UNITED STATES OF AMERICA WASHINGTON, D. C. OPO 16—67244-1 651718222523 A DISSERTATION ON DROPSY. Submitted to the Examination of John Andrews, D. D. Provost, the Trustees and Medical Professors, of the University of Penn- sylvania, on the 25th of April, 1811, FOR THE DEGREE OF DOCTOR OF MEDICINE BY HENRY CHAMBERS, OF VlKu.j... Honorary Member of the Medical Society of Philadelphia I PHILADELPHIA: PRINTED FOR THE AUTHOR Fry and Kammerer, Printers, 1811. £ n TO JOHN R. LUCAS, M. D. OF MECKLENBURG, VIRGINIA. THE publication of this Dissertation might well have been dispensed with. But my feelings and du- ty demanded of me some public testimonial of my gratitude to you for the many great and friendly services, together with the invaluable private in- structions I received from you, while your pupil. Accept of this, not as a recompense, but as a mani- festation of the grateful sense I have of your fa- vours. That you may long continue to pursue that pro- fession to which you have done so much honour, and enjoy the domestic happiness with which Pro- vidence has so liberally blessed you, is the most cordial wish of your friend and pupil, THE AUTHOR TO GEORGE CRAIG, Esq. OF LUNENBURG, VIRGDJIA. BLESSED by nature with the first rate talents, and highly cultivated by education, it has long been a serious cause of regret to your friends and ac- quaintances, that you have not before this taken a more active part in the service of your country; whose situation has so much required it. I am hap- py to hear you have at length come forward, and I sanguinely anticipate that before long you will be one of its brightest ornaments. Accept this humble tribute of respect from your friend, THE AUTHOR : ..::.>;]■:■ hi -ino r ;o *ruov f i .,, A DISSERTATION ON DROPSY. A FEW years ago this disease was j'ustly termed one of the opprobria medicina. But a new era has appeared. No longer does the physician approach the hydropic patient with fear and despondence, conscious of his skill being baffled. Nor is this alone the case with dropsy: the same doctrine, which raised the veil from this, has directed our before wayward and uncertain efforts in opposing other diseases of the same terrific as- pect. I mean the doctrine of the unity of disease. Before this was taught, the practice of physicians had been entirely empirical: like the mariner borne on the stormy deep without needle or compass to di- rect him. Whence sprung the great diversity among physicians in treating diseases. Whence the success which attended the different, and even opposite modes of treating the same disease. They were all right and all wrong. From these circumstances, 8 doubt began to be entertained of the power of medi- cine. For what could be inferred from these appa- rent contradictions? Either that opposite causes would produce identity in effect; or that nature had a prescribed mode of curing disease, which over- leaped ordinary medical power. Happily for mankind, the doctrine of the unity of disease has solved the difficulty, and restored thou- sands to health and happiness, who otherwise would have been immolated on the altar of ignorance. That dropsy depends on increased effusion or di- minished absorption is admitted by every one; and that this depends on an increased action in the arte- rial system, in all cases of general dropsy, shall be the object of the following dissertation to prove. In delivering this opinion, I am conscious I differ from all authors on the subject. Even the immortal author of the doctrine of the unity of disease, whose observations on dropsy stand unrivalled, believes there are some cases which are not preceded by high arterial action. I would not be understood to assert that this exists in every stage of dropsy; for I am certain in many cases, after the dropsical effu- sion has taken place, great debility is induced in the whole system: which is nothing more than we find in other violent affections, in which spontaneous evacuations occur. Thus arterial action is reduced 9 by hemorrhages, by sweats, and by evacuations from the bowels. And why should not the same thing occur from hydropic effusions? Debility is no doubt the predisposing cause of dropsy; and that this should give rise to a disease of high morbid action is manifest from the course of all diseases: and that high arterial action should exist in one when obvious debility pervades every other system alike accords with the observation of every intelligent physician. Indeed it seems to be a law of the animal econo- my, that when high action exists in one system, a minus grade should be induced in the others. Having premised thus much, I proceed to men- tion some of the most obvious causes of dropsy. In a healthy person, a watery or serous fluid is constantly exhaled into every cavity of the body; and this without being accumulated is immediately absorbed by a set of vessels adapted for the purpose. Whatever increases this exhalation or prevents ab- sorption must produce dropsy. It has not been sufficiently attended to by physi- cians what effect high arterial action has in produ- cing dropsy. Nor can there ever be a rational or successful method of practice, in this form of dis- ease, until this be attentively regarded. We find it occurring at the close of all fevers B 10 of high morbid action in which bloodletting has not been used, or used too sparingly. That it only takes place under these circumstances in fevers, I infer from its never occurring when de- pletion has been freely employed, or in those of low morbid action, from the beginning. That in this case it depends on increased excitement in the arte- real system is very evident. But how it should be produced by it in some other cases is not so easily explained. Dropsy often occurs in women either from ob- struction or retention of the menstrual discharge; and this we know is often productive of the highest grade of morbid excitement: and may it not be, that the dropsical effusion only takes place when some increased action does exist? It may be asked, if this be a fact, why does not dropsy occur in all cases of increased arterial action? To this I answer, that preternatural action may exist, and not rise to the point at which dropsical effusions take place; or it may transcend it: as we often see morbid action either not rising to, or transcending, the point of inflammation. It is sometimes produced by excessive evacua- tions; and indeed all the causes which produce ob- vious debility in the system. I very much regret my never having seen a case 11 of this description; for I have no doubt observation would prove, that high arterial action existed even here before the dropsical effusion took place. This, to some, may appear paradoxical; yet it is easily explained. Thus persons who fast a long time are seized with a violent fever; the abstraction of the stimulus of food producing direct debility; and of course the system becomes more excitable: on the same principle is the former position explicable. It is certainly preposterous to undertake to prove the physical possibility of high morbid action origi- nating from debility; for I believe no physician of the present day doubts debility being the predispo- sing cause of all forms of disease. From this it is evident, the above position is in perfect consistence with the common and established laws of nature. Reasoning from cause to effect is certainly one of the fairest ways of ascertaining truth; for, cteterh paribus, identity of cause will produce identity of effect. And reasoning from analogy, though some* times fallacious, is often correct. Thus we see gout and rheumatism produce serous effusions in the joints. This never occurs when low morbid action exists. In many diseases we find the pulse reduced by sweats; the same thing takes from dropsical effu- sion; but in many of violent action, we observe sweats occur without effecting any reduction of the 12 arterial action. The same thing takes place in the hydropic state of fever; for we often find high action after the effusion of water: all of which we find in states of disease in which spontaneous hemorrhages occur. In fact, it is all a unit, whether morbid ex- citement be reduced by sweats, by spontaneous he- morrhages, or by dropsical effusions. Dropsy often arises from obstructions of the vis- cera. From analogy, I am forced to believe that either local or general morbid excitement must ex- ist even here previously to the dropsical effusion. Thus obstructions of the liver, as often as any others, produce it; and these, we know, often assume the form of an active disease. In fact, as soon should I expect a discharge from the skin by an application which would not stimu- late it, as dropsy not preceded by high arterial ac- tion. Dropsy is no disease: it is only the effect of dis- ease. With the same propriety could we say that the lymph, which lines the trachefi in cynanche trache- alis, is the morbus ipse, as the effusion of water in any cavity of the body constitutes the disease itself. I have mentioned it as a disease only in obedience to custom, and for sake of perspicuity. Small indeed has been my opportunity of deriving any benefit from experience. My knowledge has 13 necessarily been drawn from books: and with re- gret I assert, until lately none have described, with sufficient precision, the symptoms accompanying this disease. But a few years ago, a physician would have been ridiculed, who would have dared, to feel the, pulse of an hydropic patient: he would probably have been stigmatized as an empiric or a fool. But the new world has been peculiarly blessed. Liberated from the iron grasp of despotism, we ventured to think for ourselves, and forever turned our backs on the absurd dogmas of the old schools. Nullius addictus jurare in verba magistri, was the motto. Ages to come will venerate the name of him, who first threw off the shackles and taught physicians how to think. Having, in a slight and succinct manner, consider- ed some of the most obvious causes of dropsy, and endeavoured to prove it is always preceded by high arterial action, it remains for me to say something of the method of cure; from which I think the princi- ples I have advanced will derive additional support. Of this it is not my intention to treat at length. I shall not descend to minutiae, but only speak of general indications. A case, which came under my observation some short time since, I think deserves to be noticed here; particularly as it is decidedly in favour of the opinion frhave advanced. 14 A servant about thirty* five years of age, after a violent fever was taken with a general dropsy. His abdomen was very much distended; and he was completely anasarcous. In defiance of all the medical aid which could be obtained, his disease continued to increase. Finally the physicians deter- mined it was useless to persevere. At this time the difficulty of breathing was prodigious, and he was compelled to remain erect to prevent suffocation* In fact every symptom marked impending dissolu- tion. His fears and despondence were so great as to prevent his taking any kind of nourishment: and now, together with the distress occasioned by the water, danger was to be apprehended from his ex- treme debility. In a very short time all were as- tonished at the rapid increase in his discharge of urine. Instead of the red and feverish appearance it had formerly exhibited, it was now perfectly natural and in large quantity. From this time his re- covery was rapid and perfect. I should observe no depleting remedies were used, (diuretics excepted), and tonics and stimulants were for the most part relied on. In this case the rationale is evident. High morbid action doubtless existed. And as long as the medicines before mentioned were given they only served to increase the disease; but as soon as they were omitted the sedative effect of fear cooperating 15 reduced the morbid excitement of the bloodvessels, and absorption took place. No doubt, had depleting remedies been used the disease would have been conquered at a much earlier period. In which asser- tion I am warranted by subsequent facts, which al- most incontestably prove it. The same man after three years interval was taken with a violent fever. I had an opportunity of seeing him: and, being ap- prised of his old complaint, I examined and found his lower extremities completely edematous. His head was considerably affected; and his pulse syno- cha. It was not without much reluctance, his friends permitted the physician to bleed him, from his great debility and emaciation. His disease continued to increase for several days; but, by strict adherence to the antiphlogistic plan of treatment, in three weeks the swelling subsided; and he perfectly recovered. In this case, there was the greatest possible degree of obvious debility in the system; and few, I imagine, would have ventured to prescribe bloodletting. But the result proves, beyond the possibility of doubt, the propriety of the plan. May not the edematous swellings, which occur in certain fevers, be the result of nature's efforts to free the system from disease? Perhaps no form of dropsy will serve better to 16 elucidate my ideas, on the subject generally, than hydrocephalus internus. I hope therefore I shall be excused the following digression. To give all the symptoms of this proteiform dis- ease, as Dr. Quin has justly termed it, would swell this dissertation to too great length. I will mention a few of the most characteristic, and refer to Dn Rush's Inquiries for the rest. This disease steals on almost imperceptibly. At first the patient is languid and inactive, often drow- sy and peevish. After a while, a sharp headach comes on, together with an intolerance of light, and not unfrequently a dilatation of the pupils. In fact, every symptom manifests a great degree of morbid action existing in the bloodvessels of the brain. These symptoms continuing for some time, subject as they always are, to great fluctuation, a very dif- ferent set make their appearance. The pulse, which, before was slow, intermitting and irregular, now be- comes weak, quick and regular. The breathing dif- ficult, nearly resembling stertor apoplecticus. The causes, both direct and indirect, are such as deter- mine a preternatural quantity of blood to the brain. We find it occurring particularly in infancy; from this obvious cause, the brain in children is larger in proportion to other parts of the body than in adults; and of course a greater proportion of blood is sent 17 to it than in subsequent periods of life. When we consider the seat, causes and symptoms of this di- sease, we without hesitancy decide, it alone depends on increased action in the arterial system; and that the dropsical effusion is not the disease, but only the effect. In what respect then does this differ from dropsy in other parts of the body? It certainly dif- fers in its seat; but in every other respect, I believe the discrimination to be imaginary. In no disease does the advice, given by the illustrious professor of the practice of medicine, appear more indispensable than in this, viz. to attack disease in its forming state, to eradicate it from the system before it has taken deep roots. Nature dictates this to us; whose directions I fear we too often slight: we too often quit realities to meditate on chimeras, and slight ex- perience to pursue hypothesis and conjecture. If this be not attended to, all our efforts will be of no avail. Few indeed have been cured when the dis- ease has been suffered to form itself; but thousands have been restored to health by attacking it in em- bryo. A small bleeding or cathartic, in this stage, will more probably succeed, than the most power- ful remedies in the former. In addition, I will only remark, that in the first stage only, those remedies can be successfully employed, which are calculated to take down high arterial action: viz. bleeding. C 18 blistering, purging, and cold applications. My time will not admit of my treating particularly of the me- thod of cure in every stage of this disease. For a more minute account of which I refer to Doctor Rush's Inquiries. In examining those authors who have particular- ly written on the cure of dropsy, one circumstance immediately strikes our attention: That all cases of sudden and profuse evacuations of water, by the uri- nary organs, uniformly have been preceded by some sedative cause. From this we rationally infer reme- dies of that description have been too sparingly used. OF BLOODLETTING IN THE CURE OF DROPSY. This is certainly one of our most valuable reme- dies. And if the opinion I have supported be cor- rect, although much used of late, it yet deserves to be more extensively employed: that it is indispen- sably requisite, when high morbid action exists, no person doubts: but that it is admissible, when only ordinary excitement exists, will not be so readily admitted. When we consider what has been the uniform effect of large spontaneous evacuations in dropsy, and what has been the result of sudden and direct debility in the system by whatever cause induced in promoting absorption, I think we should be war- ranted in the experiment. 19 The case related of Dr. Johnson, by Sir John Hawkins, and noticed by Dr. Rush m his excellent treatise on dropsy, certainly somewhat supports this opinion. Here the fear of death, fasting, and the devotional exercises which engaged his attention. all cooperated in reducing the excitement of his sys- tem very low; and absorption took place. Certainly the same result would have been produced much more directly by bloodletting. Dr. Rush mentions several cases, in which he prescribed fasting with manifest advantage. Fear has been found successful from this obvious reason: it is a debilitating passion, and had the effect of reducing morbid excitement. That fear acts in this manner is evidently establish- ed, by cases which are related of sudden and copious evacuations of urine just as the surgeon was about to perform paracentesis. Here the excitement was reduced very low; and indeed death, in some in- stances, has been occasioned. From these facts I again assert that, in my opinion, in many cases the physician would be warranted in making the expe- riment of inducing great sudden debility in the sys- tem by depletion. And, even when preternatural ac- tion does not exist in the bloodvessels, I have no doubt but that fasting, fear, and bloodletting, all act alike in dropsy: viz, taking down morbid ^excite- ment. 20 Purges have often been recommended and ad- vantageously employed. Mr. Murray observes a balance is preserved in the system between exhala- tion and absorption; so that when one is increased the other must be also. The increased secretion and discharge of serous fluid, which cathartics occasion, causes an increased absorption; whence the effused fluid in dropsy is removed. Had Mr. Murray said that this balance exists in the healthy body, doubt- less he would have been correct; but in the system, labouring under dropsy, precisely the reverse takes place. For, as long as a balance between exhalation and absorption exists, there can be -no dropsy: as exhalation must be in over proportion to absorption to form the disease. Therefore the modus operandi of cathartics in dropsy cannot be explained on that principle. I have no doubt they act by producing a diminution of fluids in the system, and of course cause an abstraction of stimuli. From this it ap- pears, they can only be used in those cases which require depletion. Emetics have frequently been beneficially used in dropsy. The modus operandi of these medicines is one of the arcana natura which time alone can develop. My observations, I think, have proved that absorption takes place in much greater degree when sudden debility is induced, than at any other time. 21 Then may not the operation of emetics, when ab- sorption is immediately induced by them, (which is often the case), be explained in the following man- ner: The nausea excited, being a disagreeable sen- sation, is equivalent to the abstraction of stimuli, and of course brings on direct and sudden debility. From this it must be evident that bloodletting, cathartics, emetics, fear, and fasting, all act alike in dropsy: viz. favouring absorption by taking down morbid excitement. It remains for me to say something of that class of medicines termed diuretics. They are such medicines as are supposed to increase the uri- nary7 discharge. They either act directly on the se- creting vessels of the kidneys, or by means of sym- pathy: the action being primarily excited in the sto- mach and propagated by nervous communication* It is a question of some moment, whether ever very great benefit be derived from the use of these medi- cines in dropsy. I am very much inclined to think that they seldom, if ever, are powerful remedies in this disease; and that when any of them are usefully employed, they produce their good effects by an ac- tion on the whole system. Thus many of the diu- retics are of a cooling nature, and others of a tonic; and to these qualities I believe their good effects are to be referred. I do not mean that they have no specific operation 22 on the urinary organs; for I have no doubt they have, and are often palliatives. But that they ever produce a radical cure I cannot believe. After the effusion of water has taken place, great debility sometimes occurs with very feeble arterial action. Here tonics and stimulants alone are to be depend- ed on. I have now, gentlemen, concluded my Inaugural Dissertation. I am fully sensible of its many imper- fections; for which my only apology is the short time I have been allowed to compose it. To con- clude without returning my most cordial thanks to the professors of medicine in the university of Penn- sylvania, for the kindness and attention shown me while a student, and the many opportunities of ac- quiring useful knowledge which they have severally afforded, would argue the greatest ingratitude. That happiness and prosperity may attend you all, gentlemen, is my most sincere wish. To doctor Rush I am particularly indebted. His assiduous attention1 to me, while confined to a bed of sickness, merits my most grateful acknowledg- ments. / .f..., HeJu. Hist. no 1811 c-) ■f *•*/■■'J^&svi '■'"■-V ', Y-V^'V '•«■" "•.^S-a"''»;i. '.■'■'£■■'}■ '">■".'i-fi " ■■' '',•"'■ A **«