A system of practical medicine. By American authors. Vol. 2

by Unknown

DaCosta thinks he has lately had a case of chronic peritonitis attended by ascites. It was in a woman thirty years of age, who had been thrown with force upon the frame of an iron bedstead, striking the lower part of the bowels. Pain and tenderness followed. These were not confined to the injured part, but extended to the whole abdomen; and there was menorrhagia. After a time there was fluid effusion in the peritoneal cavity, which slowly increased till her state demanded relief from tapping. The fluid after this operation did not return. The pain and tenderness were constant symptoms all through. She slowly improved, and at the time the case was reported it was believed that she would soon be discharged from the hospital. The only doubt which DaCosta finds regarding the diagnosis is in the facts that the liver was diminished in size and that the spleen was moderately enlarged, and he admits the possibility that an adventitious capsule of the liver may have caused the ascites, but believes that it was dependent on chronic peritonitis.

Acute peritonitis subsiding into chronic, with increase of fluid effusion, as I have already said, I am not familiar with. That occurring in cancerous and tuberculous peritonitis has already been considered. But in relation to these some facts regarding frequency of occurrence, collected by Bristowe, are worth quoting. He says that in 48 cases of tubercular peritonitis, dropsy was found in 12, and that in 22 of peritoneal cancer, 12 had more or less ascites. He further adds, regarding cirrhosis, that of 46 cases observed post-mortem, there was dropsy in only 20. This is not surprising, as in all the diseased conditions of the liver that produce dropsy the anatomical changes must reach the point at which there is considerable portal obstruction before the effusion will occur.

The amount of fluid found in ascites varies greatly. In some it may remain for a long time stationary at four or five quarts; in others the suffering caused by an accumulation of nine or ten quarts will demand its removal; and in a few cases twenty quarts have been removed in one operation. It is in cirrhosis that the largest quantity is found, and it is in this disease and in cancerous peritonitis that the most frequent tappings are required. The quality of the fluid also varies markedly: from being almost as clear and thin as spring-water it may be almost ropy, or in color greenish or yellowish or slightly red; it is very likely to contain albumen; and it is probable that a further study of its microscopic elements may enable us to resolve doubts regarding the cause of the effusion. It very often contains blood-corpuscles.

Bristowe finds from hospital records that ascites occurs in about equal frequency in males and females, but, as everybody has noticed, that hepatic dropsy is much more frequent in men than in women. Ascites, he says, is most frequent between the ages of thirty and fifty, and next between twenty and thirty and between fifty and sixty, but is not uncommon above the latter age; and it occurs in children.

SYMPTOMS.—In general, ascites is easily recognized by the swollen state of the bowels: a well-rounded swelling when the patient stands or sits, but spread out in the flanks when he lies on his back; the fulness of the side on which the patient may be lying, and the flattened condition of the opposite side,—belong to this disease, and as a group to no other. The results of percussion are significant in the movement it causes in the fluid, and for the resonance or flatness it produces. When the patient lies on his back, tapping with the finger-ends on one side of the abdomen sends a wave of the fluid across to the other side, where it is perceived as a gentle blow by the applied fingers of the other hand. If the abdomen is not full, this wave will be produced at the upper level of the fluid, but not above that. If this wave cannot be sent across the body, it may be found on either side by percussing above and feeling for it below; percussion also teaches where the fluid is, and where it is not, by the dull sound it produces. It is rare in ascites that the intestines do not float on the surface of the fluid, at least from the umbilicus upward, and there give a loud percussion sound, while toward the back, and often toward the pelvis, it is dull, or even flat; changing the position of the body, the resonance will be uppermost and the dulness in the most dependent part. Then the softness or impressibility of the abdomen till the tension becomes great is noticeable. The changed position of the fluid as the body is turned from side to side is important. A very small quantity of fluid can be detected in this manner. The patient is placed on his right side and percussion is made in the right flank: there is dulness, while in the left flank there is resonance. The patient turns on to the left side: dulness now changes position, and is on the left, and on the right resonance. If it is feared that some undetected fluid remains in the pelvic cavity, the pelvis may be raised by pillows and the same examination repeated, or he may be placed in the knee-and-elbow position referred to by Bristowe, and the percussion will then be made upward in the umbilical region. In some cases the contraction of the mesentery will not allow the intestines to rise through a large amount of fluid and float on it; but such cases are almost confined to the cancerous and the tuberculous varieties of the disease; and as in these the symptoms are grave, the physician will probably have visited his patient many times before this contraction will embarrass him. Besides, when mesenteric contraction occurs there is a very strong probability that the omentum will also be contracted, be rolled up, and lumpy; as this can almost always be felt above the level of the umbilicus, he has in it an explanation of the absence of resonance on the fluid. It has happened that oedema of the abdominal walls or fatty accumulations there have given a delusive though feeble fluctuation on percussion. In such cases, if the patient make moderate pressure with the back of a small book in the course of the median line, that kind of wave will be broken, while a wave in the abdominal cavity will not be prevented. When there is considerable distension of the abdomen by fluid, weak spots in the abdominal wall often yield and make a tumor. This is very common at the umbilicus, where a little bladder is lifted half an inch or more above the general curve of the abdomen. The fluid frequently follows the track of hernias. In females it has been known to press the anterior wall of the vagina backward and downward, so as to make it protrude at the vulva. It has, in one of my own cases, by downward pressure caused complete prolapse of the uterus. It is very often attended by oedema of the lower limbs. This is accounted for by the pressure of the abdominal fluid on the veins that return the blood from these parts, or in cirrhosis by contraction of the ring or notch through which the vena cava passes in the liver. If there is general oedema, the cause will probably be found in disease of the kidneys; or if in one limb, in pressure or thrombosis of one iliac vein. As the disease advances the accumulating fluid forces the diaphragm upward, diminishes the breathing room, and threatens the life still more. Then the patient cannot lie down in bed, but spends his nights as well as days in an easy-chair, and sleeps leaning forward on a support for his forehead. The veins on the abdominal surface will fix attention. With almost any large tumor in the cavity they become more or less enlarged. But in cirrhotic dropsy this becomes more striking than in any other affection. The enlargement is attended by a reversion of the blood-current on the lower half of the abdomen. This is early shown by emptying an inch or two of a vein with the finger, drawing it either upward or downward, and noticing from which direction it is refilled when the pressure is removed. The pelvic veins do not readily discharge their blood by the natural channels, and by anastomosing branches it is forced over the surface of the abdomen and into the thoracic veins, these latter becoming in turn greatly enlarged. The appetite is commonly poor, the digestion flatulent, the pulse accelerated. Emaciation is gradual or rapid. The urine is commonly scanty, and in cirrhosis of a reddish hue. The skin is apt to be dry, particularly so in simple chronic peritonitis. The tongue has no characteristic fur, and is often, almost always toward the close, dry. The mind is not affected till near the end; then often the patient is delirious, commonly mildly. Diarrhoea is not uncommon, and even dysentery has been observed. The result is almost always unfavorable, or, as has been said, lethal.

The diagnosis is not often difficult. When, as in chronic peritonitis and in tuberculous peritonitis, the fluid is confined in a sac or sacs, each particular pool will be yielding to pressure, but elastic, and will give the percussion wave, though it may extend but a short distance. To distinguish ovarian dropsy—ovarian cysts, as it is now called—from ascites may require a few words. Ovarian tumors of all kinds are found to be more prominent on one side when they rise from the pelvis than on the other. This is not the case with ascites. The uterus and its appendages lie in front of the pelvic intestine, and when any of them ascend above the pelvis they must occupy the same relative position. In other words, a large ovarian cyst must lie in front of the intestines, while intestinal resonance should be found behind and in the sides. But if the ovarian cyst does not occupy the whole height of the bowels, intestinal resonance may exist above it, and the dulness may be found below, bounded by a portion of a circle, and sometimes the cyst walls are resisting enough to allow its boundaries to be ascertained by the fingers. This cyst can also be felt in the vagina; and the uterus, instead of being pressed down, is sometimes lifted upward, so that it cannot be reached in the vagina, but can be felt through the abdominal walls just above the pelvic bones. A condition more troublesome than this is when ovarian cyst and ascites occur together. Then the posterior or lateral resonance is lost when the patient lies on her back, but can be found on one side when she lies on the other. In that concurrence, in dorsal decubitus it is possible by pressure or a little blow to send a wave of the ascitic fluid over the front of the cyst. This can be seen as well as felt. Should the patient take the knee-and-elbow position, the intestinal resonance may be restored in both flanks.

TREATMENT.—In opening the chapter on the treatment of ascites it is usually said, Give principal consideration to the diseased conditions that have caused the dropsy; in other words, cure cirrhosis, cancerous peritonitis, tubercular peritonitis, heart disease, and the secondary affections of the abdominal organs, release the liver from the dangerous compression to which it is subjected, and all will go well. But they do not inform us how these impossibilities—at least in most cases impossibilities—are to be achieved. It is true that the physician would not shrink hopelessly from the treatment of simple chronic peritonitis. But this is one of the rarest causes of ascites. A physician in a long lifetime may not have seen a case. It is true, ascites is a symptom, always a secondary, or even a tertiary, affection; and theoretically there can be no better advice, but practically it cannot amount to much. Then, if the cause cannot be removed, it remains to do our best to relieve the patient of his load and strive to prolong his life to its utmost possible limit. In doing this the physician will often find himself able to give gratifying relief, and once in a great while to rejoice in a cure.

The three great emunctories, the skin, the bowels, and the kidneys, are chiefly appealed to for relief in this as in other serous accumulations. Most physicians prefer to use the diuretics—first, because if they will act at all, they act so quietly and produce so little debility that whatever can be gained by them is obtained at small cost to the system. The form of ascites that most resists diuretics is that which originates in cirrhosis. Often a full trial of them, with suitable changes from time to time, is of no avail, yet now and then the kidneys yield to persuasion and act freely. The saline diuretics and digitalis are most in favor with some. In the early part of the present century a pill composed of squill and digitalis in powder, and calomel, each one grain, given three times a day, was almost universally chosen. In place of the calomel the blue mass was often preferred. When this prescription had produced a little ptyalism the mercurial was omitted and the squill and digitalis continued. It has often been observed in dropsies of all kinds that diuretics act better after a little mercurial action is set up in the system. The diuretic that I most frequently prescribe is made of the carbonate of potass. ounce ss and water ounce vj; to a tablespoonful of this a tablespoonful of fresh lemon-juice is added. This is taken every two hours, and at the same time a dessertspoonful of the infusion of digitalis or more is taken three times a day. This is an old prescription. Sometimes the old sal diureticus is used. This is the acetate of potassium. It is not always kindly received by the stomach. At Bellevue Hospital the following is much used: viz. infusion of digitalis, ounce iv; bitartrate of potash, ounce j; simple syrup, ounce ss; and water added to make a pint. This is taken pretty freely. But it would require many pages to exhaust the diuretics. I will only add that I have more confidence in the salts of potash and soda, singly or combined, aided by digitalis and a mercurial, than in any others.

The diaphoretics that are most efficient are warm water and steam. A foot-bath long continued and frequently repeated, the patient covered with blankets, and the water kept at 90° or warmer, are very effectual in producing perspiration. Bricks heated or hot water in bottles, or potatoes heated, and enveloped in damp cloths and laid alongside of the body and limbs, form an extemporaneous vapor-bath of considerable efficiency. A vapor-bath can be easily extemporized in the following way: Have a kitchen vessel furnished by the tinman with a cover which has an inch tube fitted to this and bent so as reach the floor six feet from the fire. The pot should have a capacity of a gallon or more, and should be kept boiling briskly. Meantime, the patient, in his night-dress, has a double blanket brought over his shoulders from behind, and another from before, and fastened. Now he takes a chair (wooden), under which the steam is delivered. The blanket from behind is kept off his body by the back of the chair, and the front one by his knees. The steam, shut in in this way, soon brings on a sweat, and when it is sufficiently active the front blanket is thrown off, and the patient wrapped in the rear one and put to bed, when the sweating can be regulated by blankets. This is better than what is called the alcohol sweat, for in that the patient is bathed in carbonic acid gas as well as heat. A patient is sometimes enveloped in a hot, wet blanket with good effect. Pilocarpine has come into use lately as a sudorific. I have witnessed its effects many times and can testify to its certainty as a sudorific; but it is too debilitating for common use. Digitalis has sometimes acted with extraordinary power in this way, but there are grave risks in administering large doses.

Among the cathartics that may be used in ascites, it has seemed to me that the milder hydragogues are safest. One ounce of Epsom salts with a drachm of the fluid extract of senna can be taken every second or third day for months, if need be, with little reduction of strength, and sometimes with an increase of it. I had charge of a young man in the hospital in whom cirrhosis was unquestionable, and dropsy at one time extreme, in whom the abdominal veins had made furrows that would receive the little finger, who was wholly relieved by a drastic dose of elaterium every second day. I saw him three years after his discharge, and then his health was good. Notwithstanding this, I prefer the milder medicines.