ON THE LIMITATION OF FLUID IN THE FOOD AS AN AID TO THE TREATMENT OF SEROUS EFFUSIONS
IN the two remaining cases in which I have had the opportunity of applying the restriction of fluid, the treatment has been interfered with by disturbing causes. The first was that of a boy of eight years suffering from slight general dropsy dependent upon mitral regurgitation and renal disease; the urine was scanty and albuminous. Drink was restricted to sixteen ounces, a purge of calomel and jalap given, followed by a pill of digitalis, mercury, and squill three times a day. A severe
... ensued, the quantity of urine remaining small until the purging ceased, when the flow of water increased to double the previous quantity. The drain upon the fluid of the body must have been great, but the main channel of excretion being by the bowels prevented any exact estimation. The cedema disappeared in the course of a few days, and,the patient complaining much of thirst, the restriction as to drink was removed. The last case was one of pleurisy with effusion into the right side of the thorax, in A. P-, a boy ten years old. There was a history of a definite commencement of the attack, with sharp pain and fever six days before. Physical examination showed the right pleural cavity to contain a large quantity of fluid, which reached to the level of the spine of the scapula behind and to the third space in front. The urine was measured for two days before treatment was commenced, and found to be 800 cc. and 750 co. respectively; the average of drink taken for the two days being 25 oz. =707'5 cc., yielding the unusual feature of an excess of outflow = 67'5 cc. Drink was then limited to 10 oz. = 283 cc., a purge of calomel and jalap being given, followed by a pill of digitalis, squill, and mercury, every four hours. The urine fell the next day to 375 cc., or 92 cc. in excess of the fluid swallowed-a gain in drainage of only 24-5 cc. ; and the next day, again, to 350 cc., or 67 cc. in excess of inflow by drink; and a drainage equal to that existing before treatment commenced. On the third day, however, the urine rose to 450 cc., and on the fourth to 460 cc., being 167 cc. and 177 cc. in excess of inflow by drink respectively. The average for the eight days during which this restriction was maintained was 416'8 cue. ; and an excess of outflow of 133'8 cc., or an average daily gain in drainage over the condition on unlimited drink of 66-3 cc. The fluid in the chest had declined, so that the level of dulness had fallen to the lower angle of the scapula. The pulse now became very irregular, and the digitalis was stopped, the fluid taken being increased by chinchona mixture to 367'9 cc. This was at once followed by a diminution in the flow of urine during four days, at the end of which time, the temperature remaining high (102° to 104° at night), and the fever causing much thirst, drink was increased to 849 cc. The loss in drainage was at once apparent; the average flow of urine only rose to 564'2 no., so that in place of excess of outflow there was excess of inflow to the extent of 284'8 cc., or a daily drainage loss of 418'6 cc., as compared with the condition when on 283 cc. drink and the digitalis pill. The condition of the chest remained absolutely stationary; the high temperature also persisted. It was thought probable that this might be due to the presence of pus, and the chest was tapped on May 9th, three weeks after admission. Only two ounces of clear serum were obtained, with the result of improving the entry of air and giving rise to friction-sound under the right mamma. The boy was from the time of tapping allowed perfect freedom as to drink, the amount taken being registered for seven days. The comparison with urine is in curious contrast to the preceding relations. As will be seen by the table, the average amount of drink taken was no less than 1413 cc., while the average flow of urine was only 708'5 cc., showing an excess of inflow over outflow of 705 cc., and a daily drainage loss, as compared with the condition under digitalis and 283 cc. drink, of 833 cc. It must be stated, however, that the quantity of urine recorded during this period of unrestricted drink is slightly under-estimated, owing to the loss of a small quantity passed with the stools on one or two occasions; in all other calculations this was invariably included in the estimate. The condition of the patient now remained stationary; the fluid in the chest did not further diminish, and the temperature remained three degrees above the normal. A second tapping was resorted to on June 16th, and two ounces more fluid withdrawn. I.-First period of two days. Drink not restricted, but the quantity taken measured. No drugs were given. The bowels open normally. Average daily quantity of urine passed for two days on unlimited drink (or an average of 707'5 cc.) = 775 cc. Average daily excess of outflow by urine over inflow by drink = 67'5 cc. II.—Second period, comprising eight days. Fluid restricted to ten ounces of milk = 283 cc. Drugs given: a purge of calomel and compound jalap powder, followed by a pill containing half a grain of digitalis powder, a grain and a half of squill _powder, and a grain and a half of mercury pill, every four hours. Bowels open freely after the purge ; subsequently regularly in the normal manner. Average daily quantity of urine passed for eight days on 283 cc. of drink = 416.8 cc. Average daily excess of outflow by urine over inflow by drink = 133'8 cc. III.—Third period, comprising four days. Drink restricted to ten ounces ef milk and three ounces of mixture, or thirteen ounces in all = 367'9 cc. Drugs given: half an ounce of chinchona mixture every four hours. Bowels acted normallya Average daily quantity of urine passed for four days on 367'9 cc. of drink = 386'2 cc. Average daily excess of outflow by urine over inflow by drink =18-3ee.