Chapter 11

"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.

In the second and fifth volumes of the _Archives Générales de Médecine_, 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;