Pathological Physiology

A further important symptom which is seldom absent towards the close of a protracted cirrhosis, if the patient lives long enough, is ascites. This is an accumulation of serum in the peritoneal cavity, which has been produced by the altered blood pressure of the portal system and the altered composition of the blood itself. The fluid accumulates with considerable rapidity, and may reach an enormous quantity - sometimes as much as twenty-four quarts - greatly distending the abdominal walls, floating the viscera out of position, and by pressure interfering with digestion and absorption. In addition the loss of so large a quantity of fluid from the blood is a serious detriment to nutrition, inasmuch as the ascitic fluid not only contains water in large amount, but serum albumin, which may be present in the proportion of from 1 to 2 per cent to over 6 per cent. In the ascites accompanying cirrhosis the loss of albumin in this manner may be somewhat less than when the serous accumulation is due to other causes.

These facts should be borne in mind in relation to the dietetic treatment of the disease. Repeated aspiration of the abdominal cavity not only abstracts large quantities of water from the system, but also abstracts considerable albuminous material. In those cases in which fluid refills the peritoneal cavity promptly after aspiration, it is a question whether the nutrition of the body may not suffer by drawing off so much serum albumin. On the other hand, when once transuded, it is of no further service to the organism unless it can be reabsorbed. The point for consideration is whether too frequent removal of the ascitic fluid will cause greater drain on the blood than would be consequent upon letting it accumulate in the abdominal cavity. Much will depend upon the relative pressure within the peritoneal sac and the blood vessels, which will affect the rate of osmosis of albumin. This discussion leads to the query, whether it is not necessary to supply the constant loss of albumin by an increased allowance of animal food, and, secondly, to what extent water should be withheld from the dietary.

Dietetic Treatment Of Cirrhosis With Ascites

When uncomplicated ascites is present it is generally best to restrict the quantity of fluid ingested and put the patient upon a "dry diet," consisting of bread and meat chiefly. By simply withholding fluid and stimulating the force of the heart and the action of the kidneys I have sometimes seen large quantities of fluids disappear from the abdominal cavity; but this treatment is not always successful. There is more hope of success when the disease occurs in young persons, or, as it sometimes does, in children. Cirrhosis and ascites are very apt to be associated with renal and cardiac lesions and gastric catarrh, which make it much easier to say what food the patient must not eat than what he can have. If the urine is very scanty it may not be wise to withhold fluids, and some clinicians of wide experience believe in giving fluids in unrestricted amount,1 holding the view that this will increase diuresis to such an extent that not only will all the fluid drunk be promptly eliminated, but that the active kidneys will drain more from the blood, which will in time be replaced by reabsorption of the ascitic fluid. The same reasoning is often applied to cases of pleurisy, general anasarca, etc.

It seems much more rational to endeavour to promote diuresis when possible by medicinal measures than to add a large bulk of fluid to an already overbalanced circulation.

It is of importance in every case to measure and estimate carefully the total amount of fluid ingested both in beverages and as food and make a comparison with the quantity of urine voided, and if possible with the weight of the patient and girth of the abdomen at different levels.

If the fluid diet is followed by rapid reaccumulation of ascitic fluid after aspiration, for example, within a fortnight, it is desirable to replace it by as much simple solid nutriment as the patient can digest, or by predigested and concentrated foods. An outline of the appropriate diet for such cases will be found upon p. 441.

The "grape cure" and" milk cure" have been strongly recommended in Europe for the treatment of cirrhosis and ascites. They are said to ameliorate the symptoms and promote reparative processes, both acting largely through diuretic influence.