ANASARCA AS A SYMPTOM OPOT? 
FICIENT VASO-MOTQR TtfNUS>S 
BY EDWARD T. BRUEN, M.D., 
Physician to the Philadelphia Hospital, Acting Demonstrator 
of Clinical Medicine, and Lecturer on the Pathology of the 
Urine in the University of Pennsylvania. 
Read before the Philadelphia County Medical Society, No- 
vember 12, 1879. 
(Reprinted from the Philadelphia Medical Times.) 
I WISH to invite the attention of the 
Society to three cases which illustrate 
a most familiar ailment, but at the same 
time they have afforded me much food for 
reflection as to their pathology. I submit 
them in the hope that some others may 
be able to shed additional light upon the 
subject. 
The theory which I propose to offer in 
explanation of these cases may appear to 
some visionary, but I am sure that reflec- 
tion will convince the most sceptical that 
disorder of the vaso-motor nervous system 
is alone capable of explaining many ob- 
scure symptoms otherwise totally unfath- 
omable. We cannot investigate in our 
patients the state of the circulation by 
means of the apparatus employed in the 
physiological laboratory, but on that ac- 
count it is all the more important to se- 
cure all the available collateral evidence 
on the subject. Cases somewhat similar 
to my own have been reported, but they 
are not numerous, and I do not recall any 2 
in which anaemia has not been present. 
In the cases I shall relate, the opposite 
state of the blood was unquestionable. 
Without further preface, then, let me 
relate the histories of my cases. 
The first, G. W., I saw in June last: he 
had been working as a watchman on the 
wharf near South Street bridge. He was 
a stout, hearty man of one hundred and 
fifty pounds’ weight, with no trace of 
anaemia, and previously he had enjoyed 
exceptional health. He had pronounced 
quotidian intermittent fever, which yielded 
promptly to cinchonia sulphate. The day 
after he sent for me, and I found him very 
dropsical. The anasarca was general, in- 
volving face, arms, and legs; there was a 
small amount of albumen in the urine, 
but no casts. The heart was acting as 
usual, though the rapidity of the pulse 
was accelerated. No murmurs could be 
heard. The liver and spleen were of normal 
size, and the man expressed himself as feel- 
ing perfectly well except for the swelling. 
He was ordered fifteen grains of cin- 
chonia sulphate daily, with 3> ergot fid. 
ext., t. d. (the ergot was a preparation 
made by Mr. Wolff, at Twelfth and Chest- 
nut Streets, with glycerin), also tr. iron. 
Two weeks and a half afterwards he 
completely recovered, and has since en- 
joyed perfect health. 
In September I saw another case; this 
time in the Philadelphia Hospital. In 
every respect the case was so similar that I 
could not fail to recall the former. The 3 
same plan of treatment was as effective, 
though his recovery was retarded till a 
month had elapsed. 
In this case, as convalescence was pro- 
longed, I used the sulphate of zinc, one 
grain t. d., in addition to the first-named 
remedies, and stopped the quinine after 
the third week. 
The third case was a colored man raised 
in Virginia, who had suffered from chills 
and fever at intervals since 1863. After 
several of these attacks general anasarca 
supervened. He told me that he always 
rubbed himself with an infusion of salt 
and snake-root, and that in a variable 
space of time the swelling was, to quote 
him, “ rubbed out.” 
Just before his admission his malarial 
fever returned, and following it the dropsy. 
The anasarca was as extensive as I have 
ever seen it, even in the worst cases of 
Bright’s disease; the abdominal walls 
formed tumors from the puffing of the 
cellular tissue. There was no albumen in 
the urine ; no enlargement of the liver ; a 
moderate increase of the splenic dulness; 
no heart-disease. 
In this case a careful microscopic ex- 
amination of the blood (Nachet’s method) 
showed only a trifling decrease in the num- 
ber of the red blood-disks, an average of 
three examinations showing them to be 
four million seven hundred and fifty-nine 
thousand. The urine was rather high-col- 
ored, showing by tests an increase in the 
coloring-matters. There was also a mod- 4 
erate effusion of fluid into both pleural 
sacs. But, at the same time, the man’s 
spirits were good, and his general health 
was remarkable. Indeed, he was with dif- 
ficulty persuaded that he was a sick man. 
The treatment here was similar, but pur- 
gatives were freely exhibited. Digitalis 
was employed, and an effort was made to 
secure some action of the skin by means 
of hot-water bathing and steam baths. 
Operative treatment was invoked to relieve 
the hydrothorax, but no permanent benefit 
resulted, as the fluid returned, and one 
day, on rising suddenly from the bed, he 
fell over dead from asphyxia. 
In a post-mortem I have rarely seen so 
healthy a collection of organs, with the 
exception of the spleen, which was twice 
its natural size; but the tissues were fairly 
reeking with serum, and there was effusion 
into all the serous sacs. 
I would again, at this point, solicit your 
attention to the fact that these cases oc- 
curred in persons who were not anaemic. 
Now, in studying these cases for an ex- 
planation, two methods have suggested 
themselves to me. In the first place, when 
an individual suffers from a chill the blood- 
vessels of the skin become markedly con- 
tracted and the internal blood-vessels as 
markedly dilated with blood ; afterwards 
we have the febrile and sweating stages, 
during which the blood-vessels of the skin 
become dilated and remain so until a new 
nervous impulse induces contraction, re- 
peating the chill. 5 
Imagine that owing to the intensity and 
repetition of the action of the malarial 
poison the normal tonus of the inhibitory 
nerves is sufficiently impaired to occasion 
more or less persistent partial or total re- 
laxation of the blood-vessels. The effect of 
widening the arteries and capillaries would 
be to over-fill the venous system, and thus 
would dropsy occur, precisely as in the cases 
of venous congestion from cardiac disease. 
We can, I think, understand that after 
the malarial germs (?) are destroyed by 
the action of quinine, the effects of their 
action upon the nervous system should 
be more permanent, though the cause 
has been removed. Familiar illustra- 
tions of this are to be found in the en- 
larged spleen and impaired digestion of 
those suffering from malaria. This con- 
dition passes away whenever the nervous 
system is recuperated from the shock or 
the action of nervines assists nature. 
In this connection I would remark that the 
colored patient cured himself with “sim- 
ples;” in other words, the vaso-motor 
nerves, having recovered their tonus, re- 
sumed their functions. But we are not with- 
out experimental evidence on this subject. 
The first experiments upon the subject 
of oedema were made by Lower in 1680. 
He tied the venae cavae, and found that 
oedema appeared in the lower extremities, 
and he ascribed the oedema to the dimin- 
ished absorption of the intercellular fluid 
owing to venous congestion. 
Valsalva and others repeated these ex- 6 
periments, but without a similar result. 
As usual, in the middle ground the truth 
was found. 
Ranvier has proved that oedema depends 
not only on diminished absorption, but 
also upon increased exudation from the 
vessels. He first tied the venae cavae in 
the abdomen of a dog, and found, like 
Valsalva, that oedema did not appear; there 
was undoubtedly over-filling of the arteries, 
but the lymphatics were able to absorb the 
exudation without any assistance from the 
veins, and therefore no accumulation of 
fluid took place. He also found that upon 
cutting the sciatic nerve, on the wounded 
side, intense oedema occurred. 
Venous congestion was undoubtedly 
present in both legs, as the venae cavae 
had been tied, but in one the nervous in- 
fluence proceeding to the arteries through 
the sciatic nerve kept them contracted 
and prevented the exudation of more fluid 
than the lymphatics could absorb. In the 
leg in which the nerve had been paralyzed 
by division of the nerve, the vessels dilated, 
the limb became rosy and warm, and so 
much fluid was poured out that the lym- 
phatics alone could not absorb it without 
the aid of the veins. Ranvier further 
proved that this was due to the paralysis 
not of motor but of vaso-motor nerve- 
fibres which are contained in the sciatic ; 
because, after cutting in different animals 
motor and vaso-motor nerves in the lumbar 
region before they had united to form the 
nerve trunk, when the motor fibres were 7 
divided as they issue from the lumbar 
vertebrae before uniting with the sympa- 
thetic fibres, complete paralysis of the legs 
was produced, and no oedema occurred; 
but if, on the other hand, he divided the 
sympathetic fibres passing to the sacral 
plexus, there was no motor paralysis, but 
the vessels dilated, and oedema occurred. 
The experiments first cited show us that 
paralysis of the vaso-motor nerves is an 
important factor in the production of 
anasarca. It will also be seen that the 
oedema in the animals experimented upon 
is analogous to the accumulation of fluid 
in the cases of the patients whose histories 
I have cited. But deficient vascular tonus 
is not, I think, the only factor involved. 
Broadly speaking, the waste products of the 
animal economy are urea, carbonic acid, 
salts, and water. The carbonic acid and 
the water pass off by the lungs, the urea, 
salts, and water by the kidney, but by the 
skin also small portions of the above sub- 
stances are eliminated. If the function of 
the skin is suspended, these substances 
accumulate in the system, and can, I think, 
aid in the production of dropsy. In my 
cases the skin was notably harsh and dry. 
Again, the function of the skin is not 
alone dependent upon the blood-supply 
of the skin, but is also under the control 
of the innervation of the nerves supplying 
the cutaneous glands. 
Dr. Foster states that the skin of dogs 
and cats can be made to act, and sweating 
produced, by stimulation of the sciatic 8 
nerve after clamping the aorta; and the 
same result he has obtained in the leg of 
a frog by stimulating the sciatic nerve 
after amputating the leg.* In cases similar 
to those before us, if exposure to cold 
occur at the close of a malarial attack, I 
can understand that the nerves can be 
influenced by the action of the cold and 
their function suspended, as easily as I can 
understand the dilatation of the blood- 
vessels of the lungs when a pneumonia is 
traced to a cold. Indeed, I can as read- 
ily understand the action of the malarial 
poison upon the nerves of the spine, just 
as I can understand the impaired nutrition 
of those suffering from repeated malarial 
seizures,—a condition of the system uni- 
versally credited to an action of the poison 
upon the nervous system presiding over 
nutrition. Again, the inaction of the skin 
may be traced to the anasarca, which dimin- 
ishes the activity of the circulation of the 
skin, of course impairing its functional 
activity. To sum up briefly what I have 
said, I would refer to the above explana- 
tion those cases of general anasarca, often 
preceded by malaria, in which no lesion 
of the heart, kidneys, liver, or blood can 
be diagnosticated. I say blood, because 
my cases differ from others which I have 
* The existence of secretory nerves, and their special 
influence over the secretions of the skin, have also been inves- 
tigated by Dr. Isaac Ott and G. B. Wood Field in a series of 
original experiments. Their experiments are confirmatory, 
and may be found in the Journal of Physiology for 1878-79, 
entitled “ Sweat Centres : the Effect of Muscarip and Atro- 
pin on them.” 9 
seen reported, in the fact that there was 
no associated anaemia. It appears to me, 
therefore, that the theory of a lesion of 
the vaso-motor nerves, and of the nerves 
presiding over secretion, is more certainly 
established. The blood-corpuscles, it is 
true, were counted in but one case, yet I 
am sure that my hearers will support the 
statement that anaemia can be recognized 
by physical examination alone, and the 
local congestions of anaemia must deceive 
in but a very few cases. I think the 
theory which I offer is especially useful in 
the explanation of those cases of moderate 
dropsy, which is also very often local, 
which is frequently seen in persons in 
middle life, and also in young persons 
who have been subjected to depression of 
nerve-tonus. 
Before closing, let me ask you to con- 
sider a treatment by tonics, directed to 
restore the tonus of the nervous system, and 
the vaso-motor system especially,—viz., by 
strychnia, sulphate of zinc, tincture of 
chloride of iron, fluid extract of ergot, digi- 
talis, and quinine. These drugs I have suc- 
cessfully employed, sometimes dispensing 
with the digitalis, especially in the cases 
of moderate anasarca, and also in cases 
of those whose stomachs would not toler- 
ate this drug. In the first place, let me 
say that absorption of fluid from the 
tissues is, like its exudation into them, 
probably greatly controlled by the cen- 
tral nervous system. Dr. Brunton cites 
the experiments of Goltze and Nasse, in IO 
which the former found that when fluid 
was injected under the skin of the back 
of a frog it was rapidly absorbed, so long 
as the brain and spinal cord were unim- 
paired, but when these were destroyed little 
or no absorption took place. 
Physiologically speaking, absorption is 
under the influence of nerve-centres, there- 
fore stimulation of these centres will in- 
crease their physiological functions. Stimu- 
lation of a sensory nerve is capable of 
inducing contraction of the entire vaso- 
motor system. Apropos to this, Nasse 
has found that irritation of a sensory 
nerve actually did occasion increased 
absorption. To return, however, to the 
subject of medication by the drugs men- 
tioned (zinc, ergot, iron, digitalis, strych- 
nia, quinine), not only do they act as 
tonics to the nervous system, but some of 
them, viz., those which are astringents, 
possess a direct influence upon the blood- 
vessels through their local impression upon 
the vaso-motor nerves, which fact I quote 
from Rosenstein’s experiments recorded 
in Ziemssen’s “Cyclopaedia” and also in 
Dr. H. C. Wood’s “Therapeutics.” 
Iron may be said to act also by restoring 
to the red blood-corpuscles one of their 
normal constituents, enabling them to per- 
form more perfectly their function as 
carriers of oxygen to the tissues, and 
thus the material accumulated in the lym- 
phatics and veins is first oxidized and 
then eliminated from the system. 
In my last cases, because the effusion 11 
was so extreme, digitalis was employed. 
This drug, by its properties as a stimulant 
to the vaso-motor and cardiac systems, 
acts most favorably as a tonic diuretic, 
mainly, probably, through the increased 
efficiency by which the circulation is 
maintained. The only contra-indication 
occurs in cases where the stomach cannot 
bear the drug; and this remark will also 
apply to the use of iron. 
Finally, let me allude to the value of 
strychnia as a tonic. This drug is very 
highly recommended by Dr. Lauder Brun- 
ton, to whose paper on the “ Action of 
Tonics” I am much indebted. 
He remarks that strychnia by its action 
as a respiratory stimulant can aid in thor- 
oughly oxygenating the blood, thus pro- 
moting the efficiency of the circulation, 
and by this means also probably the more 
perfect elaboration of the red blood-cells is 
accomplished by the blood-making glands. 
Further, he claims a stimulant action 
not only upon the dominant vaso-motor 
centre, but also upon the vaso-motor cen- 
tres distributed through the cord. These 
centres, to quote his words, are so feebly 
developed as not to heed ordinary stimu- 
lation, but can be aroused by the use of 
strychnia to lend their aid to increase the 
vascular tonus. “For,” says he, “it has 
been proved that after section of the spinal 
cord, which of course paralyzes the vaso- 
motor centre, the blood-pressure can be 
made to rise by the irritation of a sensory 
nerve.” 12 
But, while giving the prominence to 
strychnia to which its value as a respiratory 
stimulant in bronchitis and asthma and its 
use as a tonic entitles it, I would say that, 
of the other drugs to which I have referred, 
none has yielded to my clinical experience 
more valuable results than the sulphate of 
zinc. This drug, in small doses continued 
for a considerable period, is, I think, more 
efficient than any other preparation of zinc, 
and it is an addition to our armamentarium 
with which we can combat nervous exhaus- 
tion, scientifically termed deficient vaso- 
motor tonus, whether this deficient tonus 
is or is not accompanied by oedema.