Chapter 12

"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.

When hydrothorax occurs after scarlatina, and is combined with anasarca, its course is generally rapid, and the cure difficult; partaking, as it often does, of the two-fold state of debility and excitement. When detected early, the lancet must be promptly used. Cups and leaches, followed by the warm bath, blisters, and cathartics, must also be resorted to.

"Diuretics, which are so beneficial in the less acute forms of dropsy, are commonly too inert and slow in this, unless given in doses to act immediately upon the vascular system, when the infusion of digitalis, as given by many practitioners in all the other states of the disease, may be resorted to; since the treatment here is not so much to remove the water, as to prevent, if possible, its farther effusion; for when a discharge suddenly takes place into the chest after scarlet fever, it will generally prove fatal, even though the quantity collected be inconsiderable, and only such as would occasion, if gradually effused, a moderate degree of inconvenience to the lungs."

In respect to tapping, our author remarks, that the circumstances calling for this operation are, where, from the very considerable accumulation of water, and the consequent distension it occasions, a permanent and morbid stimulus is given to the peritoneal membrane, by which its serous inflammation is perpetuated or increased; or where so much pain and irritation are produced, as to risk inducing a similar disease in the chest, and of bringing on likewise an ulcerative form of inflammation in the peritoneal lining of the abdomen.

"Whilst the objections to its employment consist in the danger which is incurred, where there is much visceral disease, of its causing a destructive form of inflammation in the peritoneum; and the probability of its occasioning, under the most favourable condition of the disease, a more rapid renewal of the serous accumulation."

Our limits not allowing us to enter on the treatment of ovarian dropsy, we proceed to offer a few remarks on the means recommended by Dr. A. for the cure of anasarca. As in the treatment of every other form of dropsy, it is necessary, in attempting the cure of anasarca, to advert to the nature and causes of the disease.

"If it be idiopathic, and unconnected with any dropsy of a circumscribed cavity, and the pulse at the same time be soft, and the urine free from serum, it may be treated solely with the view of procuring the absorption of the effused fluid, as in such cases, the watery discharge in all probability will have removed, in a considerable degree, the excitement which caused it."

It is in such cases that recoveries take place under almost any plan of treatment, and that bark and other tonics have been found beneficial. Their utility, however, in these cases is very limited, consisting only in aiding the removal of the effects of the disease, and keeping up the strength of the system, whilst the absorbents perform their function, and remove the fluid. Dr. A. recommends, in these cases, puncturing and bandages; but he very justly adds, that they must not be employed, whenever there remains any inflammation in the parts, as they would then tend to aggravate it.

"To oedematous swellings, in which the serous local inflammation, whether symptomatic or idiopathic, still subsists, I am accustomed to direct the application of leeches and cold evaporating lotions, observing not to commence the use of the latter, until twelve hours after the leeches have been used, that inflammation may not be produced in the wound." "When anasarca arises from a general excited state of the system, as denoted by the pulse, and by the serous quality of the urine, venesection becomes necessary, combined with the use of leeches, applied to the extremities, or to those parts of the body, in which the serous tissues are most affected, along with the active use of the general means already alluded to."

In anasarca, an error is sometimes committed, especially by young practitioners, of estimating the degree of danger, and the necessity for active treatment, by the single consideration of the extent of the oedematous swelling. This, however, should be guarded against, as the swelling may be very considerable, and the disease subsided, or of little consequence; whilst, in other instances, the reverse may be the case. In the first instance, where the disease is not seen early, the treatment must sometimes be limited to those means which promote the absorption of the water, and neither venesection nor leeches will be required. In such cases, the practitioner must be guided by the state of the pulse and urine; the presence or absence of vascular excitement; the history given of the case up to the period when visited, and particularly by the progress of the swelling.

"When the dropsy of the skin is considerable and long protracted, and symptomatic of some visceral disease, as it most commonly is in these cases, and is attended by a serous state of the urine, and a general failure of the strength, the cachetical state of the system may be considered as established, and the treatment is then beset with difficulties. For the general means, which are useful in the earlier states of the disease, and when the vital strength is entire, become injurious in this, by the tendency they have, aided by the effects of the visceral disease, to diminish farther the vigour of the system; whilst, at the same time, the treatment, which is suited to support the declining strength, can contribute nothing towards lessening the constitutional and local diseases, but will frequently increase the morbidly excited state of the circulation, which, analogous to what occurs in diabetes, will continue and increase under the most decided marks of general constitutional weakness. Pending the continuance of that inflammatory state of the system, in which the urine is charged with serum, the debility will be mainly derived from that drain of its nutrient parts, which is thus established in the body, assisted by the weakening effects of the organic disease. If blood be drawn, it will be found, in many of these cases, to exhibit the usual signs of inflammation; and the treatment of the tonic kind, when employed to support the strength, will be found to act unfavourably.

"The plan to be pursued must consist in the use of such means as shall assist the powers of digestion and assimilation; so that, by a highly nourishing but plain diet, the drain from the system may be somewhat counteracted; and, at the same time, the cause of the effusion is to be corrected by the use of local depletion and blistering, and by the temperate employment of those general means, which are useful in the less aggravated forms of the disease."

The diet of patients, in the symptomatic forms of dropsy, should be plain and unirritating; and in the idiopathic states, the antiphlogistic regimen should be rigidly enforced; particularly an abstinence from all fermented liquors, until the inflammatory period of the disease be removed. The clothing should be moderately warm, and selected of that kind, best suited to promote the insensible perspiration of the surface.