Medical Inquiries and Observations, Vol. 2 / The Second Edition, Revised and Enlarged by the Author

by Benjamin Rush

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 rendered hurtful, by being given in too large doses in the beginning, and useless, 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 which affect 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 certain intermediate or 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 moderate force, combined with irregularity of action in the arterial system. In dropsies of mixed action, where too much force prevails in the action of some, and too 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, the dropsy 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 debilitating medicines 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 and blood 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 to exist 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.