MEDICAL NOTES ON DROPSY.

Press, Volume XX, Issue 2901, 19 August 1872, Page 3

MEDICAL NOTES ON DROPSY.

TO THE EDITOR OP THE PRESS. Sib, —I have always been averse to writing on medical subjects to any other than medical papers. For the want of such a medium I avail myself of your columns. I make no apology for writing. I write for the sake of the living, and for the information of the profession generally. The M.D.'s of Christchurch themselves may be deficient in the knowledge and practice of the day; how much more at a disadvantage are many of our deserving country practitioners. From the May number of " The Practitioner," a medical journal, under the head of " Original Communications," I give the following extracts from that excellent article :— " Ou the Treatment of Dropsy, by Frederick T. Roberts, M.D., B.SC, Assistant Physician at University College Hospital, &c. " Though only the result of some diseased condition, either general or local, and not in itself a disease, dropsy becomes in many cases so prominent a symptom as to be the chief source of the discomfort or«sufferings of a patient. Hence our treatment is often mainly directed to the removal of the effused fluid ; and if this can be effected, not only will temporary relief follow, but, in not a few instances, a practical cure may be brought about, in so far that the ordinary occupation of the patient may be resumed for a longer or shorter period. The principles of treatment are so well known that it seems scarcely necessary to allude to them; but my object at present is to urge the carrying out of some of these principles more systematically and to a greater extent than is usually done, and to advocate the earlier and, if necessary, repeated recourse to certain measures which are generally looked upon as only to be adopted as " last resources." " Medicines may often do much in the way of getting rid of dropsical accumulations, but very frequently they are quite ineffectual for this purpose ; in the former case their action will be materially assisted by attention to some of the points hereafter to be considered, while in the latter it seems worse than useless to continue their employment if it can be shown that there are other means more likely to be successful which fairly claim a trial. "The measures to which I desire to call attention are:—l. The maintenance of rest and of an appropriate position, 2. The use of baths, both general aud local. 3. The employment of regular and systematic pressure. 4. Removal of the fluid by operation. One or other of these may be employed with advantage in different cases, and in many two or more can be combined." The author, after describing the way of carrying out rest and position, the use of baths and pressure, thus describes the 4th measure, removal of tlte fluid by operation : —" I now come to the most important part of this paper, which is, to rdvocatc the early, and if necessary, repeated performance of paracentesis abdominis, in appriate cases of ascites. There cannot be a doubt that this operation is generally looked upon with much dread, and that it is only performed with the view of giving temporary relief, whereas it may be safely employed as a means of permanent cure, so far as the ascites is concerned, and if this can only be removed the patient is often practically restored to health. The danger of wounding serous membranes and admitting air has been much exaggerated, and that fluid may be withdrawn from a serous cavity with most satisfactory results has been well proved in the case of pleuritic effusion. Now, with regard to the cases in which this operation is justifiable as a method of treatment, they are just those with which we are most likely to meet in ordinary practice, viz., where the ascites is the result of cirrhosis of the liver. In such a condition this becomes the chief symptom after a time, and the main object of our treatment is to take away the fluid, and thus give relief to the misery and discomfort which it produces. Experience proves the utter uselessness of medicinal agents in effecting this object, aud on this account we are more justified in proceeding to carry it out directly by operation, if it can be shown that this gives any fair chance of success. When the ascites is but a part of the general dropgy of cardiac or renal disease ; of course paracentesis can do no permanent good, and therefore should only be performed if absolutely required, which, judging from my own experience, does not often happen ; at the same time I may add that the presence of renal disease need not deter us from the operation, should this exist associated with cirrhosis, though it w ill necessarily render the case less favorable. Again, if the ascites is the result of some cancerous tumour pressing oa the portal vein, or of a definite cancer or tubercle in the peritoneum, the operation can only afford temporary relief. In the cases, then, that I have indicated, viz., those of ascites due to cirrhotic of the liver, it seems to mc to be a mere waste of time and the patient's power to continue a loDg course of purgatives, diuretics and diaphoretics, especially as these cannot be absorbed at all when there is such a condition of things within the abdomen, and they are much more readily taken up after the removal of the fluid; butldonot think much reliance is to be placed on them, and would rather urge the performance of paracentesis as soon as the abdomen has become tolerably full, the operation being repeated again and again, should the fluid re-accumulate. In the instances I shall bring forward, I have not seen any ill effects from the operation itself, when proper care was exercised, nor did its repetition at all weaken the patient. It is not advisable to take the whole of the fluid away, and if it collects again it is best not to wait until the abdomen has become much distended before proceeding to its removal. Of course it is necessary to maintain the patient's general health by means of a nutricious diet, and, if necessary, stimulants may be given, as well as tonic medicines. The explanation of the good effects of this treatment is evident enough. Communications normally exist between the portal system of veins, and'the general venous circulation, while new channels are formed in the adhesions which arise ; thus the blood, instead of passing throush the liver, is enabled to return through these normal and abnormal communications, which enlarge considerably, provided we can keep the patient alive for a sufficient lentrth of time, and relieve the great tension of the vessels, and consequently after a time, no further dropsy occurs. It appears highly probable that the employment of pressure in the manner already indicated, might be advantageous in con-

junction with tapping ; that is, as soon as the wound is sufficiently healed, the abdomen might be tightly bound, ami thus be prevented from refilling. I h.ivn trial this in two cases, in which it proved successful. I shall now proceed to give some brief notes of cases, on which I have founded the opinions expressed iv the preceding remarks. Case I.—An account of this case; has already been published in the Lancet of October 29, 1864, the patient having been under the care of Dr. Waters, at the Liverpool Northern Hospital, who kindly permitted mc to treat him. It is especially interesting to myself, on account of its exceedinglysatisfactory termination, and also because it first suggested to mc the adoption of paracentesis abdominis as a settled plan of treatment. J. G.. aged 32. a sailor, much addicted to drink, -was admitted into the hospital on December 29, 1563. He had had hepatic symptoms for three years, and ascites began iuthe previous July. He.presented a most miserable, sallow, and cachetic aspect, and his abdomen was greatly distended, but no dropsy existed in any other part. He became so distressed that it was thought advisable to tap him, merely to afford relief; and on January 14th, 1564, twenty-one pints of fluid were withdrawn. The liver ■was then distinctly felt, having all the characters of cirrhosis well marked. The abdomen filled again, and on February 28th, thirty pints were drawn off, which was rather too much, as the patient had some rather unpleasant symptoms on this occasion. It was found necessary to repeat the operation on March 19th and April 9th, fourteen and a-half and twenty-five pints being respectively removed on these dates. The patient improved greatly in appearance and in his general health, did not suffer in the least from the operations, and as he gave no evidence of the return of the effusion, he was soon discharged. Subsequently he was under my observation for some months as aa outpatient, but I then lost sipht of him. More than three years afterwards, however, he reappeared, having been to sea, and there had been no return whatever of the ascites, while his general health was excellent. The liver could still be felt, hard, contracted, and granular. Case 2.— G. F., aged 42, admitted into University Hospital, July 26th, 1871.—N0 cause could be ascertained in the previous history, the patient having lived regularly and steadily. The abdomen began to enlarge in March, and had gradually increased, at the same time being somewhat painful. On admission he appeared emaciated and anoemic ; complained of dyspeptic symptoms with dyspnoea and cough, due to some emphysema and bronchitis. The abdomen was very large, the skin being glazed and shiny, and the umbilicus protruded ; there was almost universal dullness, and fluctuation could be readily felt; no swelling of the legs existed ; the urine was free from albumen at first, but this afterwards appeared, and gradually increased until it became about one-fourth. The heart was weak but free from valvular disease. On August 9th, the abdomen became very tense, measuring 43J inches in circumference a little above the umbilicus, the skin looking inflamed, and the patient being much distressed. Paracentesis was performed to the extent of nearly eighteen pints, which afforded great relief, and caused no ill effects. For some days it appeared as if the effusion was again collecting, then it began to fluctuate, aud finally to diminish steadily, during which time the abdomen was tightly bandaged. He was discharged, and sent to Eastbourne, the circular measurement above the umbilicus being only thirty-two inches. Some months after I heard that there had been no subsequent enlargement. " Case 3. — M.A.C., a woman, aged fifty, admitted into University Hospital August 16th, 1871. She had been addicted to habits of intemperance, and had been ailing for about fifteen months. She first noticed a swelling in the legs, which extended up to the thighs and abdomen, and occasionally appeared in the arms and face. When admitted, she presented the signs of very abundant ascites, with much oedema of the legs, loins, and abdominal walls. The circular measurement opposite the umbilicus was H\ inches, and there was scarcely any tympanic sound on percussion, even in the highest part. The heart was healthy, but the urine contained albumen, the amount varying from onefourth to two-thirds, and sometimes casts were present. On August 26th the patient was tapped to the extent of sixteen and a half-pints, the operation being followed for a few days by slight local pain, and on account of the state of the kidneys peritonitis was feared. However, the pain soon ceased, and the patient felt much better. The swelling in the legs subsided considerably. On October 7th it was found necessary to repeat the operation, and thirteen pints were taken away. No ill effects were experienced. As soon as the wound healed, pressure was employed, along with poultices of digitalis leaves, and from that time no fresh accumulation occurred. The patient was discharged, but came to the out-patient room from time to time, where I have seen her recently, aud there had then been no return of the fluid. In addition to these three cases, the one already alluded to as showing the satisfactory results of pressure, is also an instance of the value of repeated paracentesis, seeing that this was performed several times with ultimate success, though it is not clear what the cause of the ascites was in that case. I venture to submit that the evidence brought forward in this commnnication is sufficient to give strong support to the course of treatment which I have advocated, especially when we take into consideration the improbability of any satisfactory results being produced by the administration of medicines. Of course, every precaution should be taken, both in the performance of the operation and in the subsequent treatment, and it would be well to explain to the patient and friends the possible dangers that might arise." He concludes this really excellent article by recommending punctures to the legs, &c, in dropsical swellings, as a mode of giving great relief to patients. The sound aud practical reasoning the writer has brought to bear on the subject, showing the communications that exist between the portal system and the general venous circulation, and how the blood is carried through these normal and abnormal communications instead of passing through the liver, shows that a patient can live nearly as well after such an attack as if he had a " new liver." I remain, Yours, &c, Medictjs (retired.) P.S. —As there will be many unprofessional readers, I thought it advisable to give the meaning of some of the terms used :— Paracentesis Abdominis — Tapping the belly. Ascites —Dropsy in the belly. Cirrhosis —A contracted and diseased condition of liver. Cardiac —Of the heart. Renal —Of the kidney. Dyspnoea—Difficulty of breathing. Emphysema—A diseased condition of lungs. (Edema—Swelling.