Footnotes:[17]Vol. I. p.199.[18]Sir George Baker relates, in the second volume of the Medical Transactions, that Dr. Blanchard had informed him, that he had seen the consumption brought on ten persons out of ninety, by excessive purging used to prepare the body for the small-pox. I have seen a case of consumption in a youth of 17, from the spitting produced by the intemperate use of segars.[19]Dr. Lind says, that out of 360 patients whom he attended between July 1st, 1758, and July 1st, 1760, in consumptions, the disease was brought onone fourthof them by falls, bruises, and strains, received a year or two before the disease made its appearance.[20]Treatise of the Nature and Cure of Consumptions. Exercitation X.[21]See Med. Com. Vol. II.[22]Clinical and Anatomical Observations, p. 26, 27. See also Morgagni, letter xxii. 21.[23]Pages7,8.[24]The three last-mentioned symptoms are taken notice of by Dr. Bennet, in his Treatise upon the Nature and Cure of the Consumption, asprecursorsof the disease. Dr. Boerhaave used to tell his pupils that they had never deceived him.[25]I have seen thehoarsenessin one case the first symptom of approaching consumption. In this symptom it preserves the analogy of pneumony, which often comes on with a hoarseness, and sometimes with paraphonia.[26]Observations on Scrophulous Affections.[27]Prunus Virginiana.[28]An Account of the Effects of Common Salt in the Cure of Hæmoptysis.[29]Vol. I. p.204.[30]Medical Repository of New-York. Vol. V.[31]Inquiry into the Diseases and Remedies of the Indians of North-America; and a comparative view of their diseases and remedies with those of civilized nations. Vol. I.[32]Thoughts on the Pulmonary Consumption. Vol. I.[33]The bad effects ofinconstantexercise have been taken notice of in the gout. Dr. Sydenham says, when it is used only by fits and starts in this disease, it does harm.[34]Medicina Gymnastica, p. 116.
Footnotes:
[17]Vol. I. p.199.
[17]Vol. I. p.199.
[18]Sir George Baker relates, in the second volume of the Medical Transactions, that Dr. Blanchard had informed him, that he had seen the consumption brought on ten persons out of ninety, by excessive purging used to prepare the body for the small-pox. I have seen a case of consumption in a youth of 17, from the spitting produced by the intemperate use of segars.
[18]Sir George Baker relates, in the second volume of the Medical Transactions, that Dr. Blanchard had informed him, that he had seen the consumption brought on ten persons out of ninety, by excessive purging used to prepare the body for the small-pox. I have seen a case of consumption in a youth of 17, from the spitting produced by the intemperate use of segars.
[19]Dr. Lind says, that out of 360 patients whom he attended between July 1st, 1758, and July 1st, 1760, in consumptions, the disease was brought onone fourthof them by falls, bruises, and strains, received a year or two before the disease made its appearance.
[19]Dr. Lind says, that out of 360 patients whom he attended between July 1st, 1758, and July 1st, 1760, in consumptions, the disease was brought onone fourthof them by falls, bruises, and strains, received a year or two before the disease made its appearance.
[20]Treatise of the Nature and Cure of Consumptions. Exercitation X.
[20]Treatise of the Nature and Cure of Consumptions. Exercitation X.
[21]See Med. Com. Vol. II.
[21]See Med. Com. Vol. II.
[22]Clinical and Anatomical Observations, p. 26, 27. See also Morgagni, letter xxii. 21.
[22]Clinical and Anatomical Observations, p. 26, 27. See also Morgagni, letter xxii. 21.
[23]Pages7,8.
[23]Pages7,8.
[24]The three last-mentioned symptoms are taken notice of by Dr. Bennet, in his Treatise upon the Nature and Cure of the Consumption, asprecursorsof the disease. Dr. Boerhaave used to tell his pupils that they had never deceived him.
[24]The three last-mentioned symptoms are taken notice of by Dr. Bennet, in his Treatise upon the Nature and Cure of the Consumption, asprecursorsof the disease. Dr. Boerhaave used to tell his pupils that they had never deceived him.
[25]I have seen thehoarsenessin one case the first symptom of approaching consumption. In this symptom it preserves the analogy of pneumony, which often comes on with a hoarseness, and sometimes with paraphonia.
[25]I have seen thehoarsenessin one case the first symptom of approaching consumption. In this symptom it preserves the analogy of pneumony, which often comes on with a hoarseness, and sometimes with paraphonia.
[26]Observations on Scrophulous Affections.
[26]Observations on Scrophulous Affections.
[27]Prunus Virginiana.
[27]Prunus Virginiana.
[28]An Account of the Effects of Common Salt in the Cure of Hæmoptysis.
[28]An Account of the Effects of Common Salt in the Cure of Hæmoptysis.
[29]Vol. I. p.204.
[29]Vol. I. p.204.
[30]Medical Repository of New-York. Vol. V.
[30]Medical Repository of New-York. Vol. V.
[31]Inquiry into the Diseases and Remedies of the Indians of North-America; and a comparative view of their diseases and remedies with those of civilized nations. Vol. I.
[31]Inquiry into the Diseases and Remedies of the Indians of North-America; and a comparative view of their diseases and remedies with those of civilized nations. Vol. I.
[32]Thoughts on the Pulmonary Consumption. Vol. I.
[32]Thoughts on the Pulmonary Consumption. Vol. I.
[33]The bad effects ofinconstantexercise have been taken notice of in the gout. Dr. Sydenham says, when it is used only by fits and starts in this disease, it does harm.
[33]The bad effects ofinconstantexercise have been taken notice of in the gout. Dr. Sydenham says, when it is used only by fits and starts in this disease, it does harm.
[34]Medicina Gymnastica, p. 116.
[34]Medicina Gymnastica, p. 116.
Whether we admit the exhaling and absorbing vessels to be affected in general dropsies by preternatural debility, palsy, or rupture, or by a retrograde motion of their fluids, it is certain that their exhaling and absorbing power is materially affected by too much, or too little action in the arterial system. That too little action in the arteries should favour dropsical effusions, has been long observed; but it has been less obvious, that the same effusions are sometimes promoted, and their absorption prevented, by too much action in these vessels. That this fact should have escaped our notice is the more remarkable, considering how long we have been accustomed to seeing serous swellings in the joints in the acute rheumatism, and copious, but partial effusions of water in theform of sweat, in every species of inflammatory fever.
It is nothing new that the healthy action of one part, should depend upon the healthy action of another part of the system. We see it in many of the diseases of the nerves and brain. The tetanus is cured by exciting a tone in the arterial system; madness is cured by lessening the action of the arteries by copious blood-letting; and epilepsy and hysteria are often mitigated by the moderate use of the same remedy.
By too much action in the arterial system, I mean a certain morbid excitement in the arteries, accompanied by preternatural force, which is obvious to the sense of touch. It differs from the morbid excitement of the arteries, which takes place in common inflammatory fevers, in being attended by less febrile heat, and with little or no pain in the head or limbs. The thirst is nearly the same in this state of dropsy, as in inflammatory fevers. I include here those dropsies only in which the whole system is affected by what is called a hydropic diathesis.
That debility should, under certain circumstances, dispose to excessive action, and that excessiveaction should occur in one part of the body, at the same time that debility prevailed in every other, are abundantly evident from the history and phenomena of many diseases. Inflammatory fever, active hæmorrhages, tonic gout, asthma, apoplexy, and palsy, however much they are accompanied by excessive action in the arterial system, are always preceded by original debility, and are always accompanied by obvious debility in every other part of the system.
But it has been less observed by physicians that an undue force or excess of action occurs in the arterial system in certain dropsies, and that the same theory which explains the union of predisposing and nearly general debility, with a partial excitement and preternatural action in the arterial system, in the diseases before-mentioned, will explain the symptoms and cure of certain dropsies.
That debility predisposes to every state of dropsy, is evident from the history of all the remote and occasional causes which produce them. It will be unnecessary to mention these causes, as they are to be found in all our systems of physic. Nor will it be necessary to mention any proofs of the existence of debility in nearly every part of the body. It is too plain to be denied. I shall onlymention the symptoms which indicate a morbid excitement and preternatural action of the arterial system. These are,
1. Ahard,full, andquickpulse. This symptom, I believe, is more common in dropsies than is generally supposed, for many physicians visit and examine patients in these diseases, without feeling the pulse. Dr. Home mentions thefrequencyof the pulse, in the patients whose cures he has recorded[35], but he takes no notice of its force except in two cases. Dr. Zimmerman, in his account of the dropsy which terminated the life of Frederick II, of Prussia, tells us that he found his pulsehardandfull. I have repeatedly found it full and hard in every form of dropsy, and more especially in the first stage of the disease. Indeed I have seldom found it otherwise in the beginning of the dropsy of the breast.
2.Sizy blood.This has been taken notice of by many practical writers, and has very justly been ascribed, under certain circumstances of blood-letting, to an excessive action of the vessels upon the blood.
3.Alternation of dropsies with certain diseases which were evidently accompanied by excess of action in the arterial system.I have seen anasarca alternate with vertigo, and both ascites and anasarca alternate with tonic madness. A case of nearly the same kind is related by Dr. Mead. Dr. Grimes, of Georgia, informed me that he had seen a tertian fever, in which the intermissions were attended with dropsical swellings all over the body, which suddenly disappeared in every accession of a paroxysm of the fever.
4.The occasional connection of certain dropsies with diseases evidently of an inflammatory nature, particularly pneumony, rheumatism, and gout.
5. Spontaneoushæmorrhagesfrom the lungs, hæmorrhodial vessels, and nose, cases of which shall be mentioned hereafter, when we come to treat of the cure of dropsies.
6.The appearance of dropsies in the winter and spring, in habits previously affected by the intermitting fever.The debility produced by this state of fever, frequently disposes to inflammatory diathesis, as soon as the body is exposed to the alternate action of heat and cold, nor is this inflammatory diathesis always laid aside, by the transitionof the intermitting fever into a dropsy, in the succeeding cold weather.
7.The injurious effects of stimulating medicines in certain dropsies, prove that there exists in them, at times, too much action in the blood-vessels. Dr. Tissot, in a letter to Dr. Haller, “De Variolis, apoplexia, et hydrope,” condemns, in strong terms, the use of opium in the dropsy. Now the bad effects of this medicine in dropsies, must have arisen from its having been given in cases of too much action in the arterial system; for opium, we know, increases, by its stimulating qualities, the action and tone of the blood-vessels, and hence we find, it has been prescribed with success in dropsies of too little action in the system.
8.The termination of certain fevers in dropsies in which blood-letting was not used.This has been ascertained by many observations. Dr. Wilkes relates[36], that after “an epidemical fever, which began in Kidderminster, in 1728, and soon afterwards spread, not only over Great Britain, but all Europe, more people died dropsical in three years, than did perhaps in twenty or thirty yearsbefore,” probably from the neglect of bleeding in the fever.
But the existence of too much action in the arterial system in certain dropsies, will appear more fully from the history of the effects of the remedies which have been employed either by design or accident in the cure of these diseases. I shall first mention the remedies which have been used with success in tonic or inflammatory dropsies; and afterwards mention those which have been given with success in dropsies of a weak action in the arteries. I have constantly proposed to treat only of the theory and cure of dropsies in general, without specifying any of the numerous names it derives from the different parts of the body in which they may be seated; but in speaking of the remedies which have been used with advantage in both the tonic and atonic states, I shall occasionally mention the name or seat of the dropsy in which the remedy has done service.
The first remedy that I shall mention for dropsies isblood-letting. Dr. Hoffman and Dr. Home both cured dropsies accompanied by pulmonic congestion by means of this remedy. Dr. Monroe quotes a case of dropsy from Sponius, in which bleeding succeeded, but not till after it had beenused twenty times[37]. Mr. Cruikshank relates a case[38]of accidental bleeding, which confirms the efficacy of blood-letting in these diseases. He tells us that he attended a patient with dropsical swellings in his legs, who had had a hoarseness for two years. One morning, in stooping to buckle his shoes, he bursted a blood-vessel in his lungs, from which he lost a quart of blood; in consequence of which, both the swellings and the hoarseness went off gradually, and he continued well two years afterwards. I have known one case in which spontaneous hæmorrhages from the hæmorrhodial vessels, and from the nose, suddenly reduced universal dropsical swellings. In this patient there had been an uncommon tension and fulness in the pulse.
I could add the histories of many cures of anasarca and ascites, performed by means of blood-letting, not only by myself, but by a number of respectable physicians in the United States. Indeed I conceive this remedy to be as much indicated by a tense and full pulse in those forms of dropsy, as it is in a pleurisy, or in any other common inflammatory disease.
In those deplorable cases of hydrothorax, which do not admit of a radical cure, I have given temporary relief, and thereby protracted life, by taking away occasionally a few ounces of blood. Had Dr. Zimmerman used this remedy in the case of the king of Prussia, I cannot help thinking from the account which the doctor gives us of the diet and pulse of his royal patient, that he would have lessened his sufferings much more than by plentiful doses of dandelion; for I take it for granted, from the candour and integrity which the doctor discovered in all his visits to the king, that he did not expect that dandelion, or any other medicine, would cure him.
Although afullandtensepulse is always an indication of the necessity of bleeding; yet I can easily conceive there may be such congestions, and such a degree of stimulus to the arterial system, as to produce a depressed, or aloworweakpulse. Two cases of this kind are related by Dr. Monroe, one of which was cured by bleeding. The same symptom of a low and weak pulse is often met with in thefirststage of pneumony, and apoplexy, and is only to be removed by the plentiful use of the same remedy.
II.Vomitshave often been given with advantage in dropsies. Dr. Home says, that squills were useful in these diseases only when they produced a vomiting. By abstracting excitement and action from the arterial system, it disposes the lymphatics to absorb and discharge large quantities of water. The efficacy of vomits in promoting the absorption of stagnating fluids is not confined to dropsies. Mr. Hunter was once called to visit a patient in whom he found a bubo in such a state that he purposed to open it the next day. In the mean while, the patient went on board of a vessel, where he was severely affected by sea-sickness and vomiting; in consequence of which the bubo disappeared, and the patient recovered without the use of the knife.
Mr. Cruikshank further mentions a case[39]of a swelling in the knee being nearly cured by a patient vomiting eight and forty hours, in consequence of his taking a large dose of the salt of tartar instead of soluble tartar.
III.Purges.The efficacy of this remedy, in the cure of dropsies, has been acknowledged by physicians in all ages and countries. Jalap, calomel,scammony, and gamboge, are often preferred for this purpose; but I have heard of two cases of ascites being cured by a table spoonful of sweet oil taken every day. It probably acted only as a gentle laxative. The cream of tartar, so highly commended by Dr. Home, seems to actchieflyin the same way. Gherlius, from whom Dr. Home learned the use of this medicine, says, that all the persons whom he cured by it were in the vigour of life, and that their diseases had been only of a few months continuance. From these two circumstances, it is most probable they were dropsies of great morbid action in the arterial system. He adds further, that the persons who were cured by this medicine, were reduced very low by the use of it. Dr. Home says that it produced the same effect upon the patients whom he cured by it, in the infirmary of Edinburgh. Dr. Sydenham prefers gentle to drastic purges, and recommends the exhibition of them every day. Both drastic and gentle purges act by diminishing the action of the arterial system, and thereby promote the absorption and discharge of water. That purges promote absorption, we learn not only from their effects in dropsies, but from an experiment related by Mr. Cruikshank[40], of a man who acquired severalounces of weight after the operation of a purge. The absorption in this case was from the atmosphere. So great is the effect of purges in promoting absorption, that Mr. Hunter supposes the matter of a gonorrhœa, or of topical venereal ulcers to be conveyed by them in some instances into every part of the body.
IV.Certain medicines, which, by lessening theaction of the arterial system, favour the absorption and evacuation of water. The only medicines of this class which I shall name arenitre,cream of tartar, andfoxglove.
1. Two ounces of nitre dissolved in a pint of water, and a wine-glass full of it taken three times a-day have performed perfect cures, in two cases of ascites, which have come under my notice. I think I have cured two persons of anasarca, by giving one scruple of the same medicine three times a-day for several weeks. The two last cures were evidently dropsies of violent action in the arterial system. Where nitre has been given in atonic dropsies it has generally been useless, and sometimes done harm. I have seen one instance of an incurable diarrhœa after tapping, which I suspected arose from the destruction of the tone of the stomach and bowels, by large and long continueddoses of nitre, which the patient had previously taken by the advice of a person who had been cured by that remedy. To avoid this, or any other inconvenience from the use of nitre in dropsies, it should be given at first in small doses, and should always be laid aside, if it should prove ineffectual after having been given two or three weeks.
2. I can say nothing of the efficacy ofcream of tartarin dropsies from my own experience, where it has not acted as a purge. Perhaps my want of decision upon this subject has arisen only from my not having persisted in the use of it for the same length of time which is mentioned by Dr. Home.
3. There are different opinions concerning the efficacy of foxglove in dropsies. From the cases related by Dr. Withering, it appears to have done good; but from those related by Dr. Lettsom[41]it seems to have done harm. I suspect the different accounts of those two gentlemen have arisen from their having given it in different states of the system, or perhaps from a difference in the quality of the plant from causes mentioned in another place[42].I am sorry to add further, that after many trials of this medicine I have failed in most of the cases in which I have given it. I have discharged the water in three instances by it, but the disease returned, and my patients finally died. I can ascribe only one complete cure to its use, which was in the year 1789, in a young man in the Pennsylvania hospital, of five and thirty years of age, of a robust habit, and plethoric pulse.
Where medicines have once been in use, and afterwards fall into disrepute, as was the case with the foxglove, I suspect the cases in which they were useful, to have been either few or doubtful, and that the cases in which they had done harm, were so much more numerous and unequivocal, as justly to banish them from the materia medica.
V.Hard labour, or exercise in such a degree as to produce fatigue, have, in several instances, cured the dropsy. A dispensary patient, in this city, was cured of this disease by sawing wood. And a patient in an ascites under my care in the Pennsylvania hospital, had his belly reduced seven inches in circumference in one day, by the labour of carrying wood from the yard into the hospital. A second patient belonging to the Philadelphia dispensary was cured by walking to Lancaster, 66miles from the city, in the middle of winter. The efficacy of travelling in this disease, in cold weather, is taken notice of by Dr. Monroe, who quotes a case from Dr. Holler, of a French merchant, who was cured of a dropsy by a journey from Paris to England, in the winter season. It would seem, that in these two cases, thecoldco-operated as a sedative with the fatigue produced by labour or exercise, in reducing the tone of the arterial system.
VI.Low diet.I have heard of a woman who was cured of a dropsy by eating nothing but boiled beans for three weeks, and drinking nothing but the water in which they had been boiled. Many other cases of the good effects of low diet in dropsies are to be found in the records of medicine.
VII.Thirst.This cruel remedy acts by debilitating the system in two ways: 1st, by abstracting the stimulus of distention; and, 2dly, by preventing a supply of fresh water to replace that which is discharged by the ordinary emunctories of nature.
VIII.Fasting.An accidental circumstance, related by sir John Hawkins, in the life of Dr. Johnson, first led me to observe the good effectsof fasting in the dropsy. If the fact alluded to stood alone under the present head of this essay, it would be sufficient to establish the existence of too much action, and the efficacy of debilitating remedies in certain dropsies. I am the more disposed to lay a good deal of stress upon this fact, as it was the clue which conducted me out of the labyrinth of empirical practice, in which I had been bewildered for many years, and finally led me to adopt the principles and practice which I am now endeavouring to establish. The passage which contains this interesting fact is as follows: “A few days after (says sir John) he [meaning Dr. Johnson] sent for me, and informed me, that he had discovered in himself the symptoms of a dropsy, and, indeed, his very much increased bulk, and the swollen appearance of his legs, seemed to indicate no less. It was on Thursday that I had this conversation with him; in the course thereof he declared, that he intended to devote the whole of the next day tofasting, humiliation, and such other devotional exercises as became a man in his situation. On the Saturday following I made him a visit, and, upon entering his room, I observed in his countenance such a serenity as indicated, that some remarkable crisis of his disease had produced a change in his feelings. He told me that, pursuant to the resolutionhe had mentioned to me, he had spent the preceding day in an abstraction from all worldly concerns; that to prevent interruption he had in the morning orderedFrank[his servant] not to admit any one to him, and, the better to enforce the charge, had added these awful words,for your master is preparing himself to die. He then mentioned to me, that in the course of this exercise he found himself relieved from the disease which had been growing upon him, and was becoming very oppressive, viz. thedropsy, by the gradual evacuation of water, to the amount oftwenty pints, a like instance whereof he had never before experienced.” Sir John Hawkins ascribes this immense discharge of water to the influence of Dr. Johnson's prayers; but he neglects to take notice, that these prayers were answered, in this instance, as they are in many others, in a perfect consistence with the common and established laws of nature.
To satisfy myself that this discharge of water, in the case of Dr. Johnson, was produced by the fasting only, I recommended it, soon after I read the above account, to a gentlewoman whom I was then attending in an ascites. I was delighted with the effects of it. Her urine, which for some time before had not exceeded half a pint a-day, amountedtotwo quartson the day she fasted. I repeated the same prescription once a week for several weeks, and each time was informed of an increase of urine, though it was considerably less in the last experiments than in the first. Two patients in an ascites, to whom I prescribed the same remedy, in the Pennsylvania hospital, the one in the winter of 1790, and the other in the winter of 1792, exhibited proofs in the presence of many of the students of the university, equally satisfactory of the efficacy of fasting in suddenly increasing the quantity of urine.
IX.Fear.This passion is evidently of a debilitating nature, and, therefore, it has frequently afforded an accidental aid in the cure of dropsies, of too much action. I suspect, that the fear of death, which was so distinguishing a part of the character of Dr. Johnson, added a good deal to the efficacy of fasting, in procuring the immense discharge of water before-mentioned. In support of the efficacy of fear simply applied, in discharging water from the body in dropsies, I shall mention the following facts.
In a letter which I received from Dr. John Pennington, dated Edinburgh, August 3, 1790, I was favoured with the following communication.“Since the conversation I had with you on the subject of the dropsy, I feel more and more inclined to adopt your opinion. I can furnish you with a fact which I learned from a Danish sailor, on my passage to this country, which is much in favour of your doctrine. A sailor in an ascites, fell off the end of the yard into the sea; the weather being calm, he was taken up unhurt, but, to use the sailor's own words, who told me the story, he wasfrightened half to death, and as soon as he was taken out of the water, he discharged a gallon of urine or more. A doctor on board ascribed this large evacuation to sea bathing, and accordingly ordered the man to be dipped in the sea every morning, much against his will, for, my informant adds, that he had not forgotten his fall, and that in four weeks he was perfectly well. I think this fact can only be explained on your principles. The sedative operation offearwas, no doubt, the cause of his cure.”
There is an account of an ascites being cured by a fall from an open chaise, recorded in the third volume of the Medical Memoirs, by M. Lowdell. I have heard of a complete recovery from dropsy, having suddenly followed a fall from a horse. Inboth these cases, the cures were probably the effects of fear.
Dr. Hall, of York-town, in Pennsylvania, informed me, that he had been called to visit a young woman of 19 years of age, who had taken all the usual remedies for ascites without effect. He at once proposed to her the operation of tapping. To this she objected, but so great was thefearof this operation, which the proposal of it suddenly excited in her mind, that it brought on a plentiful discharge of urine, which in a few days perfectly removed her disease.
On the 27th of August, 1790, I visited a gentlewoman in this city with the late Dr. Jones, in an ascites. We told her for the first time, that she could not be relieved without being tapped. She appeared to be much terrified upon hearing our opinion, and said that she would consider of it. I saw her two days afterwards, when she told me, with a smile on her countenance, that she hoped she should get well without tapping, for that she had discharged two quarts of water in the course of the day after we had advised her to submit to that operation. For many days before, she had not discharged more than two or three gills in twenty-four hours. The operation, notwithstanding,was still indicated, and she submitted to be tapped a few days afterwards.
I tapped the same gentlewoman a second time, in January, 1791. She was much terrified while I was preparing for the operation, and fainted immediately after the puncture was made. The second time that I visited her after the operation was performed, she told me (without being interrogated on that subject), that she had discharged a pint and a half of urine, within twenty minutes after I left the room on the day I tapped her. What made this discharge the more remarkable was, she had not made more than a table spoonful of water in a day, for several days before she was tapped.
I have seen similar discharges of urine in two other cases of tapping which have come under my notice, but they resembled so nearly those which have been mentioned, that it will be unnecessary to record them.
But the influence of fear upon the system, in the dropsy, extends far beyond the effects which I have ascribed to it. Dr. Currie, of this city, informed me that he called, some years ago, by appointment, to tap a woman. He no sooner entered the room than he observed her, as he thought,to faint away. He attempted to recover her, but to no purpose. She died of a sudden paroxysm of fear.
It is a matter of surprise, that we should have remained so long ignorant of the influence of fear upon the urinary organs in dropsies, after having been so long familiar with the same effect of that passion in the hysteria.
X.A recumbent posture of the body.It is most useful when the dropsy is seated in the lower limbs. I have often seen, with great pleasure, the happiest effects from this prescription in a few days.
XI.Punctures.These, when made in the legs and feet, often discharge in eight and forty hours the water of the whole body. I have never seen a mortification produced by them. As they are not followed by inflammation, they should be preferred to blisters, which are sometimes used for the same purpose.
I cannot dismiss the remedies which discharge water from the body through the urinary passages, without taking notice, that they furnish an additional argument in favour of blood-letting in dropsies, for they act, not by discharging the stagnatingwater, but by creating such a plentiful secretion in the kidneys from the serum of the circulating blood, as to make room for the absorption and conveyance of the stagnating water into the blood-vessels.
Now the same effect may be produced in all tonic or inflammatory dropsies, with more certainty and safety, by means of blood-letting.
In recommending the antiphlogistic treatment of certain dropsies, I must here confine myself to the dropsies of such climates as dispose to diseases of great morbid action in the system. I am satisfied that it will often be proper in the middle and eastern states of America; and I have lately met with two observations, which show that it has been used with success at Vienna, in Germany. Dr. Stoll tells us, that, in the month of January, 1780, “Hydropic and asthmatic patients discovered more or less marks of inflammatory diathesis, and that blood was drawn from them with a sparing hand with advantage;” and in the month of November, of the same year, he says, “The stronger diuretics injured dropsical patients in this season; but an antiphlogistic drink, composed of a quart of the decoction of grass, with two ounces of simple oxymel, and nitre and creamof tartar, of each a drachm, did service[43].” It is probable that the same difference should be observed between the treatment of dropsies in warm and cold climates that is observed in the treatment of fevers. The tonic action probably exists in the system in both countries. In the former it resembles the tides which are suddenly produced by a shower of rain, and as suddenly disappear; whereas, in the latter, it may be compared to those tides which are produced by the flow and gradual addition of water from numerous streams, and which continue for days and weeks together to exhibit marks of violence in every part of their course.
I come now to say a few words upon atonic dropsies, or such as are accompanied with a feeble morbid action in the blood-vessels. This morbid action is essential to the nature of dropsies, for we never see them take place without it. This is obvious from the absence of swellings after famine, marasmus, and in extreme old age, in each of which there exists the lowest degree of debility, but no morbid action in the blood-vessels. These atonic or typhus dropsies may easily be distinguished from those which have been described, by occurringin habits naturally weak; by being produced by the operation of chronic causes; by a weak and quick pulse; and by little or no preternatural heat or thirst.
The remedies for atonic dropsies are all such stimulating substances as increase the action of the arterial system, or determine the fluids to the urinary organs. These are,
I.Bitterandaromatic substancesof all kinds, exhibited in substance or in infusions of wine, spirit, beer, or water.
II.Certain acrid vegetables, such as scurvy-grass, horse-radish, mustard, water-cresses, and garlic. I knew an old man who was perfectly cured of an anasarca, by eating water-cresses, on bread and butter.
III.Opium.The efficacy of this medicine in dropsies has been attested by Dr. Willis, and several other practical writers. It seems to possess almost an exclusive power of acting alike upon the arterial, the lymphatic, the glandular, and the nervous systems.
IV.Metallic tonics, such as chalybeate medicines of all kinds, and the mild preparations of copper and mercury. I once cured an incipient ascites and anasarca by large doses of the rust of iron; and I have cured many dropsies by giving mercury in such quantities as to excite a plentiful salivation. I have, it is true, often given it without effect, probably from my former ignorance of the violent action of the arteries, which so frequently occurs in dropsies, and in which cases mercury must necessarily have done harm.
V.Diuretics, consisting of alkaline salts, nitre, and the oxymels of squills and colchicum. It is difficult to determine how far these medicines produce their salutary effects by acting directly upon the kidneys. It is remarkable that these organs are seldom affected in dropsies, and that their diseases are rarely followed by dropsical effusions in any part of the body.
VI.Generous diet, consisting of animal food, rendered cordial by spices; also sound old wine.
VII.Diluting drinkstaken in such large quantities as to excite the action of the vessels by the stimulus of distention. This effect has been produced, sir George Baker informs us, by means oflarge draughts of simple water, and of cyder and water[44]. The influence of distention in promoting absorption is evident in the urinary and gall bladders, which frequently return their contents to the blood by the lymphatics, when they are unable to discharge them through their usual emunctories. Is it not probable that the distention produced by the large quantities of liquids which we are directed to administer after giving the foxglove, may have been the means of performing some of those cures of dropsies, which have been ascribed to that remedy?
VIII.Pressure.Bandages bound tightly around the belly and limbs, sometimes prevent the increase or return of dropsical swellings. The influence of pressure upon the action of the lymphatics appears in the absorption of bone which frequently follows the pressure of contiguous tumours, also in the absorption of flesh which follows the long pressure of certain parts of the body upon a sick bed.
IX.Frictions, either by means of a dry, or oiled hand, or with linen or flannel impregnated with volatile and other stimulating substances. I have found evident advantages from following the advice of Dr. Cullen, by rubbing the lower extremitiesupwards, and that only in themorning. I have been at a loss to account for the manner in which sweet oil acts, when applied to dropsical swellings. If it act by what is improperly called a sedative power upon the blood-vessels, it will be more proper in tonic than atonic dropsies; but if it act by closing the pores, and thereby preventing the absorption of moisture from the air, it will be very proper in the state of dropsy which is now under consideration. It is in this manner that Dr. Cullen supposes that sweet oil, when applied to the body, cures that state of diabetes in which nothing but insipid water is discharged from the bladder.
X.Heat, applied either separately or combined with moisture in the form of warm or vapour baths, has been often used with success in dropsies of too little action. Dampier, in his voyage round the world, was cured of a dropsy by means of a copious sweat, excited by burying himself in a bed of warm sand. Warm fomentations to the legs, rendered moderately stimulating by the addition of saline or aromatic substances, have often done servicein the atonic dropsical swellings of the lower extremities.
XI. Thecold bath. I can say nothing in favour of the efficacy of this remedy in dropsies, from my own experience. Its good effects seem to depend wholly on its increasing the excitability of the system to common stimuli, by the diminution of its excitement. If this be the case, I would ask, whetherfearmight not be employed for the same purpose, and thus become as useful in atonic, as it was formerly proved to be in tonic dropsies?
XII.Wounds, whether excited by cutting instruments or by fire, provided they excite inflammation and action in the arteries, frequently cure atonic dropsies. The good effects of inflammation and action in these cases, appear in the cure of hydrocele by means of the needle, or the caustic.
XIII.Exercise.This is probably as necessary in the atonic dropsy, as it is in the consumption, and should never be omitted when a patient is able to take it. The passive exercises of swinging, and riding in a carriage, are most proper in the lowest stage of the disease; but as soon as the patient's strength will admit of it, he should rideon horseback. A journey should be preferred, in this disease, to short excursions from home.
XIV. Arecumbent posture of the bodyshould always be advised during the intervals of exercise, when the swellings are seated in the lower extremities.
XV.Punctures in the legs and feetafford the same relief in general dropsy, accompanied with a weak action in the blood-vessels, that has been ascribed to them in dropsies of an opposite character.
In the application of each of the remedies which have been mentioned, for the cure of both tonic and atonic dropsies, great care should be taken to use them in such a manner, as to accommodate them to the strength and excitability of the patient's system. The most powerful remedies have often been renderedhurtful, by being given in too large doses in the beginning, anduseless, by being given in too small doses in the subsequent stages of the disease.
I have avoided saying any thing of the usual operations for discharging water from different parts of the body, as my design was to treat only of the symptoms and cure of those dropsies whichaffect the whole system. I shall only remark, that if tapping and punctures have been more successful in the early, than in the late stage of these diseases, it is probably because the sudden or gradual evacuation of water takes down that excessive action in the arterial system, which is most common in their early stage, and thereby favours the speedy restoration of healthy action in the exhaling or lymphatic vessels.
Thus have I endeavoured to prove, that two different states of action take place in dropsies, and have mentioned the remedies which are proper for each of them under separate heads. But I suspect that dropsies are often connected with a certainintermediateor mixed action in the arterial system, analogous to the typhoid action which takes place in certain fevers. I am led to adopt this opinion, not only from having observed mixed action to be so universal in most of the diseases of the arterial and nervous system, but because I have so frequently observed dropsical swellings to follow the scarlatina, and the puerperile fever, two diseases which appear to derive their peculiar character from a mixture of excessive and moderateforce, combined with irregularity of action in the arterial system. In dropsies of mixed action, where too much force prevails in the action of some, andtoo little in the action of other of the arterial fibres, the remedies must be debilitating or stimulating, according to the greater or less predominance of tonic or atonic diathesis in the arterial system.
I shall conclude this history of dropsies, and of the different and opposite remedies which have cured them, by the following observations.
1. We learn, in the first place, from what has been said, the impropriety and even danger of prescribing stimulating medicines indiscriminately in every case of dropsy.
2. We are taught, by the facts which have been mentioned, the reason why physicians have differed so much in their accounts of the same remedies, and why the same remedies have operated so differently in the hands of the same physicians. It is because they have been given without a reference to the different states of the system, which have been described. Dr. Sydenham says, that he cured the first dropsical patient he was called to, by frequent purges. He began to exult in the discovery, as he thought, of a certain cure for dropsies, but his triumph was of short duration. The same remedy failed in the next case in which he prescribed it. The reason probably was, thedropsy in the first case was of a tonic, but in the second of an atonic nature; for the latter was an ascites from a quartan ague. It is agreeable, however, to discover, from the theory of dropsies which has been laid down, that all the different remedies for these diseases have been proper in their nature, and improper only in the state of the system in which they have been given. As the discovery of truth in religion reconciles the principles of the most opposite sects, so the discovery of truth in medicine reconciles the most opposite modes of practice. It would be happy if the inquirers after truth in medicine should be taught, by such discoveries, to treat each other with tenderness and respect, and to wait with patience till accident, or time, shall combine into one perfect and consistent system, all the contradictory facts and opinions, about which physicians have been so long divided.
3. If a state of great morbid action in the arteries has been demonstrated in dropsies, both from its symptoms and remedies, and if these dropsies are evidently produced by previous debility, who will deny the existence of a similar action in certain hæmorrhages, in gout, palsy, apoplexy, and madness, notwithstanding they are all the offspring of predisposing debility? And who will deny the efficacy of bleeding, purges, and other debilitatingmedicines in certain states of those diseases, that has seen the same medicines administered with success in certain dropsies? To reject bleeding, purging, and the other remedies for violent action in the system, in any of the above diseases, because that action was preceded by general debility, will lead us to reject them in the most acute inflammatory fevers, for these are as much the offspring of previous debility as dropsies or palsy. The previous debility of the former differs from that of the latter diseases, only in being of a more acute, or, in other words, of a shorter duration.
4. From the symptoms of tonic dropsy which have been mentioned, it follows, that the distinction of apoplexy into serous and sanguineous, affords no rational indication for a difference in the mode of treating that disease. If an effusion of serum in the thorax, bowels, or limbs, produce a hard and full pulse, it is reasonable to suppose that the same symptom will be produced by the effusion of serum in the brain. But the dissections collected by Lieutaud[45]place this opinion beyond all controversy. They prove that the symptoms of great and feeble morbid action, as they appear in the pulse, follow alike the effusion of serum andblood in the brain. This fact will admit of an important application to the disease, which is to be the subject of the next inquiry.
5. From the influence which has been described, of the different states of action of the arterial system, upon the lymphatic vessels, in dropsies, we are led to reject the indiscriminate use of bark, mercury, and salt water, in the scrophula. When the action of the arteries is weak, those remedies are proper; but when an opposite state of the arterial system occurs, and, above all, when scrophulous tumours are attended with inflammatory ulcers, stimulating medicines of all kinds are hurtful. By alternating the above remedies with a milk and vegetable diet, according to the tonic, or atonic states of the arterial system, I have succeeded in the cure of a case of scrophula, attended by large ulcers in the inguinal glands, which had for several years resisted the constant use of the three stimulating remedies which have been mentioned.
6. Notwithstanding I have supposed dropsies to be connected with a peculiar state of force in the blood-vessels, yet I have not ventured to assert, that dropsies may not exist from an exclusive affection of the exhaling and absorbing vessels. I conceive this to be as possible, as for a fever toexist from an exclusive affection of the arteries, or a hysteria from an exclusive affection of the nervous system. Nothing, however, can be said upon this subject, until physiology and pathology have taught us more of the structure and diseases of the lymphatic vessels. Nor have I ventured further to assert, that there are not medicines which may act specifically upon the lymphatics, independently of the arteries. This I conceive to be as possible as for asafœtida to act chiefly upon the nerves, or ipecacuanha and jalap upon the alimentary canal, without affecting other parts of the system. Until such medicines are discovered, it becomes us to avail ourselves of the access to the lymphatics, which is furnished us through the medium of the arteries, by means of most of the remedies which have been mentioned.
7. If it should appear hereafter, that we have lessened the mortality of certain dropsies by the theory and practice which have been proposed, yet many cases of dropsy must still occur in which they will afford us no aid. The cases I allude to are dropsies from enclosing cysts, from the ossification of certain arteries, from schirri of certain viscera from large ruptures of exhaling or lymphatic vessels, from a peculiar and corrosive acrimony of the fluids, and, lastly, from an exhaustedstate of the whole system. The records of medicine furnish us with instances of death from each of the above causes. But let us not despair. It becomes a physician to believe, that there is no disease necessarily incurable; and that there exist in the womb of time, certain remedies for all those morbid affections, which elude the present limits of the healing art.