Hydatid disease is very prevalent in the Argentine Republic, owing to the large number of neglected and ill-fed dogs kept on the farms, and the cattle industry. Of 952 eases treated in Buenos Ayres since 1S77, the liver was the seat of the disease in G41, the lung in 54, the spleen in 30, the kidney in IS, and the brain in 15. A very fatal form, the "peritoneal hydatidosis," in which the peritoneum is studded with thousands of small vesicles, is described. The mortal ity from operation reached 12 per cent., the death-rate being highest in cases of multiple cysts of the abdominal organs and the brain. Marsupiahization and drainage are deemed much more certain than the method of extracting the mother-membrane. Vegas and Cranwell (Revue de Chin, Apr., 1901).
Ascites.
Definition.—Accumulation of fluid in the peritoneal cavity.
Symptoms.—When the abdomen be comes greatly distended with fluid the breathing is interfered with; the heart and liver are pushed upward, causing disturbances of the circulation. Gastro intestinal symptoms—such as vomiting, constipation, and distension of the in testines with gas—are common; frequent micturition is also noted, the urine being frequently albuminous.
The abdomen presents a rounded ap pearance, and may sometimes show the lines albicantes and enlarged veins. Fluctuation may be obtained by tapping with the finger-tips of one hand and re ceiving the impression with the palm of the other, which is placed on the op posite side of the abdomen. Percussion yields dullness, which is found movable as the patient changes his position. If the intestines are much distended with gas, tympanic resonance will be obtained.
Diagnosis.—The diagnosis of ascites is usually not difficult, especially when the accumulation of fluid is large. The ab domen is distended and the skin smooth and shining. When the patient is lying on the back the greatest bulging is in the flanks when there is dullness on per cussion over the fluid. The small intes tines floating on the top of the fluid give a tympanitic note on percussion in the umbilical region. These signs neces sarily change when the patient assumes different positions. In the erect posture the dullness may reach the level of the umbilicus in front and in the axillary lines. When the patient lies on one or other side the tympanitic note is found in the opposite flank.
Tympany in the flanks may be ob served with considerable frequency in ascites even when the effusion is of con siderable size. Tyson (Jour. Amer. Med. Assoc., Aug. 7, '97).
Ascites is to be distinguished from ovarian and other cysts, pregnancy, and distended bladder. Bearing these possi bilities in mind, we will seldom make mis takes. In ovarian cyst there is seldom bulging in the flanks where we have a tympanitic note on percussion instead of dullness. There is dullness on percussion at and around the umbilicus. In other
words, the tumor displaces the intestines and seems to rest upon them, whereas in ascites the intestines float on the sur face of the fluid. In ascites vaginal ex amination often shows that the uterus is movable.
In diagnosing ascites from chronic peritonitis, a previous history of disease of the liver, heart, or kidneys; sym metrical enlargement of the abdomen; absence of hard masses upon palpation, and little or no pain would favor the former.
In pregnancy the only sign in common with ascites is enlarged abdomen. Dis tended bladder with incontinence from retention is sometimes mistaken for as cites. In doubtful cases the patient should always he catheterized.
The appearance and nature of the peritoneal fluid depends upon the cause of its formation. By aspiration we can often determine this cause. Pure as citic fluid, due to cirrhosis of the liver. is clear and serous. Blood-stained fluid may be due to cancer, tuberculosis, or ruptured extra-uterine pregnancy. The amount and appearance of the bloody fluid are aids in the differential diagnosis.
Chylous fluid caused by disease of the lymphatics is occasionally found free in the abdominal cavity. It is said to be due also to excessive milk diet and to filaria.
Etiology.—Ascites is not always due to disease of the peritoneum. It is often a symptom of disease of the liver or dis turbance of the circulation of the portal veins, by compression or inflammation. It generally accompanies cancerous or tuberculous disease of the peritoneum and malignant disease of the abdominal and is sometimes associated with benign tumors. It is said to be caused by freely movable, large, pedunculated fibroid tumors of the uterus. As a rule, when ascites is associated with tumor we may safely diagnose malignancy. The causes of ascites enumerated have been studied under their respective heads.
Treatment.—The medical treatment consists in administering hydragogic cathartics and diuretics, of which bitar trate of potassium is one of the best. Calomel and digitalis may also afford re lief. Tonics should be employed to raise the general health of the patient, and the ingestion of fluids should be restricted.
When the amount of fluid is large, puncture of the abdomen must be re sorted to and repeated at varying inter vals. According to Fitz, this puncture should be made in the median line mid way between the symphysis and navel, or on either side midway between the sym physis and antero-superior spine. A straight trocar inch or less in diam eter, previously cleaned by heat, should be used. It should be made evident by previous percussion that a coil of intes tine does not lie directly beneath where the patient is to be tapped. Every anti septic precaution is to be taken before and during the operation. (See CIR RHOSIS OF THE LIVER, volume ii.)