from my own experience, where it has not acted as a purge. Perhaps
my want of decision upon this subject has arisen only from my not
having persisted in the use of it for the same length of time which is
mentioned by Dr. Home.
3. There are different opinions concerning the efficacy of foxglove in
dropsies. From the cases related by Dr. Withering, it appears to have
done good; but from those related by Dr. Lettsom[41] it seems to have
done harm. I suspect the different accounts of those two gentlemen have
arisen from their having given it in different states of the system,
or perhaps from a difference in the quality of the plant from causes
mentioned in another place[42]. I am sorry to add further, that after
many trials of this medicine I have failed in most of the cases in which
I have given it. I have discharged the water in three instances by it,
but the disease returned, and my patients finally died. I can ascribe
only one complete cure to its use, which was in the year 1789, in a
young man in the Pennsylvania hospital, of five and thirty years of age,
of a robust habit, and plethoric pulse.
[41] Medical Memoirs, vol. II.
[42] Inquiry into the Causes and Cure of Pulmonary Consumption.
Where medicines have once been in use, and afterwards fall into
disrepute, as was the case with the foxglove, I suspect the cases in
which they were useful, to have been either few or doubtful, and that
the cases in which they had done harm, were so much more numerous and
unequivocal, as justly to banish them from the materia medica.
V. _Hard labour_, or exercise in such a degree as to produce fatigue,
have, in several instances, cured the dropsy. A dispensary patient,
in this city, was cured of this disease by sawing wood. And a patient
in an ascites under my care in the Pennsylvania hospital, had his
belly reduced seven inches in circumference in one day, by the labour
of carrying wood from the yard into the hospital. A second patient
belonging to the Philadelphia dispensary was cured by walking to
Lancaster, 66 miles from the city, in the middle of winter. The efficacy
of travelling in this disease, in cold weather, is taken notice of by
Dr. Monroe, who quotes a case from Dr. Holler, of a French merchant, who
was cured of a dropsy by a journey from Paris to England, in the winter
season. It would seem, that in these two cases, the _cold_ co-operated
as a sedative with the fatigue produced by labour or exercise, in
reducing the tone of the arterial system.
VI. _Low diet._ I have heard of a woman who was cured of a dropsy by
eating nothing but boiled beans for three weeks, and drinking nothing
but the water in which they had been boiled. Many other cases of the
good effects of low diet in dropsies are to be found in the records of
medicine.
VII. _Thirst._ This cruel remedy acts by debilitating the system in two
ways: 1st, by abstracting the stimulus of distention; and, 2dly, by
preventing a supply of fresh water to replace that which is discharged
by the ordinary emunctories of nature.
VIII. _Fasting._ An accidental circumstance, related by sir John
Hawkins, in the life of Dr. Johnson, first led me to observe the
good effects of fasting in the dropsy. If the fact alluded to stood
alone under the present head of this essay, it would be sufficient
to establish the existence of too much action, and the efficacy of
debilitating remedies in certain dropsies. I am the more disposed to lay
a good deal of stress upon this fact, as it was the clue which conducted
me out of the labyrinth of empirical practice, in which I had been
bewildered for many years, and finally led me to adopt the principles
and practice which I am now endeavouring to establish. The passage which
contains this interesting fact is as follows: "A few days after (says
sir John) he [meaning Dr. Johnson] sent for me, and informed me, that
he had discovered in himself the symptoms of a dropsy, and, indeed, his
very much increased bulk, and the swollen appearance of his legs, seemed
to indicate no less. It was on Thursday that I had this conversation
with him; in the course thereof he declared, that he intended to devote
the whole of the next day to _fasting_, humiliation, and such other
devotional exercises as became a man in his situation. On the Saturday
following I made him a visit, and, upon entering his room, I observed
in his countenance such a serenity as indicated, that some remarkable
crisis of his disease had produced a change in his feelings. He told me
that, pursuant to the resolution he had mentioned to me, he had spent
the preceding day in an abstraction from all worldly concerns; that to
prevent interruption he had in the morning ordered _Frank_ [his servant]
not to admit any one to him, and, the better to enforce the charge,
had added these awful words, _for your master is preparing himself to
die_. He then mentioned to me, that in the course of this exercise he
found himself relieved from the disease which had been growing upon him,
and was becoming very oppressive, viz. the _dropsy_, by the gradual
evacuation of water, to the amount of _twenty pints_, a like instance
whereof he had never before experienced." Sir John Hawkins ascribes this
immense discharge of water to the influence of Dr. Johnson's prayers;
but he neglects to take notice, that these prayers were answered, in
this instance, as they are in many others, in a perfect consistence with
the common and established laws of nature.
To satisfy myself that this discharge of water, in the case of Dr.
Johnson, was produced by the fasting only, I recommended it, soon after
I read the above account, to a gentlewoman whom I was then attending in
an ascites. I was delighted with the effects of it. Her urine, which for
some time before had not exceeded half a pint a-day, amounted to _two
quarts_ on the day she fasted. I repeated the same prescription once a
week for several weeks, and each time was informed of an increase of
urine, though it was considerably less in the last experiments than in
the first. Two patients in an ascites, to whom I prescribed the same
remedy, in the Pennsylvania hospital, the one in the winter of 1790,
and the other in the winter of 1792, exhibited proofs in the presence
of many of the students of the university, equally satisfactory of the
efficacy of fasting in suddenly increasing the quantity of urine.
IX. _Fear._ This passion is evidently of a debilitating nature, and,
therefore, it has frequently afforded an accidental aid in the cure of
dropsies, of too much action. I suspect, that the fear of death, which
was so distinguishing a part of the character of Dr. Johnson, added a
good deal to the efficacy of fasting, in procuring the immense discharge
of water before-mentioned. In support of the efficacy of fear simply
applied, in discharging water from the body in dropsies, I shall mention
the following facts.
In a letter which I received from Dr. John Pennington, dated Edinburgh,
August 3, 1790, I was favoured with the following communication. "Since
the conversation I had with you on the subject of the dropsy, I feel
more and more inclined to adopt your opinion. I can furnish you with
a fact which I learned from a Danish sailor, on my passage to this
country, which is much in favour of your doctrine. A sailor in an
ascites, fell off the end of the yard into the sea; the weather being
calm, he was taken up unhurt, but, to use the sailor's own words, who
told me the story, he was _frightened half to death_, and as soon as he
was taken out of the water, he discharged a gallon of urine or more.
A doctor on board ascribed this large evacuation to sea bathing, and
accordingly ordered the man to be dipped in the sea every morning, much
against his will, for, my informant adds, that he had not forgotten his
fall, and that in four weeks he was perfectly well. I think this fact
can only be explained on your principles. The sedative operation of
_fear_ was, no doubt, the cause of his cure."
There is an account of an ascites being cured by a fall from an
open chaise, recorded in the third volume of the Medical Memoirs, by
M. Lowdell. I have heard of a complete recovery from dropsy, having
suddenly followed a fall from a horse. In both these cases, the cures
were probably the effects of fear.
Dr. Hall, of York-town, in Pennsylvania, informed me, that he had been
called to visit a young woman of 19 years of age, who had taken all the
usual remedies for ascites without effect. He at once proposed to her
the operation of tapping. To this she objected, but so great was the
_fear_ of this operation, which the proposal of it suddenly excited in
her mind, that it brought on a plentiful discharge of urine, which in a
few days perfectly removed her disease.
On the 27th of August, 1790, I visited a gentlewoman in this city with
the late Dr. Jones, in an ascites. We told her for the first time,
that she could not be relieved without being tapped. She appeared to
be much terrified upon hearing our opinion, and said that she would
consider of it. I saw her two days afterwards, when she told me, with
a smile on her countenance, that she hoped she should get well without
tapping, for that she had discharged two quarts of water in the course
of the day after we had advised her to submit to that operation. For
many days before, she had not discharged more than two or three gills in
twenty-four hours. The operation, notwithstanding, was still indicated,
and she submitted to be tapped a few days afterwards.
I tapped the same gentlewoman a second time, in January, 1791. She was
much terrified while I was preparing for the operation, and fainted
immediately after the puncture was made. The second time that I visited
her after the operation was performed, she told me (without being
interrogated on that subject), that she had discharged a pint and a
half of urine, within twenty minutes after I left the room on the day I
tapped her. What made this discharge the more remarkable was, she had
not made more than a table spoonful of water in a day, for several days
before she was tapped.
I have seen similar discharges of urine in two other cases of tapping
which have come under my notice, but they resembled so nearly those
which have been mentioned, that it will be unnecessary to record them.
But the influence of fear upon the system, in the dropsy, extends far
beyond the effects which I have ascribed to it. Dr. Currie, of this
city, informed me that he called, some years ago, by appointment, to
tap a woman. He no sooner entered the room than he observed her, as he
thought, to faint away. He attempted to recover her, but to no purpose.
She died of a sudden paroxysm of fear.
It is a matter of surprise, that we should have remained so long
ignorant of the influence of fear upon the urinary organs in dropsies,
after having been so long familiar with the same effect of that passion
in the hysteria.
X. _A recumbent posture of the body._ It is most useful when the dropsy
is seated in the lower limbs. I have often seen, with great pleasure,
the happiest effects from this prescription in a few days.
XI. _Punctures._ These, when made in the legs and feet, often discharge
in eight and forty hours the water of the whole body. I have never
seen a mortification produced by them. As they are not followed by
inflammation, they should be preferred to blisters, which are sometimes
used for the same purpose.
I cannot dismiss the remedies which discharge water from the body
through the urinary passages, without taking notice, that they furnish
an additional argument in favour of blood-letting in dropsies, for they
act, not by discharging the stagnating water, but by creating such a
plentiful secretion in the kidneys from the serum of the circulating
blood, as to make room for the absorption and conveyance of the
stagnating water into the blood-vessels.
Now the same effect may be produced in all tonic or inflammatory
dropsies, with more certainty and safety, by means of blood-letting.
In recommending the antiphlogistic treatment of certain dropsies, I
must here confine myself to the dropsies of such climates as dispose to
diseases of great morbid action in the system. I am satisfied that it
will often be proper in the middle and eastern states of America; and
I have lately met with two observations, which show that it has been
used with success at Vienna, in Germany. Dr. Stoll tells us, that, in
the month of January, 1780, "Hydropic and asthmatic patients discovered
more or less marks of inflammatory diathesis, and that blood was drawn
from them with a sparing hand with advantage;" and in the month of
November, of the same year, he says, "The stronger diuretics injured
dropsical patients in this season; but an antiphlogistic drink, composed
of a quart of the decoction of grass, with two ounces of simple oxymel,
and nitre and cream of tartar, of each a drachm, did service[43]." It
is probable that the same difference should be observed between the
treatment of dropsies in warm and cold climates that is observed in the
treatment of fevers. The tonic action probably exists in the system in
both countries. In the former it resembles the tides which are suddenly
produced by a shower of rain, and as suddenly disappear; whereas, in the
latter, it may be compared to those tides which are produced by the flow
and gradual addition of water from numerous streams, and which continue
for days and weeks together to exhibit marks of violence in every part
of their course.
[43] Ratio Medendi Nosocomio Practico Vindobonensi, vol. iv. p. 56 and
99.
I come now to say a few words upon atonic dropsies, or such as are
accompanied with a feeble morbid action in the blood-vessels. This
morbid action is essential to the nature of dropsies, for we never
see them take place without it. This is obvious from the absence of
swellings after famine, marasmus, and in extreme old age, in each of
which there exists the lowest degree of debility, but no morbid action
in the blood-vessels. These atonic or typhus dropsies may easily be
distinguished from those which have been described, by occurring in
habits naturally weak; by being produced by the operation of chronic
causes; by a weak and quick pulse; and by little or no preternatural
heat or thirst.
The remedies for atonic dropsies are all such stimulating substances as
increase the action of the arterial system, or determine the fluids to
the urinary organs. These are,
I. _Bitter_ and _aromatic substances_ of all kinds, exhibited in
substance or in infusions of wine, spirit, beer, or water.
II. _Certain acrid vegetables_, such as scurvy-grass, horse-radish,
mustard, water-cresses, and garlic. I knew an old man who was perfectly
cured of an anasarca, by eating water-cresses, on bread and butter.
III. _Opium._ The efficacy of this medicine in dropsies has been
attested by Dr. Willis, and several other practical writers. It seems to
possess almost an exclusive power of acting alike upon the arterial, the
lymphatic, the glandular, and the nervous systems.
IV. _Metallic tonics_, such as chalybeate medicines of all kinds, and
the mild preparations of copper and mercury. I once cured an incipient
ascites and anasarca by large doses of the rust of iron; and I have
cured many dropsies by giving mercury in such quantities as to excite a
plentiful salivation. I have, it is true, often given it without effect,
probably from my former ignorance of the violent action of the arteries,
which so frequently occurs in dropsies, and in which cases mercury must
necessarily have done harm.
V. _Diuretics_, consisting of alkaline salts, nitre, and the oxymels
of squills and colchicum. It is difficult to determine how far these
medicines produce their salutary effects by acting directly upon the
kidneys. It is remarkable that these organs are seldom affected in
dropsies, and that their diseases are rarely followed by dropsical
effusions in any part of the body.
VI. _Generous diet_, consisting of animal food, rendered cordial by
spices; also sound old wine.
VII. _Diluting drinks_ taken in such large quantities as to excite the
action of the vessels by the stimulus of distention. This effect has
been produced, sir George Baker informs us, by means of large draughts
of simple water, and of cyder and water[44]. The influence of distention
in promoting absorption is evident in the urinary and gall bladders,
which frequently return their contents to the blood by the lymphatics,
when they are unable to discharge them through their usual emunctories.
Is it not probable that the distention produced by the large quantities
of liquids which we are directed to administer after giving the
foxglove, may have been the means of performing some of those cures of
dropsies, which have been ascribed to that remedy?
[44] The remark upon this fact by sir George, is worthy of notice, and
implies much more than was probably intended by it. "When common
means have failed, success has sometimes followed a method
_directly contrary_ to the established practice." Medical
Transactions, vol. II.
VIII. _Pressure._ Bandages bound tightly around the belly and limbs,
sometimes prevent the increase or return of dropsical swellings. The
influence of pressure upon the action of the lymphatics appears in the
absorption of bone which frequently follows the pressure of contiguous
tumours, also in the absorption of flesh which follows the long pressure
of certain parts of the body upon a sick bed.
IX. _Frictions_, either by means of a dry, or oiled hand, or with linen
or flannel impregnated with volatile and other stimulating substances.
I have found evident advantages from following the advice of Dr.
Cullen, by rubbing the lower extremities _upwards_, and that only in
the _morning_. I have been at a loss to account for the manner in which
sweet oil acts, when applied to dropsical swellings. If it act by what
is improperly called a sedative power upon the blood-vessels, it will
be more proper in tonic than atonic dropsies; but if it act by closing
the pores, and thereby preventing the absorption of moisture from the
air, it will be very proper in the state of dropsy which is now under
consideration. It is in this manner that Dr. Cullen supposes that sweet
oil, when applied to the body, cures that state of diabetes in which
nothing but insipid water is discharged from the bladder.
X. _Heat_, applied either separately or combined with moisture in
the form of warm or vapour baths, has been often used with success in
dropsies of too little action. Dampier, in his voyage round the world,
was cured of a dropsy by means of a copious sweat, excited by burying
himself in a bed of warm sand. Warm fomentations to the legs, rendered
moderately stimulating by the addition of saline or aromatic substances,
have often done service in the atonic dropsical swellings of the lower
extremities.
XI. The _cold bath_. I can say nothing in favour of the efficacy of this
remedy in dropsies, from my own experience. Its good effects seem to
depend wholly on its increasing the excitability of the system to common
stimuli, by the diminution of its excitement. If this be the case, I
would ask, whether _fear_ might not be employed for the same purpose,
and thus become as useful in atonic, as it was formerly proved to be in
tonic dropsies?
XII. _Wounds_, whether excited by cutting instruments or by fire,
provided they excite inflammation and action in the arteries, frequently
cure atonic dropsies. The good effects of inflammation and action in
these cases, appear in the cure of hydrocele by means of the needle, or
the caustic.
XIII. _Exercise._ This is probably as necessary in the atonic dropsy,
as it is in the consumption, and should never be omitted when a patient
is able to take it. The passive exercises of swinging, and riding in
a carriage, are most proper in the lowest stage of the disease; but
as soon as the patient's strength will admit of it, he should ride on
horseback. A journey should be preferred, in this disease, to short
excursions from home.
XIV. A _recumbent posture of the body_ should always be advised during
the intervals of exercise, when the swellings are seated in the lower
extremities.
XV. _Punctures in the legs and feet_ afford the same relief in general
dropsy, accompanied with a weak action in the blood-vessels, that has
been ascribed to them in dropsies of an opposite character.
In the application of each of the remedies which have been mentioned,
for the cure of both tonic and atonic dropsies, great care should be
taken to use them in such a manner, as to accommodate them to the
strength and excitability of the patient's system. The most powerful
remedies have often been rendered _hurtful_, by being given in too large
doses in the beginning, and _useless_, by being given in too small doses
in the subsequent stages of the disease.
I have avoided saying any thing of the usual operations for discharging
water from different parts of the body, as my design was to treat only
of the symptoms and cure of those dropsies which affect the whole
system. I shall only remark, that if tapping and punctures have been
more successful in the early, than in the late stage of these diseases,
it is probably because the sudden or gradual evacuation of water takes
down that excessive action in the arterial system, which is most common
in their early stage, and thereby favours the speedy restoration of
healthy action in the exhaling or lymphatic vessels.
Thus have I endeavoured to prove, that two different states of action
take place in dropsies, and have mentioned the remedies which are proper
for each of them under separate heads. But I suspect that dropsies are
often connected with a certain _intermediate_ or mixed action in the
arterial system, analogous to the typhoid action which takes place in
certain fevers. I am led to adopt this opinion, not only from having
observed mixed action to be so universal in most of the diseases of the
arterial and nervous system, but because I have so frequently observed
dropsical swellings to follow the scarlatina, and the puerperile fever,
two diseases which appear to derive their peculiar character from a
mixture of excessive and moderate _force_, combined with irregularity of
action in the arterial system. In dropsies of mixed action, where too
much force prevails in the action of some, and too little in the action
of other of the arterial fibres, the remedies must be debilitating or
stimulating, according to the greater or less predominance of tonic or
atonic diathesis in the arterial system.
I shall conclude this history of dropsies, and of the different and
opposite remedies which have cured them, by the following observations.
1. We learn, in the first place, from what has been said, the
impropriety and even danger of prescribing stimulating medicines
indiscriminately in every case of dropsy.