Ascites.

Synonyms.—Dropsy of the Peritoneum; Abdominal Dropsy.

Definition.—An accumulation of serous fluid in the peritoneal cavity.

Etiology.—Any obstruction of the portal circulation is a possible cause of ascites, the most frequent being cirrhosis of the liver. Pressure from tumors or neighboring organs may also give rise to it. Peritonitis and valvular heart disease is also responsible for ascites, and chronic pulmonary affections may impair the portal circulation to the extent of producing it.

Pronounced anemia, as seen in malarial cachexia, purpura, chlorosis, Bright's disease, etc., also give rise to ascites.

Chylous ascites is due to an exudation from the lacteals, the result of malignant infiltration.

Tuberculosis of the peritoneum is also a factor in ascites In rare instances, the fluid becomes milky in character, due to the presence of fat and not to the presence of chyle.

Pathology.—The peritoneum may be thinner than normal, and opaque; or it may simply present a blanched appearance, and some cases show little if any changes.

The quality and character of the fluid show great variation, from a few pints to several gallons, and from a straw or lemon tint to a brownish or greenish hue. It may be. blood-stained, and occasionally clean and transparent. It is usually watery in character, and though it may be viscid, is generally alkaline, with a specific gravity of from 1010 to 1015, and is rich in albumin.

Symptoms.—There is a sense of fullness or weight in the abdomen, increasing as the fluid increases. There is a distressed feeling, rather than pain. With an increase in the ascitic fluid, the liver is crowded upward and to the right, as well as the heart and lungs. This crowding upward of the diaphragm gives rise to more or less dyspnea, and the patient soon finds himself unable to lie down. Gastric disturbances are common, and constipation is the rule. Micturition is frequent, though the quantity voided is small and high-colored. General emaciation may be marked, notwithstanding the enlarged abdomen.

Physical Signs.—Inspection reveals the abdomen uniformly distended when the patient assumes the upright position, but when lying down there is bulging in the flanks and the upper part of the belly is flat. The skin is smooth, tense, and shiny, often presenting a waxy appearance. The superficial veins are generally distended.

Respiration is hurried and principally thoracic; the thorax is widened at the base, but appears much shorter than in health.

Percussion reveals dullness over the most dependent parts, and resonance at the upper portion; a change of position will give dullness wherever the fluid gravitates.

On placing the left hand flat upon one side of the abdomen, and striking the opposite side with the fingers, the fluctuating fluid is readily felt, and is a chief diagnostic symptom.

Diagnosis.—This is readily made by inspection, palpation, and percussion. We differentiate from ovarian cysts by the uniformity of the enlargement in ascites. In ovarian cysts, except those of enormous size, the enlargement is irregular, and there is nearly always a history of menstrual derangement, with an absence of cardiac or palpitating disturbances; while in ascites, there is usually a history of a disturbed liver, kidney, or heart.

Prognosis.—This depends largely upon the cause and length ' of time the disease has existed.

Treatment..—In the use of diuretics and cathartics we must be careful in our selection, and not cause too great a depression or exhaustion. Fortunately our Materia Medica is rich in efficient vegetable diuretics, and a judicial selection will bring most gratifying results.

Apocynum.—This is a veritable Samson in the treatment of dropsy. Where the urine is scanty and high-colored, and the bowels are constipated, and where the heart's action is feeble, apocynum has no superior. Of the specific tincture, from fifteen to thirty drops are to be placed in four ounces of water, and a teaspoonful of this will be given every hour. If the system does not respond to the specific tincture, do not discard the remedy, but administer the distillate of apocynum (apocandle) in from thirty to sixty drop doses every three or four hours. Should the kidney and bowels fail to respond to this, then administer the decoction made with the ground root. This last form is the most efficient way to administer this valuable agent, but, unfortunately, it is so nauseating that many can not take enough of the remedy to get the best results. Of the decoction, we begin with five drops, gradually increasing the size of the dose until we reach the limit of toleration, which is usually thirty or forty drops.

Apis is also a good remedy where there is smarting or burning sensation in voiding water.

Aralia Hispida.—This is another valuable diuretic, and should not be overlooked in ascites. The best results are obtained from the infusion. It should be given every two or three hours.

Polytrichum Juniperum.—As a hydragogue diuretic, this is one of the best remedies and should be given in infusion.

Chimaphila is another good vegetable diuretic, and, like the remedies already mentioned, should, be used as an infusion, if the specific tincture fails to give the desired results.

Strophanthus frequently accomplishes more than any other-remedy, thirty drops to a half glass of water, a teaspoonful every hour.

Sometimes the system fails to respond to these excellent agents, and we think of the compound powder of jalap and the bitartrate of potassium, in dram doses every three, four, or five hours, until we get two, three, or four copious stools in twenty-four hours.

Elaterium in one-sixth or one-eighth grain doses, combined with potassium bitartrate, is also an efficient combination.

Sometimes there is such an enormous distention of the abdomen by the effused fluid, that the absorbents are unable to do their work till the pressure is taken off by tapping. After withdrawing the fluid, the same remedies that before were ineffective, now give good results.

Where the dropsy is due to malarial cachexia or splenic disturbances, appropriate remedies should be administered for the specific conditions.

Tonics and alteratives may also be necessary.

In some cases repeated tappings will be necessary, and for this operation the patient should assume the upright position, and the trocar made to enter the median line, midway between the bladder and the umbilicus, the bladder having previously been emptied.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.