severely painful affection of the nerves of the right cheek, immediately
below the orbit of the eye, and extending to the angle of the lower jaw.
On the 14th of January 1826, she was attacked more violently than usual,
and the remedies, which had previously afforded some relief, now failed.
Stimulating cataplasms, warm embrocations, laudanum, internally and
externally, heat applied externally to the cheek by means of very hot
flannels, produced not the slightest mitigation of the pain; and she
continued to suffer excessively until the afternoon of the 15th; when
acupuncturation being proposed, she consented to the operation with this
remark,--"any thing to relieve me from this agony."
The needles were immediately procured, and three inserted about an inch
from each other. Two in a line parallel with the inferior edge of the
orbit of the eye, and half an inch below it; and a third below, and
equidistant from the others. The first two were introduced to the depth
of three-fourths of an inch; the last, a full inch. They were inserted
very gradually and with a rotary motion.
The second needle was scarcely introduced, before the patient exclaimed,
"the pain has entirely left me." When the third was introduced, she
experienced a stiffness in the muscles of the cheek, and a creeping
sensation, as if a spider's web had been drawn across the face; but no
painful sensation whatever.
Such was the exhausted state of her system from the excessive pain she
had suffered, that when thus relieved, she requested a pillow to rest
her head on, and fell into a gentle slumber.
About two hours after the insertion of the needles, I again visited my
patient, and found her still perfectly free from pain, and seated at a
table reading. She thanked me for the relief I had been the means of
affording her, and requested me not to withdraw the needles, lest the
pain might return. Upon being apprised of the risk that might attend
their being allowed to remain, she observed, that she would rather have
a servant to watch her whilst she slept. The propriety of their removal
being further urged, she at last consented. There was no return of pain.
The next morning, the patient remarked, that the stiffness of the cheek,
and a numbness of the whole right side, continued through the night; and
though she did not sleep very soundly, she was free from pain and rested
well.
By the third day, the stiffness and numbness had passed away, and there
was no return of pain. Several weeks have now passed, and she has had no
relapse; although often since exposed to causes, which, heretofore, had
always excited violent attacks. Previous to the operation, she seldom
passed as many days without severe suffering.
Although I have performed this operation many times, and been present
when others have performed it, I have never seen a case, in which its
efficacy was so decided, or in which the relief afforded was more
unquestionably attributable to the action of the needles.
ANALYTICAL REVIEWS.
ARTICLE VII.--_Researches into the Nature and Treatment of Dropsy in the
Brain, Chest, Abdomen, Ovarium, and Skin, in which a more correct and
consistent Pathology of these Diseases is attempted to be established,
and a new and more successful method of treating them, recommended and
explained._ By JOSEPH AYRE, M. D. &. London, 1825.
We have read the present work with the liveliest pleasure, and we dare
hope with considerable benefit, and hasten to lay a review of its
contents before our readers. Dr. AYRE is already advantageously known in
this country, where his Essay on Marasmus has had an extensive
circulation; but we are disposed to think, that, however he might be
esteemed for the talent he displayed in his former composition, he is
entitled to much more credit for his able researches into the nature and
treatment of dropsy. We confess that we enter upon our editorial duties
on the present occasion, with the two-fold intention of offering to our
readers what we regard, on the whole, as a very correct view of the
pathology of dropsy, and of showing to some of our medical friends, who
shudder at the mere mention of what they denominate _hunch theories_,
that the English physicians, or at least some of the most intelligent
among them, so far from considering these theories as dangerous and
unphilosophical, are beginning to entertain similar views with their
Gallic brethren, in respect to the inflammatory nature of many diseases
too long regarded as resulting from a state of debility, and classed by
nosologists among the Cachexiae.
By most writers upon the subject, dropsy has too long been considered as
a _disease_,--constituted into a separate class, and divided into many
species. Dr. AYRE entertains, however, a very different and, we believe,
a much more correct view of the pathology of this complaint; regarding
it as only one in a series of effects of a disease, and not always the
last of that series. He remarks, that the true disease is to be sought
for in that particular condition of the solids by which the effusion is
produced; and that to appreciate justly the nature and treatment of
dropsy, it is necessary to understand the nature of that condition,
which constitutes the disease, and of which the serous and watery
effusion is merely the result.
Of all the hypotheses that have been advanced to account for the nature
of the morbid state, which gives rise to general and local dropsy, there
are only three which our author regards as entitled to our notice.
According to these, all dropsical accumulations arise either, 1st, From
a want of tone or energy in the absorbent vessels, giving rise to a
deficient absorption. 2nd, From an increased exhalation of the natural
fluid, through a similar want of tone in the exhalents; and 3d, From a
mechanical obstruction to the free return of blood by the veins,
produced by tumours of various kinds, &c., by which a greater portion of
it is forced into the exhalents, and a greater effusion of their proper
fluids thereby occasioned. With these hypotheses, however, Dr. AYRE is
not satisfied, and he endeavours, in the following manner, to show their
insufficiency.
"1st. The opinion of a want of tone in the absorbents, as a
cause of dropsy, is contradicted by the fact, that in those
cases, in which it is assumed to prevail, it is found, that the
adipose matter, or fat of the body, is removed by the
absorbents; or, in other words, that emaciation takes place to
as great an extent, and as rapidly in this, as in other
diseases; and emaciation can only be effected by means of
absorption. Besides, in these cases of dropsy, mercury, when
rubbed upon the surface, or received internally, is absorbed as
readily, and affects the system as early as under other states
of the body. There is also no accumulation of the fluids in the
joints, or in the _bursae mucosae_ in these cases, which,
nevertheless would happen, if there was a general debility of
the absorbent system; and _ecchymoses_ or livid spots, though
easily induced in anasarcous limbs, are likewise easily removed
from them by the absorbents.
"2nd. The opinion of a want of tone or energy in the exhalants
involves in it one of the following conditions: namely, either,
1st, that the fluid of dropsy may escape mechanically from
them, and that the fluid thus _mechanically_ separated may be
identified in its sensible and chemical qualities with another
fluid which is confessedly secreted; or 2nd, that if the fluid
of dropsy be secreted, then that an _increase_ in the quantity
of a secretion may continue an indefinite period, under a
_decrease_ in the energy of its secreting vessels; conclusions
to which experience and analogy are alike opposed."
In answer to the third hypothesis, Dr. A. remarks, that such an
obstruction as contemplated, has never been shown to exist.
"In the case of the liver, which is commonly considered, when
in a scirrhous or enlarged state, to be the seat of these
mechanical obstructions, and thus, to be the cause of abdominal
dropsy, we have no satisfactory instance yet shown to us, of
any such precise condition of that organ. There are, indeed,
numerous instances of abdominal dropsies, in those labouring
under a scirrhous or enlarged state of the liver; but there are
also, numerous examples of such states of the liver, as well as
of the spleen and other organs, without any such effusion; and
in many cases, when such effusion has taken place, it has been
carried off by the natural passages or by tapping, without any
return of the dropsy; and yet, without any visible change in
the structural condition of the liver."
Dr. A. further remarks, that if the cause were mechanical and existed in
the liver, the effect should be constant; which, however, is not the
case. Besides, were this mechanical cause necessary, how could we
account for the appearance of abdominal dropsy, where there is no
disease of the liver, or in other cavities, where no mechanical cause is
asserted to be present, and where the remedies by which the cure is
effected, have no relation to such causes? Again, if the discharge
depended upon a mechanical cause, the water should in every case be of a
uniform fluidity, and the progress of its accumulation likewise uniform;
so that the operation of tapping should have no tendency to induce a
more rapid refilling of the cavity. Yet, the contrary of all this is a
subject of daily observation. In addition to this, Dr. A. calls the
attention to the fact, that in experiments, in which obstruction has
been artificially made, by tying the vena cava for example, the
experimenter has committed an error, in reasoning from the lower animal
to man--assuming, that as ascites had arisen in dogs, it would in like
manner have occurred in human subjects.
"But there was an effect, here overlooked, which was to be
expected to take place in the abdomen of the dog, from the
injury done to the surrounding parts by the operation itself,
and which would be quite independent of any effect arising out
of the experiment. In the human subject, the effect would be
the highest form of inflammation, by which coagulable lymph or
pus would be poured upon the surface of the peritoneum. There
would, therefore, be inflammation excited in the abdomen of the
dog; but as the lower animals are less easily acted on than
man, the inflammation would in this case be in a lower degree.
But every degree of inflammation has its particular product.
The highest occasions a discharge of pus, whilst the lowest,
when seated in a serous membrane, is a larger portion of its
proper serous fluid. This, therefore, might be the product of
the inflammation, which was produced incidentally by the
experiment in the abdomen of the dog; and it would be just as
reasonable to regard the coagulable lymph in the human subject,
which would result from such an experiment, as an effect of the
mechanical obstruction, as to consider the fluid effusion in
the dog to be so."
In respect to those instances of diseases of the liver, connected with
ascites, in which, in addition to its other morbid states, a partial
occlusion of the vena portae, by the effusion of coagulable lymph into
it, is said to have existed, our author remarks, that they are very few
in number, occurring, perhaps, in one out of several hundred cases of
ascites with hepatic disease; and that we are justified, from analogy,
to assume, that any obstruction given to the circulation by diseased
vessels, would be quickly relieved by the enlargement of the
anastomosing branches, and that no effusion of water into the abdomen
would result from it. After referring to some cases, related by the late
Mr. WILSON, in which the vena cava was completely obliterated, and no
effusion took place; and some cases of morbid condition of the heart of
an analogous kind, by which the course of the circulation became greatly
obstructed, and yet, without being followed by effusion; our author
concludes, that from these facts and others, to be presently noticed, it
appears evident,
"That the dropsical effusion, in whatever part it may be
seated, does not arise from any want of tone in the exhalant or
absorbent system, or from a mechanical obstruction in the liver
or other viscus; but, that it proceeds from a morbid action in
the cellular or serous tissues, and that this action, as we
shall now proceed to show, is allied in its nature to
inflammation."
In support of this opinion, Dr. AYRE remarks, that all the phenomena
belonging to cases of watery effusion, met with under one or other of
the forms of inflammation, are common to those of dropsy. Thus the
fluid, discharged under the cuticle in erysipelas or in inflammation
induced by heat or a blister, or in cases of pemphigus, is a secretion,
and resembles in all respects the fluid found in dropsy. In some cases
of acknowledged inflammation, the fluid effused is found to vary greatly
in its degree of tenuity, so as to be sometimes of quite a viscid
nature. The same circumstance is met with in dropsy; the fluid of which
varies sometimes in different forms of the disease, and at different
periods in the same patient. With regard to the absence of pain, in
ordinary cases of local or general dropsy, which, in the minds of many
physicians, might seem to militate against this view of the
subject,--since pain accompanies the inflammation of a blister, Dr. A.
very justly says, that the difference is referrible to a different
degree of sensibility of the parts affected; that, moreover, in
pemphigus there is no pain, and that chronic inflammation of the serous
membranes is little painful.
That the morbid action producing the effusion is only a modification of
inflammation, our author thinks may be further shown by the fact that it
obeys the same laws--being translated occasionally, like it, from one
part of the body to another. On this subject, Dr. AYRE makes the very
pertinent remark, that in these cases, the fluid alone has been thought
to be translated; but that the metastasis, is without doubt, exclusively
of the action which produces the serous discharge. Analogous also to
what occurs in inflammation, especially of the erysipelatous kind, the
action occasioning the effusion, as seen in anasarca, commences at a
given point, and gradually extends from thence in a continuous course.
It ought also to be noticed, that the results of common inflammation
vary according to the intensity of the cause; the lowest degree of it,
occasioning an increase in the quantity of the proper fluids of the
part,--a higher degree, yielding for its product coagulable lymph, and a
still higher one producing pus. All these several products of common
inflammation, are more or less remedial of their cause; or in other
words, are the immediate means of the cessation or abatement of the
inflammation which produces them. This same power is likewise a
property, though in a much less degree, of the hydropic effusion, when
the inflammation which produces it, is idiopathic; or in other words,
not created by a visceral or other disease, or some particular
excitement of the general system, as is seen in cases of anasarca.
"And here," continues our author, "it may be proper to remark
upon a common error, committed by those, who, mistaking the
nature of the action which produces the serous effusion, look
in the _post mortem_ examination, for some of the common signs
of an inflammation having existed; and who conclude, upon not
finding such, that the water was derived from some mechanical
or other cause foreign to the true one. But in the higher forms
of abdominal inflammation, the products are pus or lymph, and
these are found upon the surface of the peritoneum, with
sometimes a thickening and discoloration or ulceration of its
substance; whilst in the lowest form of that increased action
to which the serous membranes are subject, the only product is
the serous fluid, and there can be, therefore, no visible
alteration produced by it in the structure of the serous
tissue."
"By the hydropic or serous inflammation, obeying the same laws
which govern the other degrees of common inflammation, it
follows, that upon a higher excitement being superinduced upon
it, the serous effusion should cease. This, therefore, is found
to happen in every case, where such higher excitement is
brought on. This increased inflammation is sometimes occasioned
by design or accident, and at other times, it occurs in the
natural and progressive course of some disease, formed within
the cavity, which is the seat of the dropsical effusion."
This is exemplified in the effects of the operation for the radical cure
of hydrocele; or in the operation of tapping in some cases of ovarian
dropsy; or even in some instances, of ascites from chronic inflammation
of the liver, spleen, mesentery, &c. In all these cases, the serous
membrane, which directly or indirectly was affected to a sufficient
degree to occasion a serous effusion, takes on, from the extension of a
visceral disease, or from some other cause, a higher degree of
inflammation--lymph is thrown out, and the cavity becomes obliterated.
"Now from these, and similar examples, which have fallen under
my observations, I think it may be assumed, that ascites, when
proceeding from some visceral disease, (and the principle
applies to hydropic effusions from the pressure of disease in
other cavities,) does so by the gradual extension of the
chronic inflammation of the internal cellular or serous tissues
of the diseased organ, to its outer external coverings; and
that, commencing here as from a point, the serous or hydropic
inflammation is progressively propagated through the whole of
the serous membrane of the cavity. By the disease within the
cellular tissue of the diseased viscous increasing, a
corresponding increase, in these cases, will ensue of the
disease on the surface of the membrane investing it; until at
length a susceptibility to take on a higher action is induced,
which only requires any slight occasional cause to establish.
Under this condition of an increased excitement in the
peritoneal or other serous membrane, coagulable lymph is
discharged into its cellular tissue, and a thickening of it
takes place; until at length the operation of paracentesis,
which in the early stage of the disease was attended with only
inconsiderable inconvenience, becomes an adequate cause of a
still higher inflammation, which terminates perhaps in
suppuration; and, in the _post mortem_ examination the serous
fluid is found so mixed with coagulable lymph, and purulent
matter, as to give a whey or milk-like appearance to the mass.
The quantity of serous fluid, in these cases, is generally
small, when compared with what was accumulated in the
intervals of former tappings; for the vascular excitement
which occasions the discharge of coagulable lymph, is
destructive of that which pours out the serous fluid."
Dr. A. remarks, that, besides the particular facts deduced from
observations on dropsy as a local disease, and which prove its relation
to diseases of local excitement, there is a further support to be given
to these views by various proofs that are afforded from observations
upon the urine, of serous inflammation producing local dropsy, being
frequently connected with one of a general kind. "So that the
inflammatory state of the system becomes sometimes a cause of the
effusion into a cavity, and at other times an effect of this state."
After giving full credit to Drs. WELLS and BLACKALL for their researches
into the state of the urine in dropsy, our author remarks, that there
are certain conclusions deducible, which appear not to have been
contemplated by those gentlemen, but which are strictly accordant with
the pathological views he has endeavoured to establish in the present
work.
"According to these facts, it appears, that when the disease of
dropsy is under a sub-acute form, and of the anasarcous kind,
it is usually idiopathic, and, often originating from cold; and
in this state, as well as in the symptomatic form, though in a
less degree, the urine is found to contain a portion of serum.
It is nearly peculiar to this disease, and denotes, according
to the quantity of it contained in the urine, the amount of
that excitement in the cellular tissue, and of the general
vascular system, which may be termed serous inflammation: for
it is met with most considerably in those forms of the disease,
in which these particular states of the body are most
apparent."
Serum is therefore found in greater abundance, when anasarca precedes
the local dropsy, which, in Dr. A.'s opinion, denotes the operation of a
general cause. This is found to be the case especially in anasarca after
scarlet fever. In cases of anasarca, the skin, kidneys, and bowels are
very defective in their operation. Serum is also found, though in a
smaller quantity, in those cases in which the anasarca has followed the
local dropsy; for the disease of the viscus, which is the cause of the
inflammation in the serous membrane of the cavity, may produce an
adequate degree of the vascular excitement which gives rise to a
discharge in the cellular tissue. Our author sums up his observations on
this subject, by remarking, that there appear to be four distinct
conditions of the system by which the occurrence of serum in the urine
is regulated.
"1. It is in the greatest quantity, where along with a copious
and continued effusion, there is a nearly corresponding
quickness in the absorption of the serous fluid, and which will
occur most commonly when the general excitement precedes, and
is cause of the local one.
"2. It is consequently, _caeteris paribus_, in a less quantity
where the general hydropic excitement of the system succeeds,
and is dependent on the local one.
"3. It is absent, or found only in a minute proportion, in all
those cases where the local increased excitement in the serous
membrane is only partially extended to the rest of the system,
and where the absorption from the part is inconsiderable; as
particularly happens in the encysted kinds, or,
"4. Where the effusion of the serous fluid has proved remedial
of the inflammation producing it; in which case the disease, as
it respects the presence of water in a part, may visibly
resemble another example, and yet be essentially different from
it, by the serous inflammation, which produced it in both,
having ceased, on its occurrence, in one of them."
Dr. A. discovers a further evidence of the relation which dropsy bears
to diseases of local excitement, in the effects it produces on the
general system. Thus, during the continued effusion of serum in
anasarca, there is sometimes a large quantity absorbed and carried out
of the body; by which a regular draught is made upon the nutrient
principles of the blood, which must naturally create effects like those
arising from the continued discharge of pus from a suppurating surface.
In both cases the local disease, when extensive and of long duration,
will necessarily occasion an exhaustion of the vital powers, by which
that condition of the system termed cachexy will be induced.
"The exhausted or cachectical state, therefore, of the system,
which has been so variously accounted for, and so frequently
assigned as a principal cause of both local and general dropsy,
is a direct consequence of the agency of some power diminishing
the vital strength at its source; and in the case of a chronic
and long continued serous inflammation, it will proceed from
the daily abduction from the circulation of a portion of its
vital fluid: and whether it be pus or serum that is drawn from
the body; or whether it be from any permanent failure in the
supplies of nutriment to it, the effect will be the same, as if
a certain quantity of blood was daily abstracted from the
system."
Dr. A. continues to remark that, under these circumstances, a
suppurating surface will readily become gangrenous, from any cause
temporarily exciting it, and that, in like manner, a higher
inflammation may sometimes supervene upon an oedematous limb, as in
the former case, and terminate in gangrene.
"Hence, therefore, the tendency of dropsical parts to fall into
gangrene, and which has been urged, as an argument, in proof of
debility being the cause of the serous effusion, is only what
is common to other forms of local inflammation, under a similar
condition of the body."