HYDROTORAX.

Dropsy of the Breast.

Hydrotorax, Sauv. gen. 150. Vog. 311. Boerh. 1219.

This affection, particularly with respect to its causes, is in many circumstances similar to other kinds of dropsy, particularly to aficte. But from the situation of the water, which is here deposited in the cavity of the thorax, it may naturally be supposed that some peculiar symptoms will occur. Besides the common symptoms of dropsy, paleness of the countenance, scarcity of urine, and the like, this disease is, in some instances, attended with a fluctuation of water within the breast; which when it does occur may be considered as a certain distinguishing mark of this affection. But besides this, it is also distinguished by the remarkable affections of circulation and respiration with which it is attended.

The breathing is peculiarly difficult, especially in a recumbent posture; and in many instances patients cannot breathe with tolerable ease, unless when sitting erect, or even stooping somewhat forwards. The pulse is very irregular, and has often remarkable intermissions. But the disease has been thought to be principally characterized by a sudden starting from sleep, in consequence of an almost inexpressible uneasy sensation referred to the breast, and attended with strong palpitation, which may probably arise from an affection either of circulation or of respiration.

That these symptoms are common attendants of this disease, is undeniable; and they are certainly the best characteristics of this affection with which we are yet acquainted; but it must be allowed that they are present in some cases where there is no water in the breast; and and that in other instances where the disease exists, they are either altogether wanting, or occur only to a very slight degree. Certain diagnostics, therefore, of this disease still remain to be discovered.

When hydrothorax is present, from the affection of the vital functions with which it is attended, it may readily be concluded that it is a dangerous disease, and in many instances it proves fatal. The cure, as far as it can be accomplished, is obtained very much on the same principles as in other dropsies. Here, however, probably from the uncertainty of the diagnostics, the artificial abstraction of water, by paracentesis of the thorax, is less frequently had recourse to than in ascites; though in some instances, after other means have failed, it has been said not only to give relief of symptoms highly urgent, particularly dyspnoea, but even to produce a complete cure. Benefit is often obtained from an artificial discharge of water by the application of blisters to the breast; but in this, as well as other dropsies, a discharge is chiefly effected by the natural outlets, particularly from the use of cathartics and diuretics. In this species of dropsy, more perhaps than in any other, recourse has been had to the use of the digitalis purpurea, or foxglove, so strongly recommended as a diuretic by Dr Withering in his treatise respecting the use of it. There can be no doubt that this article, though sometimes productive of inconvenience from the distressing sickness and severe vomiting which it not unfrequently excites, though used even but in small doses, often operates as a powerful diuretic, and produces a complete evacuation of water, after other articles have failed. From the effects mentioned above, however, as well as from its influence on the pulse, which it renders much slower, it is necessary that it should be employed with great caution, and in small doses. A dram of the dried leaves of the digitalis, macerated for four hours in half a pint of warm water, forms an infusion which may be given in doses of an ounce, and the dried powder of the leaves in doses of one or two grains; these doses may be gradually increased, and repeated twice or oftener in the day; but this requires to be done with great caution, lest severe vomiting, or other distressing symptoms, should take place.

GENUS LXXIX. ASCITES.

Dropsy of the Abdomen.

Ascites, Sauv. gen. 288. Lin. 217. Vog. 314. Sog. gen. 115. Boerh. 1226. Hoffm. III. 322. Junck. 87. Dr Monro on the Dropsy, 1765. Milman, Animadverfiones de Hydrope, 1779.

Description. This disease assumes three different forms: 1. When the water immediately washes the intestines. 2. When it is interposed between the abdominal muscles and peritoneum; or, 3. When it is contained in fleshy hollow vesicles; in which case it is called the encysted dropsy. Some physicians of great reputation have alleged, that the water was often placed within the duplicature of the peritoneum; but this is alleged by Dr Milman to be a mistake, as that membrane is looked upon by the best anatomists to be single; and he thinks that the above-mentioned physicians have been led into this error from observing the water collected in the cellular substance of the peritoneum.

In the beginning of an ascites the patient becomes languid, breathless, and has an aversion to motion; his belly swells; and, when struck, the sound of fluctuating water is perceptible; there is a difficulty of breathing when the belly is pressed. There is an almost continual thirst, which, in the progress of the disease becomes very urgent; the urine is thick, in small quantity, and high coloured. The pulse is small and frequent; and as the belly swells, the other parts waste away. A fever at last arises, which, constantly increasing, in the end carries off the patient. These symptoms are most urgent where the waters are in immediate contact with the intestines; in the other kinds the rest of the body is less wasted; nor is there so great thirst or difficulty of breathing.

Causes, &c. The immediate cause of dropsy is a greater effusion of serum by the exhalant arteries than the absorbers take up. This may be occasioned either by too great a quantity of liquid thrown out by the former, or by an inability of the latter to perform their office. This commonly happens in people whose bodies are of a weak and lax texture, and hence women are more subject to this malady than men; chlorotic girls especially are very apt to become dropsical.

Sometimes, however, this disease is occasioned by a debility of the vital powers, by great evacuations of blood, or by acute diseases accidentally prolonged beyond their usual period; and although this cause seems very different from a laxity of fibres, yet the dropsy seems to be produced in a similar manner by both. For the vital powers being debilitated by either of these causes, naturally bring on a certain debility and laxity of the solids; and, on the other hand, a debility of the solids always brings on a debility of the vital powers; and from this debility of the vital powers in both cases it happens, that those humours which ought to be expelled from the body are not discharged, but accumulate by degrees in its cavities. There is, however, this difference between the two kinds of dropsy arising from these two different causes: That in the one which arises from laxity the solid parts are more injured that in that which arises from a debility of the vital powers. In the former, therefore, the water seems to flow out from every quarter, and the body swells all over. But when the disease is occasioned by a debility of the vital powers, though the solids be less diseased, yet the power of the heart being much diminished, and the humours scarce propelled through the extreme vessels, the thin liquids, by which in a healthy state the body is daily recruited, are carried by their own weight either into the cavities or into the cellular texture. Hence those aqueous effusions which follow great evacuations of blood, or violent loofenesses, begin in the more depending parts of the body, gradually ascending, till they arrive at the cavity of the abdomen, or even the thorax.

But another and much more sufficient cause for the production of dropsy is an obstruction of the circulation; and this may take place from polypi in the heart or large vessels, and hard swellings in the abdomen. Instances have been observed of a dropsy arising from fleatomatous tumors in the omentum, and many more from a scirrhou liver or spleen, and from an infarction... tion and obstruction of the mesenteric glands, by which means the lymph coming from the extremities is prevented from arriving at the heart. Scirrhosity of the liver, the most common cause of ascites, probably operates by augmenting effusion, in consequence of its preventing the return of the venous blood, the greater part of the veins from the abdomen going to the formation of the vena portarum.

Lastly, Whatever, either within or without the vessels, contracts or shuts up their cavities, produces a more copious and easy transmission of the thin humours through the exhalant arteries, at the same time that it prevents their return by the absorbent veins. This has been established by experiment: For Lower having perforated the right side of the thorax in a dog, tied the vena cava, and sewed up the wound. The animal languished for a few hours, and then died. On dissection, a great quantity of serum was found in the abdomen, as if he had long laboured under an ascites. In like manner, having tied the jugular veins of another dog, a surprising swelling took place in those parts above the ligatures, and in two days the animal died. On dissection, all the muscles and glands were vastly distended, and quite pellucid, with limpid serum. From these experiments, and some cases of the disease mentioned by different authors, it appears, that when the veins are obstructed so that they cannot receive the arterial blood, the serum is separated as by a filter into the more open cavities and laxer parts of the body, while the thicker part stagnates and is collected in the proper blood vessels.

The too great tenacity of the humours is very frequently accused as the cause of dropsy, and many authors have asserted that dropsy might arise merely from a superabundance of water in the blood. For this, some experiments are quoted, from which they would infer, that when a great quantity of aqueous fluid is introduced into the blood, the superfluous fluid ought by no means to pass through the extremities of the languorous arteries into the veins in the common course of circulation, but by being effused into the cavities should produce a dropsy. But this can only happen when the vital powers are very much diminished; for, in a natural state, the superfluous quantity is immediately thrown out by the skin or the kidneys: and agreeable to this we have an experiment of Schulzius, who induced a dropsy in a dog by causing him drink a great quantity of water; but he had first bled him almost ad deliquium, so that the vital powers were in a manner oppressed by the deluge of water. In this manner do those become hydropic who are seized with the disease on drinking large quantities of water either when wearied with labour, or weakened by some kinds of diseases. Dr Fothergill relates an instance of a person who, being advised to drink plentifully of barley-water, in order to remove a fever, rashly drank 12 pounds of that liquor every day for a month, and thus fell into an almost incurable dropsy. But if this quantity had been taken only during the prevalence of the fever, he would, in all probability, have suffered no inconvenience, as may be inferred from what has been related concerning the dieta aqua used by the Italians.

It is moreover evident from experiments, that, in a healthy state, not only water is not deposited in the cavities, but that if it is injected into them it will be absorbed, unless some laxity of the solids has already taken place. Dr Mulgrave injected into the right side of the thorax of a dog four ounces of warm water; whence a difficulty of breathing and weakness immediately followed. But these symptoms continually lessened, and in the space of a week the animal seemed to be in as good health as before. Afterwards he injected 16 ounces of warm water into the left cavity of the thorax in the same dog; the same effects followed, together with great heat, and strong pulsation of the heart; but he again recovered in the space of a week. Lastly, he injected 18 ounces of water into one side of the thorax, and only six into the other: the same symptoms followed, but vanished in a much shorter time; for within five days the dog was restored to perfect health. During this time, however, he observed that the dog made a greater quantity of urine than usual.

The remote causes of dropsy are many and various. Whatever relaxes the solids in such a manner as to give an occasion of accumulation to the serous fluids, dispose to the dropsy. A lazy indolent life, rainy wet weather, a swampy or low soil, and every thing which conduces to vitiate the viscera, or insensibly to produce obstructions in them, paves the way for a dropsy. Hence those are ready to fall into the disease who use hard and viscid aliments, such as poor people in some countries who use coarse brown bread, and children who are fed with unwholesome aliments; and the same thing happens to those who drink immoderately of spirituous liquors.

Prognosis. When the dropsy arises from a scirrhus of the liver or spleen, or any of the other viscera, the prognosis must always be unfavourable, and also when it arises from disorders of the lungs. Neither is the case more favourable to those in whom the small vessels are ruptured, and pour out their liquids into the cavity of the abdomen. Those certainly die who have polypi in the vessels, or tumors compressing the veins and vessels of the abdomen. A dropsy arising from obstructions in the mesenteric glands is likewise difficult to cure, whether such obstructions arise from a bad habit of body, or from any other cause; if we can, however, by any means remove the disease of the glands, the dropsy soon ceases. But in those who fall into dropsy without any disease preceding, it is not quite so dangerous; and even though a disease has preceded, if the patient's strength be not greatly weakened, if the respiration be free, and the person be not affected with any particular pain, we may entertain great hopes of a cure. But where a great loss of blood is followed by a fever, and that by a dropsy, the patients almost always die, and that in a short time: those, however, are very frequently cured who fall into this disease without any preceding haemorrhage.

Cure. In the cure of this disease authors chiefly mention two indications: 1. To expel the effused water; and, 2. To prevent its being again collected. But before we proceed to speak of the remedies, it is necessary to take notice, that by the laws of the animal economy, if a great evacuation of a fluid takes place in any part of the body, all the other fluids in the body are directed towards that part, and those which lie, as it were, lurking in different parts will be immediately absorbed, and thrown out by the same passage. Hence the humours which in hydropic per- fons are extravasated into the different cavities of the body will be thrown into the intestines, and evacuated by purgatives; or by diuretics will be thrown upon the kidneys, and evacuated by urine. It is, however, not only necessary to excite these evacuations in order to remove this malady, but they must be affluently promoted and kept up till the abundant humour is totally expelled. For this reason Sydenham has advised purgatives to be administered every day, unless, either through the too great weakness of the body, or the violent operation of the purgative, it shall be necessary to interpose a day or two now and then; because if any considerable intervals be allowed to take place between the exhibition of the purgatives, an opportunity is given to the waters of collecting again. In this method, however, there is the following inconvenience, that, when the waters are totally evacuated, the strength is at the same time so much exhausted, that the distemper commonly returns in a very short time. Hence our chief hopes of curing a dropy consist in gently evacuating the waters by means of diuretics. But the efficacy of these is generally very doubtful. Dr Freind has long ago observed, that this part of medicine is of all others the most lame and imperfect; but a French physician, Mr Bacher, lately discovered, as he alleges, a method of making the diuretics much more successful. His reputation became at last so great, that the French king thought proper to purchase his secret for a great sum of money. The basis of his medicine was the black hellebore root, the malignant qualities of which he pretended to correct in the following manner: A quantity of the dried roots of black hellebore were pounded, and then put into a glazed earthen vessel, and afterwards sprinkled with spirit of wine. They were suffered to stand for twelve hours, stirring them about twice or thrice during that space of time. They were then sprinkled again, and at last good Rhine wine was poured on till it stood five fingers above the roots. The mixture was frequently agitated with a wooden spatula; and as the wine was imbibed by the roots, more was poured on, so as to keep it always at the same height for 48 hours. The whole was then put on the fire and boiled for half an hour, after which the decoction was violently pressed out; the same quantity of wine was added as at first, and the mixture boiled as before. After the second expression the woody residuum was thrown away as useless. Both the strained liquors were then mixed together with two parts of boiling water to one of the decoction. The whole is afterwards evaporated in a silver vessel to the consistence of a syrup. One part of the extract is again mixed with two parts of boiling water, and the whole infusified as before.—By this means, says he, the volatile nauseous acrid particles are separated by evaporation, and the fixed ones remain corrected and prepared for medicinal uses; adding, towards the end, a ninth part of old brandy, and evaporating to the consistence of turpentine. Mr Bacher reasons a good deal on the way in which this process corrects the medicine; but tells us, that notwithstanding the improvement, his pills will not have the desired effect unless properly made up. For forming them, they ought to be mixed with matters both of an invigorating and indurating nature; yet so prepared that it will be readily soluble in the stomach, even of a person much debilitated. For answering these purposes, he chose myrrh and carduus benedictus, and he gives the following receipt for the formation of his pills:

"Take of the extract of hellebore prepared as above directed, and of solution of myrrh, each one ounce; of powdered carduus benedictus, three drams and a scruple. Mix them together, and form into a mass, dividing it into pills of a grain and a half each."

To these pills Mr Bacher gives the name of the pulcher tonicae, from an idea, that while they evacuate the water, they at the same time act as tonics; and thus, from augmenting the action of the lymphatics, prevent the return of the disease. And if both these intentions could be effectually answered by the use of the same remedy, it would unquestionably be of great importance in practice.

The effects of these pills were, we are told, very surprising. Dr Daignan relates, that he gave them to 18 hydroptic patients at once; and these he divided into three classes, according to the degree of the disease with which they were affected. The first class contained those who laboured under an anaeroma following intermittent fevers. The second class contained those who had an anaeroma, together with some degree of ascites, arising from tedious febrile disorders. All these were cured; but these two classes consisted of such cases as are most easily removed. But the third contained six who were seized with a most violent anaeroma and ascites, after being much weakened by tedious disorders, and of consequence in whom the disease was very difficult to be cured. Even of these, however, four were cured, and the other two died. The body of one of these being dissected, both sides of the cavity of the thorax were found to be full of a blackish-red water. The lungs were unfound; there was a polypous concretion in the right ventricle of the heart; the liver and spleen were hard, and of a supernatural bulk; and the glands of the mesentery were obstructed and infarcted. In the other, the liver and pancreas were scirrhouss, and the spleen very hard.

The same medicines were given by De Horne to eight persons, six of whom had both an anaeroma and ascites, but the other two only an ascites. Four of these recovered; three died without being freed from the dropy; one in whom the dropy was cured died in a short time after, having for some time before his death become speechless.

By these patients 10 of the pills were taken at once; and the same dose repeated to the third time, with an interval of an hour betwixt each dose. At first they proved purgative, and then diuretic; by which last evacuation they finally cured the disease. But though Mr Bacher was firmly of opinion that his pills cured the dropy by reason of the above-related correction, yet it is certain that, in the hands of other practitioners, these very pills have failed, unless they also made use of the same regimen recommended by that physician; while, on the other hand, it is also certain, that different medicines will prove equally efficacious in dropical cases, provided this regimen is made use of.

For a great number of ages it has been recommended to dropical patients to abstain as much as possible from drink, and thus to the torments of their disease was added that of an intolerable thirst; and how great this torment was, we may understand from an example of a friend of King Antigonus, who, having been closely watched both by order of the physicians and also of the king, was so unable to bear the raging thirst occasioned by his disease, that he swallowed his own excrements and urine, and thus speedily put an end to his life. Dr Milman shows at great length the pernicious tendency of this practice. He maintains that it is quite contrary to the sentiments of Hippocrates and the best ancient physicians. He affirms, that unless plenty of diluting drink be given, the best diuretics can have no effect. He condemns also in the strongest terms the practice of giving dropsical patients only dry, hard, and indigestible aliments. These would oppress the stomach even of the most healthy; and how much more must they do to those who are already debilitated by labouring under a tedious disorder! By what means also are these aliments to be dissolved in the stomach when drink is withheld? In this disease the saliva is viscid, and in small quantity; from whence it may be reasonably conjectured, that the rest of the fluids are of the same nature, and the gastric juices likewise depraved. Thus the aliments lie long in the stomach; and if the visceræ were formerly free of obstructions, they are now generated; the strength fails; perspiration and other excretions are obstructed; the viscid and pituitous humours produced by these kinds of food float about the precordia, and increase the disease, while the surface of the body becomes quite dry. Nay, so much does this kind of diet conspire with the disease, that 100 pounds of fluid will sometimes be imbibed in a few days by hydropic persons who take no drink. Even in health, if the body from any cause becomes dry, or deprived of a considerable part of its juices, as by hunger, labour, &c. it will imbibe a considerable quantity of moisture from the air; so that we must impute the above-mentioned extraordinary inhalation, in part at least, to the denial of drink, and to the nature of the aliment given to the sick. The following is the account given by Sir Francis Milman of his practice in the Middlesex hospital.

If the patient be not very much debilitated, he is sometimes treated with the purging waters, and a dose of jalap and calomel alternately. On the intermediate days he gets a saline mixture, with 40 or 60 drops of acium sellitum every fifth hour; drinking with the purgatives oat-guel and some thin broths. That he might the better ascertain what share the liquids given along with the medicines had in producing a copious flow of urine, he sometimes gave the medicines in the beginning of the distemper without allowing the drink; but though the swellings were usually diminished a little by the purgatives, the urine still continued scanty, and the patients were greatly weakened. Fearing, therefore, lest, by following this course, the strength of the sick might be too much reduced, he then began his course of diuretic medicines, evoking large quantities of barley water with a little sal diuretum; by which means, sometimes in the short space of 48 hours after the course was begun, the urine flowed out in very large quantity; but as saline drinks are very disagreeable to the taste, a drink was composed purposely for hydropic persons, of half an ounce of supertartrate of potash, dissolved in two pounds of barley water, made agreeably sweet with syrup, adding one or two ounces of French brandy.

To this composition Sir Francis Milman was induced by the great praises given to supertartrate of potash by some physicians in hydropic cases. In the Ada Bono-mensa, 15 cases of hydropic patients are related who were cured only by taking half an ounce of cream of tartar daily. But it is remarkable, that by these very patients the cream of tartar was taken for 20, 30, or 40 days, often without any perceptible effect; yet when dissolved in a large quantity of water, it showed its salutary effects frequently within as many hours, by producing a plentiful flow of urine. This liquor is now the common drink of hydropic patients in the hospital above mentioned, of which they drink at pleasure along with their medicines.

Among purgative medicines Sir Francis Milman recommends the radix fenicæ; but says the decoction of it, according to the Edinburgh Pharmacopoeia is too strong, as he always found it excite vomiting when prepared as there directed, and thus greatly to distress the patients: but when only half an ounce or six drams of the root are used to a pound of decoction, instead of a whole ounce as directed by the Edinburgh college, he finds it an excellent remedy; and though it may sometimes induce a little vomiting, and frequently a nausea, yet it seldom failed to procure nine or ten floods a day, and sometimes also proved diuretic. But we must take care not to be too free in the use of fenicæ, or any other purgative, if the patients be very weak; and therefore, after having used purgatives for some time, it will be proper to depend upon diuretics entirely for perfecting the cure; and of the success of this method our author gives some very remarkable instances. But he observes, that after the dropsy is removed, the patients will sometimes die without any evident cause; and of this it is proper that the physicians should be aware. It is remarkable with what ease a flux of urine is induced in those who have a scirrhouss liver; while, on the other hand, in one who had the mesenteric glands obstructed, along with a scirrhosity of the liver and vitiated state of the lungs, the most powerful diuretics proved ineffectual. In some cases Sir Francis Milman thinks the kidneys may be so pressed with the weight of the water, as to be unable to perform their office. With regard, however, to diuretics in general, it may be remarked, that the operation of none of them can be certainly depended upon. In particular constitutions, and at particular times, one will be observed to succeed, after another, though commonly much more powerful, has been tried in vain. Accordingly various articles of this kind are often used in succession. Reconstitute is particularly often had to the root of taraxacum, of colchicum, and of squills; the latter, especially when combined with calomel, is often found to be a very powerful diuretic. And indeed mercury in different forms, probably from acting as a deobstruent, is often of very great use in dropsical complaints. Among other diuretics, the lactuca virosa has of late been highly extolled by Dr Collins of Vienna, and the nicotiana tabacum by Dr Fowler of York; but neither has been extensively introduced into practice, although we have known some instances in which the latter, in particular, has been used with great advantage.

The water having been drawn off, we are to put the patient on a course of strengtheners; such as cinchona, with some of the warm aromatics, and a due proportion of rhubarb infused in wine and chalybeates. Gentle exercise, and frictions on the belly, with such a course of diet as shall be light and nourishing, are also to be enjoined: and it may be observed, that the use of tonic medicines is by no means to be delayed till a complete evacuation of the water can be obtained. On the contrary, by alternating, and even combining the use of evacuants and tonics, the influence of both is often very much promoted.

When the patient can by no other means be relieved, the operation of paracentesis must be had recourse to, which is described under the article Surgery.