An Improvement on the Practice of Tapping; Whereby That Operation, Instead of a Relief for Symptoms, Becomes an Absolute Cure for an Ascites, Exemplified in the Case of Jane Roman; And Recommended to the Consideration of the Royal Society, by Christopher Warrick, of Truro, Surgeon

III. An Improvement on the Practice of Tapping; whereby that Operation, instead of a Relief for Symptoms, becomes an absolute Cure for an Ascites, exemplified in the Case of Jane Roman; and recommended to the Consideration of the Royal Society, by Christopher Warrick, of Truro, Surgeon. Read Feb. 16. Among all the Operations of Surgery, perhaps there is not one, of equal Importance, less oblig'd to Improvements, than that of the Paracentesis; it being, at this time, notwithstanding the frequent Use thereof, in the same State of Imperfection as when first introduced among us; a mere palliative Remedy, or a Relief for Symptoms. Mr. Monro and Mr. Garengeot have, indeed, thrown some considerable Lights thereon; the former, * by substituting a Belt, instead of the ordinary long Bandage for compressing the Abdomen, and in ascertaining the proper Place of Puncture; the latter, in making the Evacuation at once, and in rinsing the emptied Cavity, to remove the feculent Part of the Waters; which, subsiding therein, and being apt, by its Acrimony, to make rude Impressions on the Viscera, he says, † frequently occasion Mortifications thereof. These are, I believe, the only Improvements therein; at least, that seem to * Vide Medical Essays, Vol. I. Art. 18. † Traité des Operations de Chirurgie, Chap. 6. Art. 6. de la Paracenthese. have sufficient Solidity in them to recommend themselves to our Practice. Its proper Object, an Ascites, however, still baffles our Endeavours, and renders the Use of it contemptible and precarious; always assuring us of a Relapse, by returning as constantly as ever we put this Method alone in Practice to remove it; so that, even in case of its being consider'd as a palliative Remedy, or a Relief of the Symptoms, by repeating the Use of the Trochar, we must suppose, at the same time, an equal Certainty of Pain, continual Anxiety, and, perhaps, Death; which, at last, must be the inevitable Consequence of it. From these Considerations, and a sincere Willingness to communicate to others what I think herein has been of Service to myself, I am inclined to believe the following Piece of Practice, considering the Nature and Importance of it, may not be unacceptable to the Public; not only as it tends to establish an absolute Cure for an Ascites, but likewise as it may afford us some Light in the Treatment of an Hydrocele, Hydrops Pectoris, Ovarii, and other Diseases incident to the human Fabric. In 1742, among a great many Hydropics that fell under my Care that Year, I was called to the Afflstance of one Jane Roman. She was an Inhabitant of the Parish of St. Agnes, near Fifty Years of Age, and confined to her Bed, under that Species of Dropsy called Ascites, owing its Rise, some Years before, to the Severity of a lingering intermittent Fever. The most remarkable of her Complaints were, Loss of Appetite, difficult Breathing, unquenchable Thirst, Suppression of Urine, and a short, importunate, asthmatic Cough, joined to that essential Symptom Symptom of the Disease, a large Quantity of extravasated Waters in the Cavity of the Abdomen, distending it to an enormous Size, and perceptibly fluctuating. Her more inferior Parts were likewise swollen to an uncommon Magnitude, with livid Spots and Vesications in divers Places. Under these Circumstances, and already satiated with tedious Courses of ineffectual Medicines, I drew from her (Sept. 20th) Thirty-six Pints of a greenish transparent Lymph, by a Paracentesis made after the usual Manner; whereby her Complaints vanished, and she was soon re-established on Foot again. With some Part of the extracted Lymph, which I had conveyed to my own House, on my Return thither, I made the following Observations: Obs. I. Being as warm as it came from the Abdomen, with one Pint of it I mixed the like Quantity of fresh Bristol Water; and immediately a slight Coagulum ensued. Obs. II. In mixing equal Parts of warmed Lymph and Cohore Claret together, the same Phænomenon appeared; the Coagulum subsided, and the Mixture became milky. Obs. III. Being mixed with Pyrmont Water, it manifested little or no Change, only went turbid. Obs. IV. I mixed a Decoction of the Cortex with the like Quantity of warm Lymph, and it dropped a branny Sediment. Obs. Obs. V. Lymph *per se*, boiled, became gelatinous; but, being mixed with a strong Solution of *Terra foliata Tartari*, it soon resumed its former Fluidity. Obs. VI. In bringing the above Mixture to a State of boiling, the Phænomenon of Coagulation appeared more eminently in each of them; especially that with Claret. *Eaton's* Styptic, Tormentil-roots, Pomegranate-peels, and almost every Restrictive, more or less afforded the same Appearances of Coagulation. Notwithstanding the Disappearance of the Symptoms, and the favourable Prospect that ensued the Evacuation of the Waters, the Relief which she had thereby was only temporary, and of a short Duration: For, Sept. 30. An Inundation again alarmed her, and obliged her forthwith to remove the Bandage, for Fear of Suffocation. Hence, to the latter End of October, she re-filled incredibly; and, notwithstanding any Method used to prevent it, within Forty Days after the *Paracentesis*, there was again collected, in the *Abdomen*, and depending Parts, a Quantity of Lymph, equal to, if not greater than, that which I had but just before thence extracted. All her former Complaints, especially the *Dyspnea*, likewise returned, and oppressed her more violently than ever. Oct. 29. The Waters being ready to break their Confines, and the Pain and Distention insupportable under them, she again desired my Assistance to relieve lieve her. I had, by this time, drawn some Conclusions from the above Observations on Lymph and Restrингents, and flattered myself, that some of them, especially those of the warmest kind, applied immediately to the Parts affected, (the ruptured Lymphatics) must, according to their known Modus of Operation, close up their Mouths, and prevent a further Effusion of their Contents, and, consequently, a Return of the Disease. In order then to obtain this desirable End, I resolved to try their Efficacy, by way of Injection, on the emptied Cavity: And, for this Purpose, the Claret and Bristol Water seemed to claim the Superiority in my Esteem; not only as they produced the strongest Coagulum with Lymph, but likewise in being the safest, and least liable to create any uneasy Sensations on the Viscera. The Experiment, however, being of a pretty singular Nature, I communicated my Sentiments thereof to Dr. Colwell, and Dr. Russell, Two eminent Physicians of our County, and had the Pleasure of finding them meet in their Approbation: The latter, favouring me with his Presence, saw the Conduct of the whole Affair. My Apparatus was, a large Trois-quarts, made on purpose, and dipped in Oil; an Injector, capable of containing Two or Three Pints, adapted thereto; and Three or Four Gallons of blood-warm Injection, composed of equal Parts of Cohore Claret, and fresh Bristol Water; besides Compress, Bandage, &c. as is usual on these Occasions. It was conducted pretty near after the Manner following: Being seated on her Bed-side, and proper Assistants attending her, I plunged the Trois-quart into the Abdomen. Abdomen, about Five or Six Inches below, and as much on the Left Side of the Umbilicus; and thereby soon discharged upwards of Twenty Pints of such clear briny Lymph as I had before; which Quantity did not exceed Two Thirds of the Whole, though as much as her Strength could well bear: The Cigaret and Bristol Water being then in Readiness, I began to replenish the empty Cavity therewith; but I had scarce injected Ten or Twelve Pints of it, before a Syncope, a very material Obstruction, made some Advances, and would fain baffle my Design. Here I perceived the great Expedition necessary in conducting this Experiment; that Symptom being more or less violent, as I happened to be dextrous, or remiss, therein; and was, for the most part, the only one of Consequence that attended it. Quicken- ing therefore my Hand as fast as I was able, and an Assistant stopping the Mouth of the Cannula with his Finger, to prevent a Return, I soon brought her up to her former Magnitude, and had the Pleasure thereby of seeing the above Symptom suspended. I had then Time to ask her, what kind of Sensation this new Piece of Practice excited within the Cavity? and whether or not she thought herself capable of undergoing it a second time? She answered me in the Affirmative; and said, It seemed as it were entering her Stomach. Notwithstanding I had Reason to believe my Intentions already answered, as much as in bringing those Restrictingents in Contact with the Parts affected, yet, as there was a great Quantity of Lymph left behind in the Cavity undischarged, which, on account of the Syncope, I could not well prevent, I imagined their Action, and full Efficacy, might thereby thereby be, in some degree, interrupted. Everything therefore being in a favourable Way, I repeated the Mixture for a second Injection (the Claret being in a double Proportion of the Water, to render it the more efficacious for that Purpose); drew off the whole Contents of the Abdomen to as much as would flow through the Cannula; repeated my Injections as before; and once more, without the least Interruption, replenished her therewith. This total Discharge, however, made a great Alteration in the Face of Affairs; and her being full, and under Distention, now, altered not, as it did at first, the Case. A pungent Pain possessed her Breast, frequently darting through all the Viscera; her Breathing became extremely difficult; her Pulse faltered; the Syncope returned; and she became speechless. Under these Circumstances it was high time to conclude my Design; and therefore, having emptied the Cavity, as well as the Violence of them would permit it, I withdrew the Cannula, applied proper Compress and Bandage, and finished the Operation after the usual Manner; which was the more agreeable, as it ended with the perfect Recovery of her Senses. The Day following, (Oct. 30.) on repeating my Visit, which I did for divers others successively, I had the Pleasure of finding Things under a favourable Disposition; a gentle Diaphoresis, from a liberal Use of Cardiac Medicines, having totally removed the Syncope, Dyspnœa, and all other Complaints. November 12. I renewed my Bandage, and set her on Foot again. The 24th I waited on her again for the same Purpose; found the Swelling in the Extremities going off, her Heart in a cheerful Disposition, her Appetite strong, and no Symptom of a Relapse, as she formerly had long before that time approaching. Dec. 1. the last Visit I made her, she told me, That there was no further Occasion for my Assistance; and that the only Complaint she had then, was, in not having the good Luck to experience this Remedy sooner. Finding every thing therefore in a favourable Way, her Appetite well, her Urine in due Quantity, her Breathing clear, and the extreme Parts of their natural Size, I left her in Pursuit of that Health which she soon acquired, and now enjoys in as eminent a Degree as any other Person whatsoever. To conclude; The Integuments, and other Parts of the Abdomen, having not yet recovered their former Tone; or, for aught I know, some of the Injection being coagulated therein; she still is, and ever has been, since the Operation, somewhat above her natural Bigness: However, it is so far from being an Inconvenience to her, that she made me a Visit, on a trifling Occasion, a few Days since, on Foot; and informed me, that she had, of her own Choice, walked Seven Miles that Morning for the Purpose. Her Welfare now is upwards of a Twelvemonth's Standing.