that the excitement of the parts, giving rise to the effusion, may be
either 1st. Sub-acute or chronic. 2nd. Symptomatic or idiopathic. In
other words, that it may arise from a local disease, or from the common
causes of inflammation; and that these causes may be either general or
particular. 3d. That the serous inflammation may be either local or
general, giving rise to a general or local effusion.
After offering so copious an analysis of Dr. AYRE'S sentiments
respecting the pathology of dropsy, it is unnecessary to enlarge very
fully on the application of his theory to the particular forms of that
disease. We shall, however, offer a rapid review, of some of his
opinions, and next detail the method of treatment he proposes for the
cure of these dangerous maladies. We commence with hydrocephalus, which
he remarks has been divided into an acute and chronic form. This
division, our author thinks, is correct in a certain sense; for the
disease varies much in duration,--running its course, sometimes in a few
days; and at other times continuing several weeks. Yet, he continues,
the terms acute and chronic must be understood as restricted to that
particular form of inflammation producing a serous effusion, and not as
denoting the highest and lowest degrees of common inflammation. It is
from the want of this distinction that much confusion has arisen in our
speculations relative to the pathology of hydrocephalus.
Dr. AYRE calls our attention to the fact, that the forms of
hydrocephalus denominated by Dr. GOLIS hyperacute and acute, do not
differ from the sub-acute phrenitis of nosologists, in which pus and
coagulable lymph are the proper products, with sometimes a serous
effusion into the ventricles as an accidental effect; all of which forms
of inflammation, the serous membranes of the brain, and of other
cavities are liable to take on; and adds:
"Now, the true hydrocephalus internus stands distinguished from
these, in the nature of the inflammation of which it consists,
in the same way, precisely, that the serous inflammation of the
pleura, producing simple hydrothorax, is distinct from that
higher degree of vascular excitement, which occasions an
effusion of pus or lymph. Relatively to these, therefore, the
disease is in a chronic form; and consists, we may repeat, of
that lowest degree of inflammation to which serous membranes
are subject, and the effect of which is to increase the natural
secretion of the part, so as to cause, in regard to the brain,
an accumulation of that fluid in its cavities."
Dropsy of the brain is usually divided into three stages. In the first,
continues our author, vascular excitement exists, as denoted by pain in
the head increasing in acuteness with the increase of the disease; and
in infants by a restless movement of the head upon the pillow, moaning,
occasional screamings, sickness, retching, impatience of light and
noise, contractions of the pupils, delirious terrors, &c. The second
stage is indicated by signs of pressure on the brain by effused fluid,
and by an absence of pain, excepting upon raising or moving the head,
convulsions, permanent dilatation of the pupils, squinting, blindness,
slow intermitting pulse, hemiplegia, and a peculiar placid expression of
the countenance, &c. The third stage is made up of some of these
symptoms, together with other ulterior ones which follow the vascular
reaction. On this subject, Dr. A. offers the following remarks:
"With respect, however, to the division thus formed of this
disease, it is, I think, somewhat questionable, whether it be
pathologically correct; for strictly speaking, the true disease
is comprised between the incipient beginnings of the
inflammation, and its termination by the effusion; since the
symptoms which follow, and compose what are called the second
and third stages, are little more than the consequences of the
disease, and arise from the mechanical pressure of the water
upon the brain. The progress, therefore, of what may be
strictly considered the disease, should perhaps be considered
as terminating with the occurrence of the effusion, which is
often remedial of the excitement causing it; and the whole
disorder, to be thus made up of two distinct states, the first
consisting of symptoms, which commencing with the excitement,
terminate with the serous discharge; whilst the second is
composed of those of a secondary kind, and which are wholly
dependent for their origin and continuance, on a mechanical
pressure from the effused fluid."
Hydrocephalus may occur, either as an idiopathic or symptomatic
affection. As the first, it may arise, where there exists a
predisposition in the brain, from various injuries inflicted on the head
by slight blows;--from all the general causes of inflammation--from the
sudden drying up of long established discharges--the sudden repulsion of
cutaneous eruptions, or the imperfect evolution of that or other
sanative actions of the system, at the close of some febrile diseases,
usually denominated defect of crisis. When, on the other hand, the
disease is symptomatic, it may arise from a particular cause seated
within the head, or in some distant part of the body. The former variety
is not common among children, and when it does occur, it is the result
of some chronic disease, as a tumour or a thickened state of the
arachnoid or other membranes of the brain, resulting from a former
inflammation. "Sometimes, adult patients wholly recover from chronic or
sub-acute inflammation, which induced the structural disease, and this
last becomes, at some future period, the occasional cause of the
hydropic one." At other times, the chronic inflammation continues, and
finally extends to the serous membrane, giving rise to the effusion.
"The most usual cause of the disease, however, particularly in
children, is an irritation which is sympathetically
communicated to the brain, from a disturbance in the
chylopoietic organs; and particularly from a functional
disorder of the liver. The cerebral disorder, to which a
derangement in the digestive functions thus gives rise, is only
one of those numerous effects which arise out of sympathies,
subsisting between these organs and different parts of the
system. In many cases, the same sympathetic irritation is
successively and variously directed to different parts of the
system. It will thus leave one organ or part, and suddenly move
to another; and through the operation of causes, which are not
always obvious, but which have a relation to some particular
predisposition, inherent or acquired. In this way, an
irritation may occasion an eruption upon the skin, and thence
be translated to the bronchial lining, producing a cough; and
next perhaps, to the serous tissue of the brain, exciting there
a turgescent or congestive state of the cerebral vessels, by
which symptoms are produced, through the pressure of the
congestive vessels, that simulate those of hydrocephalus; or
the true disease is brought on by an arterial re-action,
ensuing upon the congestion, which is resolved by a serous
effusion."
Dr. GOLIS, from observing the marked connexion "between the turgescent
state of the brain from chylopoietic disturbance, and its serous
inflammation, has concluded, that it essentially pertains to it;"
consequently, that "whenever it occurs, it is a part of it;" that it
should be considered as forming the first stage of the disease, and that
in all instances, it precedes the excitement. He has, for the same
reason, constituted all the symptoms of the chylopoietic disease into
the first stage of hydrocephalus. Dr. AYRE shows, however, that this
state of turgescence, is not essential to the disease, and is only a
sympathetic effect, which in the majority of instances, requires no
treatment, (at least a very subordinate one,) other than that of the
primary affection. He concludes his remarks on hydrocephalus, with the
following words.
"The cerebral turgescence and disturbance, therefore, in
whatever degree they may exist, are only, when sympathetically
produced, to be considered as morbid causes, whose presence,
where the predisposition prevails, may lead to a serous
inflammation of the tissues of the brain, but which do not
form, in any sense, parts of the disease itself; since, under
every degree of them, they are so frequently remediable, by
means which are alone available, for the removal of their
distant and sympathetic cause."
Of _Hydrothorax_, Dr. AYRE very justly remarks, that, as its name
imports and as defined by Nosologists, it consists of symptoms, which
strictly speaking, pertain only remotely to the true disease--arising,
as they do, from a certain disturbance given to the lungs, by the
pressure of water upon them. They are only the symptoms, therefore, of
the effusion, and as the excitement sometimes terminates with the
occurrence of the serous discharge, its existence, in many cases, is
discoverable only by its effects--there existing no signs, which clearly
point out the presence of that state, previous to the appearance of the
effusion; and what are usually called, by writers on the subject,
premonitory symptoms, being only those of an inferior degree of the
effusion which has already commenced.
Like hydrocephalus, hydrothorax may be idiopathic or symptomatic; and
proceed from a local or general cause--the nature of the inflammation
being the same in both cases. It may likewise be divided into an acute
and chronic form. When the disease is symptomatic, and arises from a
local cause, it is generally chronic. When it arises secondarily from a
disease of the lungs, our author thinks, that
"The mode by which this state is induced in the serous
membranes, is by the chronic inflammation that exists in the
diseased organ extending to them; and not by the same form of
inflammation being set up in them, by a certain sympathy or
consent of parts, which, from a loose analogy, has been thought
to subsist between similar structures."
All diseases of the thoracic organs, are not equally prone to occasion
effusion; some of these also, are only dangerous to life, in proportion
to their disposition in occasioning such an effusion; whilst in other
cases, if it occurs at all, the effusion is only the sequel of a disease
essentially fatal.
"To distinguish between these two conditions, is a desideratum
pathology. Modern writers on pathological anatomy have
prosecuted with considerable zeal and ability, their researches
into the nature of the diseases of the organs within the chest,
but they have done but little towards elucidating the true
relation, which subsists between the diseases of the several
viscera, and the serous effusions which take place into their
cavities; for, by limiting their views to the disease which the
_post mortem_ examination exhibited, they have overlooked those
intermediate actions or states of excitement which connect the
organic disease with such effusions."
Whenever the excitement, producing hydrothorax, is idiopathic and
independent of an organic disease of the lungs, heart, &c. its remote
causes may be either of a general or local kind; and are the same which
produce, when applied in a higher degree, or under different states of
the system, the other forms of inflammation. The effusion may take place
in those cases in which, the individual being predisposed, the
inflammation, owing to some peculiarity in the cause, does not reach
beyond its lowest grade; or in those in which the inflammation being
high, and treated too late, or by insufficient means, a chronic form
succeeds to the acute one, which may produce a watery effusion; or some
structural disease remains and eventually becomes a cause of the
effusion. The occurrence of this effect, in those latter cases, is
sometimes attributed to a debility, resulting from the large depletion
required in consequence of the severity of the previous inflammation.
"That such opinions, however, are founded in error, may be
shown from this, that the effusion, thus imputed to debility,
does not occur sometimes, until some weeks or months after the
period when the bleeding was employed; and although the
debility is confessedly of a general kind, yet the effusion is
local, and is precisely in the very cavity where the disease
existed, which required the unjustly condemned evacuations. The
truth of the matter is, that in such cases, either the
depletory means have been employed in an insufficient degree,
or too late." "The imperfect recovery of such patients from
their first attack, and, which is attributed to the depletion,
arises from the disease which is left by it, and to the
injudicious means, perhaps, that are employed by the too
anxious attendants, with the view of restoring the strength."
Among the ordinary predisposing and exciting causes of the inflammation
which produces hydrothorax, Dr. A. mentions a certain congestive or
plethoric state of the circulation, which is brought on in some persons
of particular habits, by indulging in the pleasures of the table, and
taking little exercise. These cases are analogous to those occurring in
the brain, and giving rise, by rupture, to a sanguineous apoplexy, or,
by arterial reaction, inducing an effusion of serum.
Dr. A. next proceeds to the subject of _ascites_, the symptoms of which
he remarks are at first so obscure, that the disease is sometimes with
difficulty detected. The remote causes of ascites may be either
symptomatic or idiopathic, and either local or general. When
symptomatic, it may be seated in some diseased viscus, as the liver,
spleen, or in the mesenteric glands, &c.
"To produce, however, a dropsical effusion into the abdomen
from this cause, it is necessary that the disease of this
viscus should be making progress; for, in its indolent state,
or, in other words, if inflammation be not present in it, it is
incapable from its mere bulk, as is commonly but erroneously
supposed, of producing this effect." "Nor does the serous
discharge always take place into the abdomen, in every case
where these organs are morbidly affected, but only where their
peritoneal covering participates in the disease; for the
chronic inflammation in those cases, where it occasions
ascites, does so by extending from the cellular tissue of the
internal structure of the organ, to the serous tissue investing
in it." "When ascites is an idiopathic affection, it may
proceed from all the common causes of inflammation. The most
frequent cause is cold, and which may act either locally or
generally. When in the latter mode, the ascites is usually
combined with anasarca, and the disorder generally comes on
suddenly, and has a rapid progress. The vascular system is
excited, and there is more than usual thirst; the blood when
drawn exhibits the buffy appearance; and the urine, when
subjected to heat, is found to coagulate strongly, from the
large quantity of serum contained in it. In some of the severer
cases, the effusion into the abdomen takes place very suddenly,
and yet, by a copious bleeding the disease may be at once
arrested, and the water be afterwards absorbed."
Unlike what occurs in hydrothorax and hydrocephalus, the effusion in the
present form of dropsy is of inconsiderable importance, compared to the
visceral disease which is its remote cause. When, however, the
accumulation becomes very considerable, the pressure of the fluid may
affect the organs, and more particularly the peritoneal lining, which
from the irritation induced in it, may take on a higher grade of
inflammation, terminating in effusion of coagulable lymph or pus, and in
death. The necessity which arises of tapping, where the effusion is very
considerable, proves sometimes a farther cause, perhaps, of aggravating
the disease of the affected viscus, and either of renewing or extending
the hydropic excitement, or of converting it into a higher or more
destructive form of inflammation.
By most writers on dropsy, anasarca has been maintained to originate, in
all instances, in debility, and to be curable only by a tonic and
invigorating plan. It is true that some writers, especially among the
ancients, (for we can hardly class PORTAL among the moderns,) have
spoken of the disease as arising occasionally from a plethoric state of
the circulation, and enforced the necessity, under these circumstances,
of venesection. This view of the pathology of anasarca, although leading
in many instances to a successful practice, was, however, vague and
often unsatisfactory. To the late Dr. RUSH, and to Dr. PARRY, much
credit is certainly due for their labours on this subject; but so far as
we are informed, it was not until within a few years, that the subject
was cleared of part of the obscurity in which is was involved, and that
the disease, at least the active sort, has been referred to an
irritation of the cellular tissue. Following up this opinion, and
generalizing still more than the French pathologists, our author asserts
that anasarca invariably consists in an inflammation of the cellular
membrane of the body, with a serous effusion as its result. The
accumulation, he continues, may be either idiopathic or symptomatic, and
either general or local; occurring only under two forms, the one being
of greater intensity that the other. In general, the disease derives all
its importance from the nature of the remote cause.
"When it is idiopathic and proceeding from cold, it is usually
unimportant, for though the progress of the swelling be rapid,
and the appearance of the disease formidable, yet it readily
subsides under proper treatment, as the effusion proves in
these cases, either partially or fully corrective of its cause;
and little more, under such circumstances, is required in its
treatment, than to promote the absorption of the water. In some
cases of general anasarca, however, the disease is more severe;
for sometimes the action of the heart and arteries is
increased, the urine becomes loaded with serum, and there is
thirst and other indications of general vascular excitement,
similar to the state which was noticed, as producing effusion
into the brain, or the other cavities of the body."
In some cases, the serous effusion appears to be translated from one
part to another. Our author very justly adds, however, that this
translation is not of the serous fluid, but only of the serous
inflammation giving rise to the effusion. It usually takes place from
one portion of the cellular membrane to another; but sometimes from this
membrane to the serous tissue of the brain, chest, or abdomen.
Oedema of the feet and ankles is often symptomatic of chylopoietic
disturbance, and particularly in young women, in whom the menstrual
function is obstructed. In these cases, as well as in the oedema
following gout or rheumatism, the swelling usually commences with
considerable pain and stiffness of the parts, and hardness of the
swelling.
"But the most common form of anasarca is that which is
symptomatic of some visceral disease; and which, as it
ordinarily appears, arises from a state of the system that
answers to the hydropic diathesis of systematic authors."
This form of the disease begins in the lower extremities, and is rarely
attended with strong signs of local excitement so obvious in anasarca of
the idiopathic kind. Its occurrence has been referred to various causes.
When combined with ascites, it is supposed to arise from pressure of the
iliac veins by the fluid accumulated in the abdomen,--an opinion which
our author combats by repeating, in great measure, the arguments we have
already noticed.
"But here let me observe, that the denial of ascites producing
an anasarcous state of the legs, from the water compressing the
iliac veins, must not be understood as implying, that a
mechanical compression of a vein will not in other cases
produce an effect of this kind. A pressure made on the brachial
vein and its branches by scirrhous glands in the axilla, is a
common cause of this state. The remote cause is here, indeed,
of a mechanical kind, but not so the proximate cause of the
effusion. By the resistance given, in this case, to the blood's
return by the principal veins of the limb, a reaction is
occasioned in the extremities of the arteries leading into the
corresponding extreme branches of the veins, and which reaction
is in this, as in a multitude of other occasions of congestive
fulness in these vessels, a sanative effort of nature to
overcome the primary obstruction."
The disease has often been referred, when occurring under these
circumstances, to a local and general debility; and this opinion is
thought to be supported by the facts that the swelling is increased by a
depending position of the limb, and diminished by a horizontal one--by
the occurrence of an inflammatory state of the parts being incompatible
with such a degree of debility, and lastly by the absence of
preternatural heat on the surface of an oedematous part. To these
pretended arguments, Dr. A. opposes, that the effusion cannot be
attributed purely to debility; because the effects are in no
correspondence with the assigned cause,--the debility being, in some
instances of chronic and acute disease, very considerable, and the
effusion small, and vice versa;--because anasarcous limbs will occur in
the strongest individuals when the limbs have remained a long time in an
erect posture,--because there is in certain fatal chronic diseases, a
tendency in the lower limbs to take on an inflammatory action, often of
an erysipelatous kind,--and because the fact of oedema increasing by
an erect posture and diminishing in the horizontal one is readily
explained by the greater congestion of the vessels induced in the limb
by such a position, as it occurs in the higher grades of inflammation.
"And with respect to the temperature of the surface of
oedematous parts not being preternaturally raised, the
objection, if of any force, must apply to all, for all have
this peculiarity, and yet some cases of oedema confessedly
arise from inflammation; differing not, in this respect, from
several other morbid states, as those for instance, of chronic
rheumatism, and which are indubitably, as indicated by the
nature of their causes and remedies, of a truly inflammatory
kind."
Dr. AYRE, therefore, regards all these cases as secondary to a serous
inflammation seated in a cavity; and lastly as arising from some
disturbance in the digestive functions, by which this and other distant
irritations are produced through the operation of that law of the animal
economy, denominated sympathy.
Having thus offered, in the preceding pages, an analysis of Dr. AYRE'S
views of the pathology of the principal forms of dropsy, we must be
allowed, before proceeding to the treatment of the disease, to make a
few remarks. It appears to us that Dr. A. has treated the subject in a
very able manner, and contributed greatly to remove many objections,
that could be adduced against the opinion of the inflammatory nature of
some of the more obscure cases of dropsy. We cannot help thinking,
however, that he is too exclusive in his theories, and that he has
rejected too positively the idea of a passive dropsy; in other words, of
a dropsy independent of inflammation. Some cases of the disease which
follow extensive losses of blood, (profuse uterine hemorrhages, for
example) and which are cured by tonics and an invigorating diet, without
the aid of diuretics, cannot always, though they may sometimes, be
accounted for by admitting the existence of inflammation. Such instances
have fallen under our own observations, and could not be explained by
supposing that the effusion had relieved the inflammation; since there
had not existed, at least as far as we could ascertain, any local
inflammation. In one case it followed abortion, attended with profuse
hemorrhage, and produced, not by disease, but by an accident.