II. At the same time that we endeavour to remove or diminish the causes of cholera, we should not neglect to put the system of the child in such a condition, as may enable it most effectually to resist their operation. As cholera is a disease of irritation, originating generally in a debilitated state of the alimentary canal, I believe this end may be most easily attained, by preserving the natural tone of the digestive organs. For this purpose, all flatulent and indigestible food should be carefully avoided. During the first year, the mother's milk is, in general, the most appropriate nutriment. When the stomach of the infant is very delicate, the diet of the mother should be strictly regulated; and, in all cases, it would be adviseable for her to avoid articles of a flatulent nature. While the child is still at the breast, if a predisposition to cholera be suspected, I would recommend the occasional use of nutritious animal juices. The sucking of small pieces of salt meat, as ham or dried beef for example, will sometimes be found productive of advantage. After weaning, animal food should always enter into the diet of the child. Many parents, fearing to render their children gross and unhealthy, restrict them altogether to vegetable aliments; and thus, by weakening the powers of digestion, prepare the way for that very result which they are most anxious to avoid.
With the same view of giving tone to the stomach, aromatics should be used habitually during the summer, in those cases, in which there is strong reason to apprehend the occurrence of cholera. While they produce a cordial impression on the stomach, and invigorate generally the digestive powers, they are liable to none of those objections which may be urged against the employment of the narcotic stimulants. Indeed, nature herself seems to have pointed them out as prophylactics against the diseases of hot weather. Our most powerful and valuable spices are the products of warm countries. Cinnamon, ginger, pepper, the clove, the nutmeg, are to be found only in tropical climates. In this arrangement, we see the hand of a beneficent Creator, who has provided, that, by the same high temperature, which renders the equatorial regions so fruitful of cholera, and other disorders of the bowels, the growth of those plants should be promoted, which are best calculated to invigorate the alimentary canal, and to fortify it against the inroads of disease. Facts are not wanting to prove the efficacy of spices in preventing intestinal complaints. We are informed by DEWAR, in his treatise on the Diarrhoea and Dysentery, by which the British army in Egypt was attacked, that among the Mamalukes of that country, it was a universal practice, when they apprehended the approach of these disorders, to make use of cinnamon or ginger, with the almost uniform effect of averting them; and where the same practice was followed by the British soldiers, equal advantages were experienced. In the French army, so highly was the prophylactic power of the aromatics estimated, that every soldier was provided with a box of spices, which he was directed to use freely with his diet of fruit and melons.
When attending surgeon of the Alms-house hospital in this city, I had occasion frequently to prescribe in a syphilitic ward, which being situated directly under the roof, in a large garret, was liable, in the summer season, to become very much heated. As the patients were numerous, and the windows insufficient to admit of proper ventilation, the air became much contaminated; and the consequence was, that bowel complaints were very frequent and troublesome. I have often entered the ward on a summer's morning, and found almost every patient affected more or less with diarrhoea or cholera. It occurred to me, that the free use of some of the aromatics might be found serviceable in preventing the occurrence of these complaints. I accordingly directed, that every individual in the ward should drink a portion of strong ginger tea daily. I also ordered, that salt meat should be used twice in the week. By the steady pursuit of this plan, a very considerable change for the better was effected.
The employment of aromatics as prophylactics is not less beneficial in children than in adults. I would not, however, advise, that they should be given indiscriminately to all children, during the summer. It is only to those cases, in which a predisposition to cholera infantum exists, that I consider them peculiarly applicable; and here I believe they are capable of producing much good.
Before dismissing the subject of the paper, I will simply remark, in addition to what has been already said, that the occasional use of the cold bath, by the vigour it imparts to the system generally, and through it to the digestive organs, will often be found an excellent preservative against the summer complaint of children.
In this short account of the preventive treatment of cholera infantum, I have been less anxious to give a dissertation, embracing all that might be said on the subject, than to communicate those particular measures, which, according to my own experience, I have found most effectual. I will conclude the paper by the relation of a case, in which a strong predisposition to the disease was successfully counteracted. It will be proper, however, to premise, that the treatment of this case is by no means held out as an example to be generally followed with every infant, which may possibly become the subject of cholera. It is applicable in all its details only to those, in which, as in the present instance, there is every reason to apprehend, that the only alternative is between almost certain death, and the most careful prophylactic treatment.
CASE.—A gentleman of this city, whose wife had arrived at a period of life, when she could not expect to be the mother of many more children, consulted me respecting an infant daughter, their only surviving child. I was informed, that they had already lost eight children, all of whom, with one exception, had died of cholera. It may readily be imagined, that every feeling of parental anxiety was awakened for their babe; and that no degree of attention on their part was considered too great, which might contribute to its preservation. It was placed under my care, not to be cured, but that I might, if possible, devise some plan of management which would avert the disease they had so much reason to apprehend. I felt the responsibility of the trust, and endeavoured to find it to the best of my ability. Every opportunity which I could desire was afforded me; for the infant, from its birth was submitted to my direction; and both the disposition and ability existed, on the part of the parents, to carry implicitly into effect every measure which I might recommend.
As the mother was unable to furnish sufficient nourishment, the first step was to provide a healthy wet-nurse, who might be willing to submit to the necessary regulations in respect to diet.
I believed the children of these parents to possess a constitutional weakness in the alimentary canal; and, on inquiry, I was told, that they had been kept upon a vapid diet, under the impression that it would contribute to their health. In the present case, therefore, the principal object was to communicate strength to the stomach and bowels. With this view, the child was accustomed, from an early period of infancy, to a generous diet. When very young, portions of ginger tea were given to it daily; and as soon as it was old enough to suck the juice of meat, it was encouraged to do so. The nurse, during the warm season, was kept upon a nutritious diet, consisting principally of animal food, with the occasional use of ginger tea; and every description of recent fruit and fresh vegetable food was forbidden. Under this management, the first summer was passed without any symptom of the disease; but I looked forward to the second with no little anxiety, when the child would have to struggle with the irritation arising from dentition.
The same plan was continued during the second summer, and still more rigidly enforced. The child was now old enough to take animal food freely in addition to the breast. It was allowed as much salt fish, ham, beef-steak, essence of beef, &c. as it desired; ginger tea was given daily; a little sound old port wine was occasionally directed; and both the child and the nurse were restricted from every species of flatulent and indigestible aliment. So anxious, indeed, were the parents, and so careful to carry my directions into full effect, that they allowed no forbidden article of food to enter the house, and denied themselves their wonted comforts, lest possibly their child might be injured.
The gums were carefully attended to, and lanced whenever the operation appeared to be requisite. All those measures, which I have before mentioned as serviceable in obviating the effects of great heat, so far as they were applicable to the case, were adopted. The second summer was spent wholly in the country.
Very little medicine was required, and none was administered, except of the mildest description. Frequently, when summoned to visit the babe, I have found the mother trembling with fear, and anxious that something might be done; and often, under such circumstances, have I begged it off from a dose of physic, having determined to avoid a resort to every thing of the kind, unless real necessity should demand it.
By a strict adherence to the plan above detailed, the period of dentition was passed in safety; and it is with heartfelt pleasure I can say, that no symptom of cholera afterwards made its appearance.
ARTICLE VI.—Case of Neuralgia cured by Acupuncturation. Communicated by J. HUNTER EWING, M. D.
The attention of the medical public having been of late much excited on the subject of acupuncturation, I am induced to communicate the following case.
For eighteen months, Miss —— had been afflicted, at intervals, with a severely painful affection of the nerves of the right cheek, immediately below the orbit of the eye, and extending to the angle of the lower jaw. On the 14th of January 1826, she was attacked more violently than usual, and the remedies, which had previously afforded some relief, now failed. Stimulating cataplasms, warm embrocations, laudanum, internally and externally, heat applied externally to the cheek by means of very hot flannels, produced not the slightest mitigation of the pain; and she continued to suffer excessively until the afternoon of the 15th; when acupuncturation being proposed, she consented to the operation with this remark,—"any thing to relieve me from this agony."
The needles were immediately procured, and three inserted about an inch from each other. Two in a line parallel with the inferior edge of the orbit of the eye, and half an inch below it; and a third below, and equidistant from the others. The first two were introduced to the depth of three-fourths of an inch; the last, a full inch. They were inserted very gradually and with a rotary motion.
The second needle was scarcely introduced, before the patient exclaimed, "the pain has entirely left me." When the third was introduced, she experienced a stiffness in the muscles of the cheek, and a creeping sensation, as if a spider's web had been drawn across the face; but no painful sensation whatever.
Such was the exhausted state of her system from the excessive pain she had suffered, that when thus relieved, she requested a pillow to rest her head on, and fell into a gentle slumber.
About two hours after the insertion of the needles, I again visited my patient, and found her still perfectly free from pain, and seated at a table reading. She thanked me for the relief I had been the means of affording her, and requested me not to withdraw the needles, lest the pain might return. Upon being apprised of the risk that might attend their being allowed to remain, she observed, that she would rather have a servant to watch her whilst she slept. The propriety of their removal being further urged, she at last consented. There was no return of pain.
The next morning, the patient remarked, that the stiffness of the cheek, and a numbness of the whole right side, continued through the night; and though she did not sleep very soundly, she was free from pain and rested well.
By the third day, the stiffness and numbness had passed away, and there was no return of pain. Several weeks have now passed, and she has had no relapse; although often since exposed to causes, which, heretofore, had always excited violent attacks. Previous to the operation, she seldom passed as many days without severe suffering.
Although I have performed this operation many times, and been present when others have performed it, I have never seen a case, in which its efficacy was so decided, or in which the relief afforded was more unquestionably attributable to the action of the needles.
ARTICLE VII.—Researches into the Nature and Treatment of Dropsy in the Brain, Chest, Abdomen, Ovarium, and Skin, in which a more correct and consistent Pathology of these Diseases is attempted to be established, and a new and more successful method of treating them, recommended and explained. By JOSEPH AYRE, M. D. &. London, 1825.
We have read the present work with the liveliest pleasure, and we dare hope with considerable benefit, and hasten to lay a review of its contents before our readers. Dr. AYRE is already advantageously known in this country, where his Essay on Marasmus has had an extensive circulation; but we are disposed to think, that, however he might be esteemed for the talent he displayed in his former composition, he is entitled to much more credit for his able researches into the nature and treatment of dropsy. We confess that we enter upon our editorial duties on the present occasion, with the two-fold intention of offering to our readers what we regard, on the whole, as a very correct view of the pathology of dropsy, and of showing to some of our medical friends, who shudder at the mere mention of what they denominate hunch theories, that the English physicians, or at least some of the most intelligent among them, so far from considering these theories as dangerous and unphilosophical, are beginning to entertain similar views with their Gallic brethren, in respect to the inflammatory nature of many diseases too long regarded as resulting from a state of debility, and classed by nosologists among the Cachexiae.
By most writers upon the subject, dropsy has too long been considered as a disease,—constituted into a separate class, and divided into many species. Dr. AYRE entertains, however, a very different and, we believe, a much more correct view of the pathology of this complaint; regarding it as only one in a series of effects of a disease, and not always the last of that series. He remarks, that the true disease is to be sought for in that particular condition of the solids by which the effusion is produced; and that to appreciate justly the nature and treatment of dropsy, it is necessary to understand the nature of that condition, which constitutes the disease, and of which the serous and watery effusion is merely the result.
Of all the hypotheses that have been advanced to account for the nature of the morbid state, which gives rise to general and local dropsy, there are only three which our author regards as entitled to our notice. According to these, all dropsical accumulations arise either, 1st, From a want of tone or energy in the absorbent vessels, giving rise to a deficient absorption. 2nd, From an increased exhalation of the natural fluid, through a similar want of tone in the exhalents; and 3d, From a mechanical obstruction to the free return of blood by the veins, produced by tumours of various kinds, &c., by which a greater portion of it is forced into the exhalents, and a greater effusion of their proper fluids thereby occasioned. With these hypotheses, however, Dr. AYRE is not satisfied, and he endeavours, in the following manner, to show their insufficiency.
"1st. The opinion of a want of tone in the absorbents, as a cause of dropsy, is contradicted by the fact, that in those cases, in which it is assumed to prevail, it is found, that the adipose matter, or fat of the body, is removed by the absorbents; or, in other words, that emaciation takes place to as great an extent, and as rapidly in this, as in other diseases; and emaciation can only be effected by means of absorption. Besides, in these cases of dropsy, mercury, when rubbed upon the surface, or received internally, is absorbed as readily, and affects the system as early as under other states of the body. There is also no accumulation of the fluids in the joints, or in the bursae mucosae in these cases, which, nevertheless would happen, if there was a general debility of the absorbent system; and ecchymoses or livid spots, though easily induced in anasarcous limbs, are likewise easily removed from them by the absorbents.
"2nd. The opinion of a want of tone or energy in the exhalants involves in it one of the following conditions: namely, either, 1st, that the fluid of dropsy may escape mechanically from them, and that the fluid thus mechanically separated may be identified in its sensible and chemical qualities with another fluid which is confessedly secreted; or 2nd, that if the fluid of dropsy be secreted, then that an increase in the quantity of a secretion may continue an indefinite period, under a decrease in the energy of its secreting vessels; conclusions to which experience and analogy are alike opposed."
In answer to the third hypothesis, Dr. A. remarks, that such an obstruction as contemplated, has never been shown to exist.
"In the case of the liver, which is commonly considered, when in a scirrhous or enlarged state, to be the seat of these mechanical obstructions, and thus, to be the cause of abdominal dropsy, we have no satisfactory instance yet shown to us, of any such precise condition of that organ. There are, indeed, numerous instances of abdominal dropsies, in those labouring under a scirrhous or enlarged state of the liver; but there are also, numerous examples of such states of the liver, as well as of the spleen and other organs, without any such effusion; and in many cases, when such effusion has taken place, it has been carried off by the natural passages or by tapping, without any return of the dropsy; and yet, without any visible change in the structural condition of the liver."
Dr. A. further remarks, that if the cause were mechanical and existed in the liver, the effect should be constant; which, however, is not the case. Besides, were this mechanical cause necessary, how could we account for the appearance of abdominal dropsy, where there is no disease of the liver, or in other cavities, where no mechanical cause is asserted to be present, and where the remedies by which the cure is effected, have no relation to such causes? Again, if the discharge depended upon a mechanical cause, the water should in every case be of a uniform fluidity, and the progress of its accumulation likewise uniform; so that the operation of tapping should have no tendency to induce a more rapid refilling of the cavity. Yet, the contrary of all this is a subject of daily observation. In addition to this, Dr. A. calls the attention to the fact, that in experiments, in which obstruction has been artificially made, by tying the vena cava for example, the experimenter has committed an error, in reasoning from the lower animal to man—assuming, that as ascites had arisen in dogs, it would in like manner have occurred in human subjects.
"But there was an effect, here overlooked, which was to be expected to take place in the abdomen of the dog, from the injury done to the surrounding parts by the operation itself, and which would be quite independent of any effect arising out of the experiment. In the human subject, the effect would be the highest form of inflammation, by which coagulable lymph or pus would be poured upon the surface of the peritoneum. There would, therefore, be inflammation excited in the abdomen of the dog; but as the lower animals are less easily acted on than man, the inflammation would in this case be in a lower degree. But every degree of inflammation has its particular product. The highest occasions a discharge of pus, whilst the lowest, when seated in a serous membrane, is a larger portion of its proper serous fluid. This, therefore, might be the product of the inflammation, which was produced incidentally by the experiment in the abdomen of the dog; and it would be just as reasonable to regard the coagulable lymph in the human subject, which would result from such an experiment, as an effect of the mechanical obstruction, as to consider the fluid effusion in the dog to be so."
In respect to those instances of diseases of the liver, connected with ascites, in which, in addition to its other morbid states, a partial occlusion of the vena portae, by the effusion of coagulable lymph into it, is said to have existed, our author remarks, that they are very few in number, occurring, perhaps, in one out of several hundred cases of ascites with hepatic disease; and that we are justified, from analogy, to assume, that any obstruction given to the circulation by diseased vessels, would be quickly relieved by the enlargement of the anastomosing branches, and that no effusion of water into the abdomen would result from it. After referring to some cases, related by the late Mr. WILSON, in which the vena cava was completely obliterated, and no effusion took place; and some cases of morbid condition of the heart of an analogous kind, by which the course of the circulation became greatly obstructed, and yet, without being followed by effusion; our author concludes, that from these facts and others, to be presently noticed, it appears evident,
"That the dropsical effusion, in whatever part it may be seated, does not arise from any want of tone in the exhalant or absorbent system, or from a mechanical obstruction in the liver or other viscus; but, that it proceeds from a morbid action in the cellular or serous tissues, and that this action, as we shall now proceed to show, is allied in its nature to inflammation."
In support of this opinion, Dr. AYRE remarks, that all the phenomena belonging to cases of watery effusion, met with under one or other of the forms of inflammation, are common to those of dropsy. Thus the fluid, discharged under the cuticle in erysipelas or in inflammation induced by heat or a blister, or in cases of pemphigus, is a secretion, and resembles in all respects the fluid found in dropsy. In some cases of acknowledged inflammation, the fluid effused is found to vary greatly in its degree of tenuity, so as to be sometimes of quite a viscid nature. The same circumstance is met with in dropsy; the fluid of which varies sometimes in different forms of the disease, and at different periods in the same patient. With regard to the absence of pain, in ordinary cases of local or general dropsy, which, in the minds of many physicians, might seem to militate against this view of the subject,—since pain accompanies the inflammation of a blister, Dr. A. very justly says, that the difference is referrible to a different degree of sensibility of the parts affected; that, moreover, in pemphigus there is no pain, and that chronic inflammation of the serous membranes is little painful.
That the morbid action producing the effusion is only a modification of inflammation, our author thinks may be further shown by the fact that it obeys the same laws—being translated occasionally, like it, from one part of the body to another. On this subject, Dr. AYRE makes the very pertinent remark, that in these cases, the fluid alone has been thought to be translated; but that the metastasis, is without doubt, exclusively of the action which produces the serous discharge. Analogous also to what occurs in inflammation, especially of the erysipelatous kind, the action occasioning the effusion, as seen in anasarca, commences at a given point, and gradually extends from thence in a continuous course. It ought also to be noticed, that the results of common inflammation vary according to the intensity of the cause; the lowest degree of it, occasioning an increase in the quantity of the proper fluids of the part,—a higher degree, yielding for its product coagulable lymph, and a still higher one producing pus. All these several products of common inflammation, are more or less remedial of their cause; or in other words, are the immediate means of the cessation or abatement of the inflammation which produces them. This same power is likewise a property, though in a much less degree, of the hydropic effusion, when the inflammation which produces it, is idiopathic; or in other words, not created by a visceral or other disease, or some particular excitement of the general system, as is seen in cases of anasarca.
"And here," continues our author, "it may be proper to remark upon a common error, committed by those, who, mistaking the nature of the action which produces the serous effusion, look in the post mortem examination, for some of the common signs of an inflammation having existed; and who conclude, upon not finding such, that the water was derived from some mechanical or other cause foreign to the true one. But in the higher forms of abdominal inflammation, the products are pus or lymph, and these are found upon the surface of the peritoneum, with sometimes a thickening and discoloration or ulceration of its substance; whilst in the lowest form of that increased action to which the serous membranes are subject, the only product is the serous fluid, and there can be, therefore, no visible alteration produced by it in the structure of the serous tissue."
"By the hydropic or serous inflammation, obeying the same laws which govern the other degrees of common inflammation, it follows, that upon a higher excitement being superinduced upon it, the serous effusion should cease. This, therefore, is found to happen in every case, where such higher excitement is brought on. This increased inflammation is sometimes occasioned by design or accident, and at other times, it occurs in the natural and progressive course of some disease, formed within the cavity, which is the seat of the dropsical effusion."
This is exemplified in the effects of the operation for the radical cure of hydrocele; or in the operation of tapping in some cases of ovarian dropsy; or even in some instances, of ascites from chronic inflammation of the liver, spleen, mesentery, &c. In all these cases, the serous membrane, which directly or indirectly was affected to a sufficient degree to occasion a serous effusion, takes on, from the extension of a visceral disease, or from some other cause, a higher degree of inflammation—lymph is thrown out, and the cavity becomes obliterated.
"Now from these, and similar examples, which have fallen under my observations, I think it may be assumed, that ascites, when proceeding from some visceral disease, (and the principle applies to hydropic effusions from the pressure of disease in other cavities,) does so by the gradual extension of the chronic inflammation of the internal cellular or serous tissues of the diseased organ, to its outer external coverings; and that, commencing here as from a point, the serous or hydropic inflammation is progressively propagated through the whole of the serous membrane of the cavity. By the disease within the cellular tissue of the diseased viscous increasing, a corresponding increase, in these cases, will ensue of the disease on the surface of the membrane investing it; until at length a susceptibility to take on a higher action is induced, which only requires any slight occasional cause to establish. Under this condition of an increased excitement in the peritoneal or other serous membrane, coagulable lymph is discharged into its cellular tissue, and a thickening of it takes place; until at length the operation of paracentesis, which in the early stage of the disease was attended with only inconsiderable inconvenience, becomes an adequate cause of a still higher inflammation, which terminates perhaps in suppuration; and, in the post mortem examination the serous fluid is found so mixed with coagulable lymph, and purulent matter, as to give a whey or milk-like appearance to the mass. The quantity of serous fluid, in these cases, is generally small, when compared with what was accumulated in the intervals of former tappings; for the vascular excitement which occasions the discharge of coagulable lymph, is destructive of that which pours out the serous fluid."
Dr. A. remarks, that, besides the particular facts deduced from observations on dropsy as a local disease, and which prove its relation to diseases of local excitement, there is a further support to be given to these views by various proofs that are afforded from observations upon the urine, of serous inflammation producing local dropsy, being frequently connected with one of a general kind. "So that the inflammatory state of the system becomes sometimes a cause of the effusion into a cavity, and at other times an effect of this state." After giving full credit to Drs. WELLS and BLACKALL for their researches into the state of the urine in dropsy, our author remarks, that there are certain conclusions deducible, which appear not to have been contemplated by those gentlemen, but which are strictly accordant with the pathological views he has endeavoured to establish in the present work.
"According to these facts, it appears, that when the disease of dropsy is under a sub-acute form, and of the anasarcous kind, it is usually idiopathic, and, often originating from cold; and in this state, as well as in the symptomatic form, though in a less degree, the urine is found to contain a portion of serum. It is nearly peculiar to this disease, and denotes, according to the quantity of it contained in the urine, the amount of that excitement in the cellular tissue, and of the general vascular system, which may be termed serous inflammation: for it is met with most considerably in those forms of the disease, in which these particular states of the body are most apparent."
Serum is therefore found in greater abundance, when anasarca precedes the local dropsy, which, in Dr. A.'s opinion, denotes the operation of a general cause. This is found to be the case especially in anasarca after scarlet fever. In cases of anasarca, the skin, kidneys, and bowels are very defective in their operation. Serum is also found, though in a smaller quantity, in those cases in which the anasarca has followed the local dropsy; for the disease of the viscus, which is the cause of the inflammation in the serous membrane of the cavity, may produce an adequate degree of the vascular excitement which gives rise to a discharge in the cellular tissue. Our author sums up his observations on this subject, by remarking, that there appear to be four distinct conditions of the system by which the occurrence of serum in the urine is regulated.
"1. It is in the greatest quantity, where along with a copious and continued effusion, there is a nearly corresponding quickness in the absorption of the serous fluid, and which will occur most commonly when the general excitement precedes, and is cause of the local one.
"2. It is consequently, caeteris paribus, in a less quantity where the general hydropic excitement of the system succeeds, and is dependent on the local one.
"3. It is absent, or found only in a minute proportion, in all those cases where the local increased excitement in the serous membrane is only partially extended to the rest of the system, and where the absorption from the part is inconsiderable; as particularly happens in the encysted kinds, or,
"4. Where the effusion of the serous fluid has proved remedial of the inflammation producing it; in which case the disease, as it respects the presence of water in a part, may visibly resemble another example, and yet be essentially different from it, by the serous inflammation, which produced it in both, having ceased, on its occurrence, in one of them."
Dr. A. discovers a further evidence of the relation which dropsy bears to diseases of local excitement, in the effects it produces on the general system. Thus, during the continued effusion of serum in anasarca, there is sometimes a large quantity absorbed and carried out of the body; by which a regular draught is made upon the nutrient principles of the blood, which must naturally create effects like those arising from the continued discharge of pus from a suppurating surface. In both cases the local disease, when extensive and of long duration, will necessarily occasion an exhaustion of the vital powers, by which that condition of the system termed cachexy will be induced.
"The exhausted or cachectical state, therefore, of the system, which has been so variously accounted for, and so frequently assigned as a principal cause of both local and general dropsy, is a direct consequence of the agency of some power diminishing the vital strength at its source; and in the case of a chronic and long continued serous inflammation, it will proceed from the daily abduction from the circulation of a portion of its vital fluid: and whether it be pus or serum that is drawn from the body; or whether it be from any permanent failure in the supplies of nutriment to it, the effect will be the same, as if a certain quantity of blood was daily abstracted from the system."
Dr. A. continues to remark that, under these circumstances, a suppurating surface will readily become gangrenous, from any cause temporarily exciting it, and that, in like manner, a higher inflammation may sometimes supervene upon an oedematous limb, as in the former case, and terminate in gangrene.
"Hence, therefore, the tendency of dropsical parts to fall into gangrene, and which has been urged, as an argument, in proof of debility being the cause of the serous effusion, is only what is common to other forms of local inflammation, under a similar condition of the body."
From the view he has adopted of the nature of dropsy, Dr. AYRE thinks 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.
In the second and fifth volumes of the Archives Generales de Medecine, 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.
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."