222 Med. Times and Gazette, Jan., 1880.
SYMPTOMS.—The general accumulation of watery fluid is not attended by any pronounced symptom until it has reached the point of interfering mechanically with the normal play of the lungs. At first dyspnoea is only perceptible on increased physical exercise. When the quantity is excessive, the individual suffers when perfectly quiet. The patient, until the fluid is excessive, lies on his back as the most comfortable position, but as the quantity increases he is often obliged to sit up in bed.
The dyspnoea is ordinarily much more oppressive than in pleuritic effusions, because both lungs are compressed. There is no rise of temperature, no pain in the side, no tenderness on pressure, no acceleration of the pulse, and but rarely any cough, as there is in pleurisy. The dyspnoea often becomes very painful, and may even produce orthopnoea, being accompanied by short and frequent acts of breathing. Where there are very large amounts of fluid the mechanical interference with the breathing is so great that cold sweats, cyanosis, and asphyxia follow, the pulse becoming smaller and more feeble until the patient dies.
The physical signs are, in general, the same as those of pleuritic effusions, especially the subacute form, with some slight variation. Inspection and mensuration do not aid us as in pleurisy, for in hydrothorax the accumulation of fluid is bilateral instead of unilateral. The tension is not sufficient to dilate the walls of the chest. Palpation shows absence of vocal resonance, but not invariably, for we are unable to compare the two sides. We must remember that we have oedema of the walls of the chest, which would partially prevent the thoracic vibrations from being felt. Percussion flatness is not as absolute as it is in pleurisy, unless the fluid is in excessive quantity, for the tension of the fluid is feebler and the lung contains more air. The lung is never completely compressed, as in pleurisy, there being no fibrinous bands to constrict it. The percussion vibrations, unless very lightly made, are communicated to the lung; and so there is dulness instead of flatness. The absence of fibrinous bands permits the fluid to change its position with the varying postures of the patient. This rarely occurs in pleuritic effusions after the first few days. Finally, Skodaic tympanic resonance at the apex is but seldom met with in simple hydrothorax.
Auscultation.—The presence of fluid between the lung and parietes prevents us from hearing the vesicular murmur. The distant bronchial respiration is rarely heard in hydrothorax, as it is in pleurisy, because the lungs are not completely deprived of air, and when present is less intense. Ægophony is frequently heard over the upper limit of the fluid, the whispering voice being transmitted through the fluid. Owing to pulmonary oedema there are subcrepitant râles, but never pleuritical friction sounds.
DIAGNOSIS.—Ordinarily, the diagnosis ought to be made without difficulty. The only disease with which there can be any danger of confounding it is subacute pleurisy. The principal points of differential diagnosis have been enumerated above. In subacute pleurisy (latent pleurisy) we have, in less intensity, the ordinary pleuritic symptoms. The pleuritic friction murmur is present, and a fluid containing the products of inflammation. Very exceptionally is subacute pleurisy double, whereas hydrothorax is almost invariably so.
The history of the case enables us to arrive at an accurate diagnosis. The withdrawal of a small quantity of fluid with a fine perforated needle, and its chemical and microscopical examination, will complete the diagnosis in doubtful cases.
Oedema of the lung can scarcely be confounded with hydrothorax. The absence of the physical evidences of water in the cavity, and the crackling sound heard in auscultation, are distinctive of oedema.
PROGNOSIS.—The prognosis is always serious, but it depends upon the nature of the disease producing the dropsy. If this can be removed, the collection of water may disappear. But, unfortunately, the circulatory diseases which produce it are generally chronic and incurable. The fluid can, by general treatment and mechanical means, be reduced, and the life of the patient prolonged and made comparatively comfortable. Sooner or later a large number of cases must succumb.
TREATMENT.—The treatment should first be directed to the primary disease causing the dropsy. If heart disease be the promoting cause, we must, by means of digitalis, endeavor to promote compensating hypertrophy, and by arsenic and iron improve the quality of the blood. If Bright's disease be the cause, the skimmed-milk diet, with iron and manganese, must be given with remedies which lessen the hydræmic condition of the blood. Digitalis, diuretics, jaborandi, and drastic purgatives give decided results. Of all purgatives, elaterium in decided doses (¼ grain), guarded by conium or hyoscyamus, causes most relief by producing free watery stools. Mechanical means must be resorted to without hesitation. It is best first to remove the fluid from the lower extremities by the insertion of Southey's capillary canula with caoutchouc tubing attached. Large quantities of water may thus be drawn off without local irritation, erysipelatous in its nature, being produced. Thoracentesis by aspiration averts death very often, and gives the greatest possible relief when the effusion is large enough to produce dyspnoea. In a case under the author's care life was prolonged many months and large quantities of fluid were removed. Altogether, there were twenty-two operations and 1563½ ounces of water removed. As often as every week one or other side had to be emptied, the quantity removed each time varying from 49 ounces to 112 ounces. For two months previous to death filtrates collected in the abdominal cavity also, and had to be frequently withdrawn.