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 œdematous 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 œdema 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 œdematous 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 œdema 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 Générales de Médecine, 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, œdema 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.