Dr. BOUILLAUD has related many cases of partial and general dropsy,
which undoubtedly originated in obstruction to the venous circulation,
from adhesion of the parietes of the principal veins. It is true that
Dr. A. is compelled to admit this among the causes of dropsy; but
faithful to his theory, he supposed the supervention of an arterial
reaction resulting in an effusion of serum. It does not appear to us,
however, that this arterial reaction is admissible in all cases of the
sort, and we prefer on the whole the explanation of the mechanism of the
effusion, originally given, by DONALD MONRO, and lately by Drs.
BOUILLAUD and BROUSSAIS, who refer it to an obstruction in the venous
circulation and to a consequent deficient venous absorption. By
admitting this explanation, it is readily perceived, that we admit a
passive dropsy, and we think the view well exemplified by a case which
occurred last summer. The individual had recently recovered from a
violent attack of disease, and was left much debilitated. Induced by
this circumstance to travel to the north, he had occasion to notice that
when seated long in a stage with his feet depending on the veins
compressed, oedema invariably came on, and that it as invariably went
off the next day if he did not ride. This occurred so often as to lead
us to think there could not always be an arterial reaction occasioning
the effusion, and that this effect arose from the mere obstruction to
the venous circulation.
In making these remarks we are not actuated by the desire of detracting
from the merits of Dr. A.'s views of the pathology of dropsy; convinced
as we are, that the great majority of cases of the disease, which are
thought by many physicians to arise from debility, do not owe their
origin to this condition of the system, but to an increased excitement
of the membranes or cellular tissue. Were it otherwise, how could we
account for the fact, that dropsy is generally _local_, whilst the
_debility_ to which it is in most instances referred, is general?
But whilst maintaining the correctness of many of Dr. A.'s views, we are
inclined to the opinion, that he may do some injury to the doctrine he
is advocating, by invariably making use of the word _inflammation_, to
express that condition of the vessels, giving rise to an excessive
secretion of serous fluid. We are ready to admit, and we dare hope, that
few will refuse to do so, that _inflammation_, strictly speaking, will
occasion such an effect; yet, it often happens, that effusion will occur
in cases, where no inflammation can be detected. In such instances, the
vessels are evidently in a state of increased excitement; or in other
words, in a state of irritation, but not of inflammation, which always
implies congestion. This latter morbid condition, may supervene on the
irritation, and occasion a suppression of the serous effusion, and the
formation of coagulable lymph or pus. It is true, it may be said, that
both these states (irritation and inflammation) being an increase of the
life of the part, and requiring the same treatment, may be designated by
the same name. Nevertheless, to prevent confusion, and the quibbling of
some of the opponents of the theory of inflammation in dropsy, we are
inclined to believe, that it is better to substitute the word
irritation, whenever there is merely an increased secretion, and reserve
the word inflammation, to designate those cases, in which there are
decided marks of local excitement and congestion, attended or not with
general fever.
Dr. AYRE, adopting the opinion of Dr. PARRY, regards some cases of local
dropsy as an effect of a general hydropic diathesis, or of a general
inflammatory action of the vascular system, occasioning a local
excitement, ending in dropsy. This is a natural consequence of the
views, entertained by many physicians in Europe and this country, that
fever produces local inflammation. We must confess, however, that all
Dr. A. has said on the subject, is not calculated to carry conviction to
our minds. Thus, one of his reasons for regarding some cases, as arising
from this general vascular excitement is, that they are produced by what
he considers as a general cause,--as cold, for example. But cold
produces local diseases, occasioning, and not preceded by, a febrile
excitement; and if it can, and does occasion anasarca, who will pretend
to assert, from its being a _general_ cause, that this anasarca is a
general disease? Does not cold occasion also ascites, which, in many
cases, is regarded by every one as a local disease, sometimes
terminating in anasarca? If so, why shall we regard anasarca, ending in
ascites, as a general disease? The cases are analogous, and the action
in both should not be explained differently. If the action of such a
cause were really general, and extended to all parts of the body, then
the effects should also be general, and the dropsy should be universal,
which is very far from being always the case.
2nd. It is also said in support of this opinion, that where anasarca is
idiopathic, it is attended with fever, but that this latter does not
exist, when the disease follows ascites. This difference appears to us
to be very readily explained by the fact, that the disease in the former
case, is more acute, and that the heart sympathises more actively with
the irritated cellular tissue, than in the second case, when the disease
is milder, or more gradual in its progress.
3d. It is also maintained, that when anasarca is idiopathic, there
exists a large quantity of serum in the urine; and this is brought
forward in order to distinguish these cases from local dropsies. But it
is also admitted, that serum is found in the urine in cases of anasarca
following ascites. Consequently, if there be none in cases of simple
ascites, and if it only appears when anasarca supervenes, the only
conclusion that may be drawn from these facts, is, that anasarca is the
only form of dropsy, in which serum is absorbed, and passed off by the
kidneys; and if there be a greater quantity discharged when anasarca is
primary, it is only because the disease is more violent, and generally
more extensive. But, surely all this is far from proving, that primary
anasarca is a general disease, and owes its origin to a primary arterial
excitement of the whole system. When fever exists first, and terminates
in dropsy, who has proved, that there existed no local irritation
producing the fever, and that the hydropic irritation has not supervened
by metastasis. This takes place in scarlatina and other eruptive
diseases, which Dr. A. would surely not be justified in calling general
diseases. Dropsy follows the suppression of cutaneous diseases,
unattended with fever; consequently, when there happens to be a febrile
excitement, we are at a loss to know, why we should call this latter to
our aid, in our explanation of the dropsical effusion, and not account
for it on the same principle, as we did in the former cases; namely, by
metastasis. If febrile symptoms are sufficient to make us regard a
disease as general, then there is no local disease, except when
apyretic.
We now proceed to notice the mode of treatment, recommended by our
author, for the different forms of dropsy. From what we have seen, it is
natural to conclude, that as Dr. AYRE regards the proximate cause of the
several forms of the effusion, or in other words, the _disease_, to be
the same under all its conditions, he will be of opinion, that "the same
general principles of treatment, are alike applicable to all--subject
only to such modifications, as arise from differences in the nature and
intensity of the remote cause, and those general or local relations of
the parts implicated in the serous effusion, with the diseases of the
organs, which incidentally produce it." Founding upon these views the
indications of cure, he states them to be; 1st. To remove the visceral,
or such other disease or state, which, when present, proves a remote
cause of the effusion; 2nd. To remove the morbidly increased action in
the serous membrane or tissue, which is its proximate cause. 3d. To
promote the absorption of the effused fluid.
Agreeably to Dr. A. the treatment of hydrocephalus internus, is
divisible into three general heads:
"The first, consisting of means to correct, with its causes,
that turgescent state of the brain, which may produce the
arterial re-action and effusion; the second, of those which
shall subdue the excitement, when formed; the third, to correct
or relieve, as far as it is practicable, the effects of the
effusion, and procure, if possible, its absorption."
With respect to the general causes, tending to produce that congestive
state of the brain, precursory to its inflammation, he remarks, that
they are of three kinds; 1st. Those acting through the general system,
and consisting of an irritation, from some obstructed or required
evacuation; 2nd. A local disease, seated in the head, or a local injury
inflicted on it; 3d. Chylopoietic disturbance, acting sympathetically
upon the brain. When the first of these causes appears to have been
instrumental, in occasioning this condition of the brain, it is plain
that it must be removed, and the obstructed emunctory corrected,--the
suppressed evacuation promoted, or a new and artificial one substituted.
When there exists any structural disease within the head, or a relic of
a former state of excitement, a serous inflammation may be reasonably
apprehended, and to avert it, the most rigid and undeviating attention
must be paid to regimen, whilst cupping and leeching must be employed,
and a seton fixed in the neck.
"For the object of the treatment, in these cases, is not to
remove, but to avert the inflammation, and which, from the
strong disposition to it, conferred by the organic disease, can
only be effected by avoiding, not merely the causes of
inflammation, but likewise, all those agents, which are
calculated, in any way, to increase the momentum of the
circulation." "Beyond those, the common precautions against
morbid irritations, little else can be done."
When the turgescent state of the brain, arises from a disturbance in the
digestive organs, it will be remedied, by means directed to this cause.
Our author locates the primary seat of this disturbance, in most cases,
in the liver; though he admits, it may occasionally be in the stomach
and intestines. He places great reliance for correcting and increasing
the secretion of bile, on small doses of calomel,--purging off the
contents of the intestines by aperient medicines; and recommends, at the
same time, the application of cups and leeches to the temples, as a
measure of precaution. He very properly lays considerable stress on the
necessity of combating this secondary affection of the head;
"For though the means applied, to correct the disorder in the
digestive organs, may be sufficient to remove the turgescent
state of the brain, which arose from it, yet, those means will
have little or no control over the excitement, which that
turgescent state has created; and still less can they avail in
subduing an excitement, that may even survive its remote cause,
and continue independently of it. By overlooking these facts,
much distrust and disappointment have arisen with many, who
confided in the opinion, delivered by some writers, of the
uniform prevalency of chylopoietic disturbance, as a cause of
this disease, and of the sufficiency of calomel to remove it."
When the inflammation exists, and is a sequel of some pre-existing
structural disease in the brain or membranes, all that can be reasonably
expected, is to _palliate_ it by the antiphlogistic plan; but when it is
idiopathic it may readily be cured, by the same remedies, graduated to
the age and strength of the patient and to the violence of the attack.
Dr. A. seems to rely principally on cups and leeches;--not excluding, in
some cases, bleeding from the arm. Blisters to the summit of the head
and afterwards a cold evaporating lotion to the temples, are also
recommended. As soon as, by these means, an impression is made on the
disease, mild diaphoretic medicines, assisted by the tepid bath, or the
pediluvium, maybe prescribed;--the bowels are to be kept open by small
doses of calomel, followed after two hours by a draught of some aperient
medicine,--the antiphlogistic regimen should be rigidly enforced, and
light and noise carefully excluded.
"Many practitioners give the mild preparations of mercury, and
particularly calomel, freely in this disease, under a notion of
its having some specific power in subduing it; but it never
should be so used, excepting in cases where the disease is
symptomatic of some functional disturbance in the liver and
other chylopoietic organs, where it is calculated, in
conjunction with the local bleeding, &c. to afford the most
important service."
With a view of pointing out some characteristic sign, by which to
distinguish those cases in which the affection of the bowels is primary
from those in which it is secondary, he remarks--
"The condition of the stools at the period when a child is
labouring under the disease, will afford to such persons but an
imperfect notion of its true nature; for the disturbance of the
brain will often create a disorder in the secretions, both of
the liver and the other chylopoietic organs, producing green
looking stools; and there is often a congestive state of the
brain for a short time preceding the full development of the
idiopathic excitement, which may, in like manner, by reacting
upon the liver, create a disorder there. In cases, however,
which are symptomatic of this cause, the chylopoietic
disturbance will be found to have existed several days or even
weeks; and the origin of the disorder, in like manner, may be
commonly traced to some irregularity of diet, or other obvious
causes, and frequently in infants to those which are connected
with premature weaning; and sometimes even the cerebral
disorder itself will have been only the last of a series of
effects in the system, to which such disturbance had given
rise."
Agreeably to Dr. A., it is not proper to discontinue those means,
immediately upon the occurrence of what appears to be symptoms of
effusion, since, frequently, these symptoms, as it respects the
effusion, will immediately manifest their fictitious character, and
disappear under a treatment no wise adapted to such a state, and with a
rapidity, too, which equally betrays their true nature. He notices,
though we believe not in its proper place, a modification of the disease
in which the effusion takes place in the cellular membrane of the
substance of the brain, and thinks this species more likely to be
recovered from than when the water accumulates in the ventricles. He
concludes this section by remarking, that
"Of the means to be employed to promote the absorption of the
water, under these or other circumstances of its accumulation
in the brain, little satisfactory can be said. The treatment
must be founded on the use of such means as shall avert the
risk of renewing an inflammation in the organ. To this end,
occasional blistering the head will be proper; the diet must be
spare, and the several secretions, particularly those of the
kidneys, must be cautiously promoted."
We next turn to the treatment of hydrothorax and ascites. As the
existence of hydrothorax in its early stage is difficult to ascertain,
and as what have been called premonitory symptoms are only those proper
to the mildest forms of the disease, and not of that condition of the
parts which gives rise to the effusion, the treatment is somewhat
difficult, and, in too many instances, our remedies are directed, not to
the disease itself, but to one of its effects. Faithful to his view of
the pathology of dropsy, Dr. A. remarks, that the plan of treatment to
be pursued at an early stage of symptomatic hydrothorax, must consist in
the use of those means which shall subdue the chronic excitement of the
serous membrane, as well as the chronic inflammation of the diseased
organ. To attain this end, the antiphlogistic and revulsive plans,
graduated to the age and strength of the patient, and to the violence of
the disease are recommended. In general the frequent application of
leeches are held by Dr. A. as preferable to venesection, unless the
patient be plethoric, and the disease arise from a local congestion
within the chest, which, according to him, is often a cause of serous
inflammation of the thoracic tissue, independently of any previous
disease. Dr. AYRE calls attention to the fact, that topical bleeding is
particularly adapted to correct that chronic inflammation of the serous
membranes, which causes an effusion from them, and which is neither the
result of any inflammatory excitement of the general system, nor of a
nature to produce it; and that when properly conducted, it has the
advantage of acting only slightly on the general system, and therefore
only slightly on the general strength, and very considerably on the
local disease. Together with leeches, blisters are to be used, and after
the chronic action existing in the serous membrane is subdued by these
means, a seton fixed in the integuments of the chest will be found of
great utility.
The same treatment will be found equally serviceable, not only to
correct the chronic excitement existing in the peritoneal membrane and
giving rise to ascites, but very commonly to cure or palliate the
visceral disease producing it. In respect to the very common practice
of resorting to mercury in this complaint, our author makes the
following judicious remarks.
"With too many practitioners, it is the practice to employ
mercury freely in every case of abdominal dropsy, under the
vague notion of there existing some mechanical obstruction in
the liver or other viscus, as a cause of it; and under the
equally vague notion, that mercury so employed will remove it.
The practice, however, to speak of it in the mildest terms, is
founded on erroneous views of the pathology of these diseases;
and employed, therefore, as it is by some, on all the occasions
in which they meet with them, must be frequently very
injurious. For, independently of the injury to be inflicted by
it, when given freely in some of the forms of liver disease,
there is an effect produced by it on the urine, when given to a
person in health, resembling that which arises from the
specific excitement of dropsy. Under a salivation, the urine
becomes charged with serum. Any condition of the system,
therefore, approaching even to a state of salivation, must be
injurious, by the tendency it must have to increase that morbid
state of the body, which is nearest allied to the hydropic one.
Hence the mercurial salivation has been numbered amongst the
remote causes of dropsy; and the resemblance between the
dropsical and mercurial excitement, thus established by the
common resemblance of the urine in these states, goes far to
prove this connexion; and it is not improbable, that the
mercurial inflammation, when considerable, may survive its
specific cause, and degenerate at length into the purely
hydropic state. When, however, mercury is given in minute
doses, so that these its specific morbid effects are not
produced, it is capable of becoming highly useful, as we shall
presently have occasion to notice."
In conjunction with bleeding and other means just noticed, drastic
purges have an important influence in subduing the disease; not merely
by removing the water, but likewise by contributing to subdue the
chronic excitement which occasions its effusion. This latter effect Dr.
A. very justly refers to the counteraction and irritation these
medicines excite on the mucous membrane of the bowels, by which the
excitement of the serous tissue or of the diseased viscus is removed. He
remarks that drastic purgatives are sometimes inadmissible in ascites,
when an affection of the liver or mesentery is its remote cause, and
there is a tendency to a spontaneous diarrhoea, which even the mildest
purgatives would increase. "In the case of the mesentery, such a mode of
treating dropsy would speedily destroy the patient." Dr. A. ought,
perhaps, to have explained the real cause of the danger attending the
practice, and not referred it merely to the tendency to diarrhoea,
which itself can only be an effect of a morbid condition of the bowels.
The fact is, that most cases of hepatitis, and all cases of mesenteric
disease, are attended, whether as cause or effect we care not, with
inflammation of the stomach or bowels, which purgatives can only tend to
aggravate. In general, the practice of administering drastic purgatives
is more serviceable in hydrothorax, and especially in anasarca, or in
_idiopathic_ serous inflammation of the peritoneum. Dr. A. prefers the
gamboge to all other medicines of the same class, and gives it to the
amount of four or five grains in a single dose, with the same quantity
of some aromatic powder, and triturated with a few crystals of the
supertartrate of potassa; or in urgent cases of hydrothorax, he
prescribes ten or twelve grains, divided into four doses, one of which
is to be given every three hours. When the strength admits of it, the
purgative may be given every four or five days.
Dr. A. next notices diuretics.
"The sensible operation of these medicines," he says, "as is
well known, is to promote the secretion of the kidneys. There
appears to me, however, to be farther effects produced by them
upon the system, or particular parts of the system, which is
not referrible to the mere evacuation of a certain quantity of
fluid from the body; and these effects, it is probable, consist
in promoting the natural discharges by this and, perhaps, the
other emunctories, whose partial suppression may either produce
this disease, or serve materially to continue it; and likewise
in occasioning a derivation of blood to the kidneys, and
therefore to a part distant from the morbid one; and that thus,
whilst they are contributing materially to the removal of the
fluid, they are serving like the purgative, an important end,
in assisting to subdue the cause of it. The medicines which I
am accustomed almost entirely to rely on in this disease, are
the powder of dried squill and digitalis, given in combination
in the form of pills, and in doses, which, from their
smallness, will probably excite no little surprise in the minds
of some of my readers. The dose of the squill is something less
than a grain, and of the digitalis only a sixth part of a
grain, given uninterruptedly every third or fourth hour."
To render these medicines more effectual, a third or half a grain of
calomel may be given nightly, and an infusion of dandelion, or some
other popular diuretic, may be taken _ad libitum_. Our author speaks in
terms of merited disapprobation of the practice pursued by some
physicians, of allowing their patients daily, potions of gin punch, with
the view of aiding the operation of the diuretic medicine, and
supporting their strength. He shows, that, although by these means the
water may be promptly evacuated, the disease is not cured, and the
effusion is soon renewed with redoubled violence and danger to the
patient.
In the idiopathic form of hydropic inflammation, attacking the serous
membranes of the chest and abdomen, and which, agreeably to our author,
may be strictly local, or consist in a general specific excitement of
the system, leading to a general watery effusion, the lancet is
particularly advantageous, and should be had recourse to. The pulse is
generally hard, the blood exhibits a buffy appearance, and the urine
coagulates when subjected to heat. Leeches, in pretty large numbers,
must also be used, as well as all the remedies already enumerated. But
as in these cases, which according to Dr. AYRE are more common among
females than males, and among the younger than those of middle and
advanced age, the disease is of a more acute nature, a greater reliance
is to be placed on an active antiphlogistic plan; and if this be
steadfastly persevered in, comparatively little difficulty will be
experienced in effecting a discharge of the water.