"The condition of the stools at the period when a child is labouring under the disease, will afford to such persons but an imperfect notion of its true nature; for the disturbance of the brain will often create a disorder in the secretions, both of the liver and the other chylopoietic organs, producing green looking stools; and there is often a congestive state of the brain for a short time preceding the full development of the idiopathic excitement, which may, in like manner, by reacting upon the liver, create a disorder there. In cases, however, which are symptomatic of this cause, the chylopoietic disturbance will be found to have existed several days or even weeks; and the origin of the disorder, in like manner, may be commonly traced to some irregularity of diet, or other obvious causes, and frequently in infants to those which are connected with premature weaning; and sometimes even the cerebral disorder itself will have been only the last of a series of effects in the system, to which such disturbance had given rise."
Agreeably to Dr. A., it is not proper to discontinue those means, immediately upon the occurrence of what appears to be symptoms of effusion, since, frequently, these symptoms, as it respects the effusion, will immediately manifest their fictitious character, and disappear under a treatment no wise adapted to such a state, and with a rapidity, too, which equally betrays their true nature. He notices, though we believe not in its proper place, a modification of the disease in which the effusion takes place in the cellular membrane of the substance of the brain, and thinks this species more likely to be recovered from than when the water accumulates in the ventricles. He concludes this section by remarking, that
"Of the means to be employed to promote the absorption of the water, under these or other circumstances of its accumulation in the brain, little satisfactory can be said. The treatment must be founded on the use of such means as shall avert the risk of renewing an inflammation in the organ. To this end, occasional blistering the head will be proper; the diet must be spare, and the several secretions, particularly those of the kidneys, must be cautiously promoted."
We next turn to the treatment of hydrothorax and ascites. As the existence of hydrothorax in its early stage is difficult to ascertain, and as what have been called premonitory symptoms are only those proper to the mildest forms of the disease, and not of that condition of the parts which gives rise to the effusion, the treatment is somewhat difficult, and, in too many instances, our remedies are directed, not to the disease itself, but to one of its effects. Faithful to his view of the pathology of dropsy, Dr. A. remarks, that the plan of treatment to be pursued at an early stage of symptomatic hydrothorax, must consist in the use of those means which shall subdue the chronic excitement of the serous membrane, as well as the chronic inflammation of the diseased organ. To attain this end, the antiphlogistic and revulsive plans, graduated to the age and strength of the patient, and to the violence of the disease are recommended. In general the frequent application of leeches are held by Dr. A. as preferable to venesection, unless the patient be plethoric, and the disease arise from a local congestion within the chest, which, according to him, is often a cause of serous inflammation of the thoracic tissue, independently of any previous disease. Dr. Ayre calls attention to the fact, that topical bleeding is particularly adapted to correct that chronic inflammation of the serous membranes, which causes an effusion from them, and which is neither the result of any inflammatory excitement of the general system, nor of a nature to produce it; and that when properly conducted, it has the advantage of acting only slightly on the general system, and therefore only slightly on the general strength, and very considerably on the local disease. Together with leeches, blisters are to be used, and after the chronic action existing in the serous membrane is subdued by these means, a seton fixed in the integuments of the chest will be found of great utility.
The same treatment will be found equally serviceable, not only to correct the chronic excitement existing in the peritoneal membrane and giving rise to ascites, but very commonly to cure or palliate the visceral disease producing it. In respect to the very common practice of resorting to mercury in this complaint, our author makes the following judicious remarks.
"With too many practitioners, it is the practice to employ mercury freely in every case of abdominal dropsy, under the vague notion of there existing some mechanical obstruction in the liver or other viscus, as a cause of it; and under the equally vague notion, that mercury so employed will remove it. The practice, however, to speak of it in the mildest terms, is founded on erroneous views of the pathology of these diseases; and employed, therefore, as it is by some, on all the occasions in which they meet with them, must be frequently very injurious. For, independently of the injury to be inflicted by it, when given freely in some of the forms of liver disease, there is an effect produced by it on the urine, when given to a person in health, resembling that which arises from the specific excitement of dropsy. Under a salivation, the urine becomes charged with serum. Any condition of the system, therefore, approaching even to a state of salivation, must be injurious, by the tendency it must have to increase that morbid state of the body, which is nearest allied to the hydropic one. Hence the mercurial salivation has been numbered amongst the remote causes of dropsy; and the resemblance between the dropsical and mercurial excitement, thus established by the common resemblance of the urine in these states, goes far to prove this connexion; and it is not improbable, that the mercurial inflammation, when considerable, may survive its specific cause, and degenerate at length into the purely hydropic state. When, however, mercury is given in minute doses, so that these its specific morbid effects are not produced, it is capable of becoming highly useful, as we shall presently have occasion to notice."
In conjunction with bleeding and other means just noticed, drastic purges have an important influence in subduing the disease; not merely by removing the water, but likewise by contributing to subdue the chronic excitement which occasions its effusion. This latter effect Dr. A. very justly refers to the counteraction and irritation these medicines excite on the mucous membrane of the bowels, by which the excitement of the serous tissue or of the diseased viscus is removed. He remarks that drastic purgatives are sometimes inadmissible in ascites, when an affection of the liver or mesentery is its remote cause, and there is a tendency to a spontaneous diarrhœa, which even the mildest purgatives would increase. "In the case of the mesentery, such a mode of treating dropsy would speedily destroy the patient." Dr. A. ought, perhaps, to have explained the real cause of the danger attending the practice, and not referred it merely to the tendency to diarrhœa, which itself can only be an effect of a morbid condition of the bowels. The fact is, that most cases of hepatitis, and all cases of mesenteric disease, are attended, whether as cause or effect we care not, with inflammation of the stomach or bowels, which purgatives can only tend to aggravate. In general, the practice of administering drastic purgatives is more serviceable in hydrothorax, and especially in anasarca, or in idiopathic serous inflammation of the peritoneum. Dr. A. prefers the gamboge to all other medicines of the same class, and gives it to the amount of four or five grains in a single dose, with the same quantity of some aromatic powder, and triturated with a few crystals of the supertartrate of potassa; or in urgent cases of hydrothorax, he prescribes ten or twelve grains, divided into four doses, one of which is to be given every three hours. When the strength admits of it, the purgative may be given every four or five days.
Dr. A. next notices diuretics.
"The sensible operation of these medicines," he says, "as is well known, is to promote the secretion of the kidneys. There appears to me, however, to be farther effects produced by them upon the system, or particular parts of the system, which is not referrible to the mere evacuation of a certain quantity of fluid from the body; and these effects, it is probable, consist in promoting the natural discharges by this and, perhaps, the other emunctories, whose partial suppression may either produce this disease, or serve materially to continue it; and likewise in occasioning a derivation of blood to the kidneys, and therefore to a part distant from the morbid one; and that thus, whilst they are contributing materially to the removal of the fluid, they are serving like the purgative, an important end, in assisting to subdue the cause of it. The medicines which I am accustomed almost entirely to rely on in this disease, are the powder of dried squill and digitalis, given in combination in the form of pills, and in doses, which, from their smallness, will probably excite no little surprise in the minds of some of my readers. The dose of the squill is something less than a grain, and of the digitalis only a sixth part of a grain, given uninterruptedly every third or fourth hour."
To render these medicines more effectual, a third or half a grain of calomel may be given nightly, and an infusion of dandelion, or some other popular diuretic, may be taken ad libitum. Our author speaks in terms of merited disapprobation of the practice pursued by some physicians, of allowing their patients daily, potions of gin punch, with the view of aiding the operation of the diuretic medicine, and supporting their strength. He shows, that, although by these means the water may be promptly evacuated, the disease is not cured, and the effusion is soon renewed with redoubled violence and danger to the patient.