action, or to both of these influences. When the liver is at fault, the remedies should be selected which will influence the function of this organ.
If the dropsical accumulation is extreme in a patient of good strength, it is often not unwise to administer to the patient an active stimulant and then give two or three full doses of magnesium sulphate, in order to obtain free hydragog action. From this there may be an almost immediate relief of the symptoms of extreme distention which result from the accumulation. However, I at one time administered a teaspoonful of the fluid extract of haircap moss in a goblet of water, and repeated the dose in six hours, with a very satisfactory temporary removal of the accumulation.
Our most efficient remedy for dropsy is apocynum. The remedy must be understood, and the prescriber must have some experience with it, or he will occasionally obtain no results. Occasionally small doses of the remedy will act very nicely. I am in favor of always giving it short of its cathartic action. When the dose produces intestinal irritation it should be reduced. I prefer the use of the distilled extract of apocynum to the ordinary fluid forms, because it is less irritating to the stomach and bowels. This may be given in ten drop doses every hour, or half of a dram may be given every three hours. Occasionally the specific apocynum will act better if dropped in hot water at the time of its administration. At other times results can be obtained only from a decoction of the root, which should be given in small, frequent doses.
Among our other excellent remedies are aralia, which is indicated when there is but little urine passed, or when there is sediment in the urine, or urinary irritation, or eryngium, when the difficulty is accompanied with jaundice. At such a time we would use also chionanthus, iris and helonias, in combination with the diuretic. Chimaphila umbellata has been used in dropsy where an active alterative was demanded. Elaterium is of value also. It should be given in small doses frequently repeated; the large cathartic doses are contraindicated, especially in the asthenic cases. Among other remedies are beech leaves and sour wood. Fraxinus is indicated with polymnia where there is chronic enlargement of the spleen and a tendency to obesity. Lycopus is indicated when the heart is at fault, especially when the heart acts tumultuously with irregularity, and dyspnea. It improves the strength of the heart muscle as well as the character and force of the pulse, increases arterial tonus, thus directly antagonizing those influences which permit an outflow of serum. It exercises a conspicuous and beneficial influence also upon the kidneys, without producing irritation.
There are extreme cases in which paracentesis abdominis is demanded. These are characterized by marked obstruction of breathing and interference with the heart's action. Those, however, which are tapped early and frequently, are not thought to be as amenable to specific treatment.
