Ascites historical perspective

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]

Overview

About 20 BC, Aulus Cornelius Celsus (A.D. 30), a Roman encyclopedist explained in his book "De Medicina" three different types of fluid accumulation under the skin; which was called hydrops by Greeks. Celsus postulated that ascites is mostly secondary to quartan fever (malaria) in Rome. The principles of treatment for ascites were explained as thirst, rest, and abstinence. Drinking less fluid and sweating more, not with exercise, but with heated sand, or in the sweating-room, or with a dry oven and such- like where the other alternative therapies. In 1827, Ludwig van Beethoven involved in ascites and underwent large volumes of paracenteses. His physician write about him as "Beethoven had almost immediate relief, and when he saw the stream of water [during paracentesis], cried out that the operation made him think of Moses, who struck the rock with his staff and made the water gush forth."

Historical Perspective

• About 20 BC, Aulus Cornelius Celsus (A.D. 30), a Roman encyclopedist explained in his book "De Medicina" three different types of fluid accumulation under the skin; which was called hydrops by Greeks. Celsus postulated that ascites is mostly secondary to quartan fever (malaria) in Rome.
  • Very tense belly with frequent noise of the wind movement sound - called tympanites.
  • Uneven swelling and rising up in the body - called leukophlegmasia or hyposarca.
  • The fluid gathering all together in the belly with visible movement along with the movements of body - called ascites.
• In 25 BC, Philip of Epirus, promised to cure the certain friend of king Antigonus with ascites. Philip cured the patient with devouring poultices and drinking his own urine. The basis of his treatment was thirst, rest, and abstinence.
• 2000 years ago, Celsus, the Roman encyclopedist explain the first treatment procedure for ascites. He described a bronze tube with a specific collar to drain the abdominal fluid.
• In 1906, Frederick Maberly reported large amounts of fluid drained from ascites patient abdomen for the first time. The procedure was consisted of simultaneous paracentesis while patients sit on adjacent shoeshine chairs.
• In 1935, Daniel Darrow, an American pediatrician, suggested the role of sodium restriction in the treatment of ascites.
• In 1936, Robert Alexander McCance, a British biochemist, found the passive nature of water movement and the the importance of sodium ion in ascites.
• In 1947, John Layne, an American physician, described 20 patients with ascites which were treated by low sodium acid-ash diet.
• In 1939, Hugh Butt, an American biochemist, postulated possible relation between serum albumin level and volume overload in patients with ascites.
• In 1944, Charles Janeway, an American pathologist, suggested "high-salt" (300 mmol/L) albumin products as ascites treatment.
• In 1945, George Thorn, an American biochemist, suggested "low-salt" (15 mmol/25 g) albumin products for volume overload treatment.
• In 1949, William Faloon, an American biochemist, found that mercurial diuretics can increase the urinary sodium output dramatically, so can alleviate the fluid overload in ascites patients.
• In 1957, Kagawa, an American biologist, discovered aldosterone.
• In 1958, John Laragh, an American physician, discovered chlorothiazide diuretic as a potential treatment for ascites. Laragh proved complete cure of ascites in three out of nine patients, but they finally involved in hypokalemic hypochloremic alkalosis, though. Various diuretics have been studied in treatment of ascites until now.
• In 1949, Thomas Chalmers, an American research fellow, mentioned that complete bed rest had an important role in the management of chronic liver diseases and ascites.
• In 1949, Alexander Leaf, an American internist, revealed that passive contribution of water to fluid overload was the basis to introduce the fluid restriction as a treatment option for ascites.
• From 1896 that Drummond and Morrison, British surgeons, reported the first surgical procedure of treatment of ascites, various surgical options were suggested for these patients.
• In 1898, Talma, a German surgeon, evaluated the "omentopexy" procedure in a patient with ascites. In this procedure some adhesion were induced around the liver and portal system to prevent ascites formation. The patient was cured and lived until 2 years after surgery.
• In 1943, Charles Fergusen, an American urologist, invented a surgical procedure in which a right nephrectomy was done first and then the peritoneum anastomosis with renal pelvis was performed. In this procedure the ascites fluid continuously drained via bladder and there was no need to frequent paracentesis.
• In 1946, Crosby and Cooney, American surgeons, suggested the glass collar-button shaped instrument called "Crosby-Cooney button" to be placed in abdominal wall, allowing continuous drainage of ascites into subcutaneous tissues.
• In 1966, Marshall Orloff, an American surgeon, first described side to side porto-caval shunt for treatment of ascites.
• In 1974, Harry LeVeen, an American surgeon, suggested the "Peritoneo-venous shunt" procedure for treatment of ascites through drainage of fluid overload into the veins.
• In 1982, Colapinto, a Canadian radiologist, first presented the transjugular intrahepatic portosystemic shunt (TIPS) for ascites treatment.
• In 1967, Thomas Strazl, a British surgeon, performed the first liver transplant with more than 1 year surveillance in a patient with cirrhosis and ascites.

Landmark Events in the Development of Treatment Strategies

Ascites Treatment Developement

Ancient era

2000 years ago Celsus A Roman encyclopedist

• Explain the first treatment procedure for ascites.

Paracentesis era

1906 Frederick Maberly A British physician

• First reported large amounts of fluid drained from ascites patient abdomen.

Sodium era

1935 Daniel Darrow An American pediatrician

• Suggested the role of sodium restriction in the treatment of ascites.

1936 Robert McCance A British biochemist

• Found the passive nature of water movement and the the importance of sodium ion in ascites.

1947 John Layne An American physician

• Described 20 patients with ascites which were treated by low sodium acid-ash diet.

Albumin era

1939 Hugh Butt An American biochemist

• Postulated possible relation between serum albumin level and volume overload in patients with ascites.

1944 Charles Janeway An American pathologist

• Suggested "high-salt" (300 mmol/L) albumin products as an ascites treatment.

1945 George Thorn An American biochemist

• Suggested "low-salt" (15 mmol/25 g) albumin products for volume overload treatment.

Diuretic era

1949 William Faloon An American biochemist

• Suggested mercurial diuretics for ascites treatment via increasing the urinary sodium output.

1957 Kagawa An American biologist

• Discovered aldosterone.

1958 John Laragh An American physician

• Discovered chlorothiazide diuretic as a potential treatment for ascites.

Bed rest era

1949 Thomas Chalmers An American research fellow

• Mentioned that complete bed rest had an important role in the management of chronic liver diseases and ascites.

Fluid restriction era

1949 Alexander Leaf An American internist

• Suggested passive contribution of water to fluid overload and fluid restriction as a treatment option for ascites.

Surgery era

1896 Drummond and Morrison British surgeons

• Reported the first surgical procedure of treatment of ascites.

1898 Talma A German surgeon

• Presented the "omentopexy" procedure in a patient with ascites.

1943 Charles Fergusen An American urologist

• Invented a surgical procedure of nephrectomy and peritoneum anastomosis with renal pelvis to treat ascites.

1946 Crosby and Cooney American surgeons

• Suggested the glass collar-button shaped instrument called "Crosby-Cooney button".

Shunt era

1966 Marshall Orloff An American surgeon

• First described side to side porto-caval shunt for treatment of ascites in patients.

1974 Harry LeVeen An American surgeon

• Suggested the "Peritoneo-venous shunt" for treatment of ascites by drainage of fluid into the veins.

1982 Colapinto An American physician

• First presented the transjugular intrahepatic portosystemic shunt (TIPS) for ascites treatment.

Transplant era

1967 Thomas Strazl A British surgeon

• Performed the first liver transplant with more than 1 year surveillance in a patient with cirrhosis and ascites.

• About 20 BC, Aulus Cornelius Celsus (A.D. 30), a Roman encyclopedist explained in his book "De Medicina" mentioned that ascites was relieved in slaves more easily than freemen. Because slaves can endure thirst, hunger, and other troublesome more than unserviceable freedom.
• The principles of treatment for ascites were explained as thirst, rest, and abstinence. Drinking less fluid and sweating more, not with exercise, but with heated sand, or in the sweating-room, or with a dry oven and such- like where the other alternative therapies.
  • Pills composed of wormwood two parts and myrrh one part were given on an empty stomach to treat refractory types of ascites.
  • Various remedies for ascites were postulated as the followings:
    • Iris root
    • Spikenard
    • Saffron
    • Cinnamon
    • Cassia
    • Myrrh
    • Balsam
    • Galbanum
    • Ladanum
    • Oenanthe
    • Opopanax
    • Cardamon
    • Ebony
    • Cypress seeds
    • Taminian grape (Greeks call staphisagra)
    • Southern wood
    • Rose leaves
    • Sweet flag root
    • Bitter almonds
    • Goat’s marjoram
    • Styrax
  • The quantity of fluid input and output had to be measured and recorded daily.
  • Abdomen circumference was also measured on a daily basis.

Famous Cases

• In 1827, Ludwig van Beethoven involved in ascites and underwent large volumes of paracenteses. His physician write about him as "Beethoven had almost immediate relief, and when he saw the stream of water [during paracentesis], cried out that the operation made him think of Moses, who struck the rock with his staff and made the water gush forth."
  • 2 days later Beethoven died and autopsy showed cirrhosis and splenomegaly as "shrunken liver to half its normal volume…it was beset with knots the size of a bean…the spleen was double its proper size and dark colored and firm."
• The cirrhotic ascites, secondary to chronic alcohol and drug use, decreased lifespan in jazz musicians; result in dramatic influence on the history of jazz music.
  • Charlie Parker died from cirrhotic ascites at 35 years of age in 1955.
  • John Coltrane (inventor of avant-garde jazz) died with ascites secondary to hepatitis B and hepatocellular carcinoma at 41 years of age in 1967.
  • Stan Getz in 1990 and Steve Lacy in 2004, both saxophone stylists, died from hepatocellular carcinoma.
  • Bill Evans, a lyrical pianist, died of cirrhotic complications.
  • The famous Four Brothers from the Woody Herman band (Stan Getz, Al Cohn, Serge Chaloff, and Zoot Sims) all died from cirrhosis complications.