I **>; :3-rt ?^ I *«! ^5$S llil UNITED STATES OF AMERICA WASHINGTON, D. C. OPO 16—67244-1 A N INAUGURAL DISSERTATION O N UNIVERSAL DROPSY; SUBMITTED TO THE EXAMINATION O F T H E Revd. JOHN EWING, s. t. d. Provost; THE TRUSTEES AND MEDICAL PROFESSORS O F T H E UNIVERSITY of PENNSYLVANIA; FOR THE DEGREE OF DOCTOR OF MEDICINE: ON THE TWELFTH DAT OF MAT, A. D. 1791. By ELIJAH PERKINS, a. b. OF CONNLO 1 1CUT, Member of the American Medical Society, at Philadelphia. NIHIL EST INDAGATIONE NATURAL MELIUS, NIHIL DULCI- US, NIHIL MEDICO DIGNIUS. RATIONE DUCE PER TOT AM VITAM EUNDUM EST: MINIMA MAXIMAiHUE EX HUJUS/<^^JKLffrf > GERENDA SUNT. SENEGA."/' ^- k' f;*# , / THIS DISSERTATION IS MOST RESPECTFULLY INSCRIBED T O WILLIAM SHIPPEN, m. d. PROFESSOR of ANATOMY anb SURGERY, BOTH IN THE UNIVERSITY of PENNSYLVANIA AND COLLEGE o* PHILADELPHIA. Equally refpected in Europe and America for his univerfal Information as a Man of Science, Superior Abilities in his Profemon, Politenefs of Manners, and Unequalled Eloquence, Perfpecuity, and happy Talent of com- municating his Ideas on the mofl abflrufe Subjects as a Lecturer. By his much obliged^ And mojl affectionate PUPIL, J-l OC4b3 ALSO, T Q THE |Uv». EZRA STILES, s. t. d. l. u q, PRESIDENT of YALE COLLEGE, In CONNECTICUT; A Man defervedly refpected By the Friends of Virtue and Science, For his univerfal Literature, Penetrative Mind, Confummate Piety, Boundlefs Philanthropy, Unwearied Labours in fpreading and eftablifhing the Truths of the Chriflian Religion, By his mojl obedient Humble Servant^ E. PERKINS. LIKEWISE, T O JOSEPH PERKI N S, M. A. PRACTITIONER of MEDICINE, I N T H E STATE of CONNECTICUT} Whofe Abilities and extenfive Practice have juftly ranked him with the molt resecta- ble of his Profeflion; who., n' prefent* affords a pleafing Ex mple how fe- rene and eafy the De line of Life can be made, by a Recollection of his many important and fuccefsful Service for the RELIEF of the DISTRESSED; By his mojl affetlionate Grand/on^ The AUTHOR, INTRODUCTION. AT a period when a freedom of enquiry prevails in every department of fcr- ence, and the mind is no longer pamve to any particular feet or fet of teachers; but prefumes to think and act for itfelf. When medicine is no longer confidered as a con- jectural art, but about to emancipate from the chains of bigotry and error, and hold a Sprefpedlable rank in the feveral departments of human knowledge. It has fallen upon me to write a difTertation on fome medical fub- ject, therein giving a fpecimen of my dili- gence and application; which, by the laws of this Univerfity, has become necefTary to the obtaining a Doctor's degree in medicine. Had I adopted the long eftablifhed cuftom of publilhing inaugural differtations in the Latin language, I might, in a great meafure, B have x INTRODUCTION. have avoided the cenfure of thofe, who are too ready to overlook the merits, if any there be, and expofe to public view the defects of every performance not fanctioned by autho- rity, or fupported by fome refpectable fociety: As there are fome things advanced, in this Thefisy contrary to the general received opi- nions, and common methods of practice, I expect the fhafts of criticifm will not be un- prepared. But the propriety, not with {land- ing the many difficulties a young man has to encounter, of publifhing in a living lan- guage, I think, is fo evident, that it needs little or no apology. o F O F UNIVERSAL DROPSY- w~*mmmmm BEFORE entering upon, my ftibject, I mall mention the different genera of dropfy, as given by Dr. Wm. Cullen, in his Synopfis Nofologiae Methodical. Tom. II, C L, Cachexias, Ord. Influmefcentias. Sect. Aquofas Sive Hydropes. In this fection he has mentioned feveral kinds of dropfy, to which he has given dif- ferent appellations derived from the parts of the body, in which the affection is princi^ pally feated.—As ANASARCA. Corporis totius vel partis ejus intumefcen* tia mollis, inelaftica. HYDRO- 12 Of Universal Dropsy. HYDROCEPHALUS. Capitis intumefcentia mollis, inelaftica,, hiantibus cranii futuris. HYDRORACHITIS. Tumor fupra vertebras lumborum,moilis exiguus, hiantibus vertebris. HYDRO THORAX. Dyfpncea; faciei, pallor; pedum oedema- ta; urinaparca; decubitus difficilis; fubita et fpontanea ex fomno cum palpitatione ex- citatio; aqua in pectore fluctuant ASCITES, Abdominis intumefcentia tenfa, vix elaf- tica, fed fluctuofa, HYDROMETRA. Hypogaftrii in mulieribus paulatim cref* cens tumor, uteri figuram referens, preffui cedens fluctuanfve; citra ifchuriam et gra- viditatem. H Y.DR.OC ELE. Tumor fcroti non dolens, paulatim cre£- eens, mollis, fluctuans, pellucidu?. Some of thefe genera he has. fubdivided into different fpecies, according to the dif- ferent circumftanees with which they are combined, In Of Universal Dropsy. 13 In this differtation I {hall confider the dif- ferent kinds of dropfy recited above, as one and the fame difeafe, depending upon the fame diathefis, to be cured by the fame re- medies ; and the different phcenomena which take place, as arifing from a difference in the feat and degree of the difeafe. If a general affection fhould be diffufed over the body, and not yeilding to general remedies, fome local caufes. muft be fufpected; fuch as fchir- ri, polypi, ruptures of veffels, impofthumes, tumors, and other caufes of obflruction and compreflion. When the prefence of any of thefe can be afcertained, the complaint muft be confidered as local, and not depending on the general powers which give origin to an idiopathic difeafe. In thefe cafes, the cure, if it can be accomplimed, muft de- pend upon the removal of the morbid ftate of the part fir ft affected, and not on thofe powers which alter the general ftate of ex- citement over the whole body. Whenever this difeafe is owing to fome morbid change in the ftate, or to fome alter- ation of the organization of a particular part, and not depending on thofe powers which effect the general Hate of the fyftem ; it is for the moft part incurable by our art, and 14 Of Universal Dropsy. and cannot be confidered as an object of practice; therefore not coming within the jimits of this thefis. Thofe, who wifh a par- ticular account of the different fpecies of dropfy, depending on previous local affec- tions ; I refer to Dr. D. Monro, who has fully and amply treated the fubject, DEFINITION. "P\ R O P S Y is an increafed effufion of water into the cellular membrane, or fome principal cavity; thereby producing an enlargement of the whole, or a part of the body, SYMPTOMS. The dropfy is faid moft generally to at^ tack thofe advanced in life ; particularly the female; but this difeafe is not confined to any age, fex, or temperament; for it attacks all indifcrimin.at.ely. In giving the hiftory of this difeafe it is difficult, nay, impofli- ble to mention a fet of fymptoms, which will occur in every cafe. Some peculiarity of conftitution, or accidental circumftances, may Of Universal Dropsy. 15 may caufe different appearances to take place in different perfons, and in the fame perfon at different times in life. A variety of fymptoms is narrated by au- thors, as peculiar to this difeafe; but as they are equally applicable to other difeafes which have debility for their caufe, I fhall only mention thofe which molt commonly oc- cur, and which I have, in feveral patients, obferved to take place. In this difeafe there is always an enlarge- ment of the whole, or a part of the body, from a collection of water in the cellular membrane, or fome principal cavity. From a communication fubiifting between every part of the cellular membrane, this enlarge- ment is much influenced by the different pofitions of the body. This intumefcence is inelaftic, and when the finger is prefixed upon it, it, for a fhort time, retains the im- preffion, the water gradually returning on the preffure being removed. This difeafe moft commonly makes its appearance firft in the feet and legs, which become fwollen in the courfe of the day ; the fwelling dis- appearing in the morning, if the patient has been in an horizontal pollure during the \6 Of Universal Dropsy. the night. I have known it to appear in the abdomen in the form of afcites, and conti* nue for feveral months, then yielding to fuit- able remedies, no other part of the body fhowing a difpofition to an hydropic fwell- ing. When it begins in the feet, as -the de*. bility increafes, the fwelling proceeds up- ward till it arrives at the cheft ; feldom en- tering that cavity, unlefs the primary affec- tion, which gave rife to the general debili- ty, was feated in that part. The prepuce and fcrotum are fometimes amazingly dif- tended, in confequence of the wrater defcend- ing along the proceffes of the peritonceum into the fcrotum, and along the cellular membrane into the prepuce , the latter is many times fo fwelled as to obftruct the paf- fage of the urine. In women the labia are much enlarged, the vagina confiderably elongated; when this is the cafe, they complain of a difficulty in pafling the urine, and a bearing down of the uterus. A very frequent and difficult refpiration attend this difeafe, arifing either from a collection of water in the cheft, or from the waters of the abdomen prefling a- gainft the diaphragm; thereby diminifhing the cavity of the thorax, and obftructing the Of Universal Dropsy. 17 the circulation of the blood through the lungs. A cough is many times a very trou- blefome fymptom, this proceeds from the exhalation into the bronchia being diminifh- ed, in confequehce of which, a difagreeable tickling fenfation is excited about the glottis. In the advanced ftages of dropfy the ap- petite fails, the thirft is almoft unfupporta- ble, the perfpiration diminifhed, the fkin dry, and the urine in fmall quantity.— Thefe fymptoms indicate great debility, particularly in the fecretory and excretory veffels, deftined to thofe particular offices, and fhow, that, the determination to thefe parts is not fufficiently fupported. The ap- pearance of the urine is very precarious, it is fometimes white and tUrbid, fometimes clear, but molt commonly depofiting a la- teritious fediment: the pulfe fmall and frequent, often very irregular, and fcarcely to be feltt In women fome of the principal fymptoms, which diftinguifh hyfteria, occafionally fu- pervene, and the mind is very much affected, as in hypochondriafis. Livid fpots appear on different parts of the body, moft com- monly on the extremities; if they open, a C watery i8 Of Universal Dropsy* watery liquor is difcharged, frequently of* an acrid nature, which corrodes the adjacent parts; to this, fphacelation foon fucceeds, and puts a period to the perfon's life. In proportion as the abdomen and lower extre- mities fwell, the upper extremities become emaciated: fometimes it happens that the upper extremities are fwelled> when this is the cafe, the fwelling paffes from one arm to the other, feldom, both equally affected at the fame time. The tympanites accompanying this difeafe is very juftly confidered as a dan- gerous fymptom; for fcarce an inftance is recorded of a perfon, who recovered after this fymptom came on. The fymptoms, which prognoftic ate death, are, a difficulty of breathing, fo that the pa- tient is obliged to keep an erect pofture; a lofs of appetite and ftrength; a difficult cough ; an emaciation of the upper extremi- ties; excefiive thirft; fcarcity of urine; fmall and frequent pulfe, fome degree of fever; li- vid fpots on the legs, and a violent diarrhaea. When the whole, or a principal part of thefe fymptoms fupervene, death foon clofes the fcene. CAUSES. Of Universal Dropsy. 19 CAUSES. Such has been the activity of inveftiga-. tion in the minds of thofe, who have writ- ten upon this difeafe, that, not only a vari- ety, but oppofite caufes have been afligned. By one, it is faid to be caufed by obflruction, for inftance, of the menfes, by another, to a7 rife from an exceflive evacuation of them, and the fame author, who gives obflruction as a caufe, a few pages farther, relates this cafe: A woman, forty or fifty years of age, never married, a valetudinarian for twenty years, and fubject to an immoderate flux of the menfes, was affected with an univerfal anafarca. Monro.—If an obflruction of the catamenia is the caufe of dropfy; why does it not always obferve an uniform effect? Why does not dropfy take place in afthenic mania—In epilepfy ? in which difeafes the catamenia feldom or never appear. Why fhould this obflruction produce dropfy in preference to any other difeafe of debility ? I prefume no phyfician at the prefent day, be^ caufe this fymptom is prefent, will fly to it, to account for the different phenomena which take place in every afthenic difeafe. This is no other than a fymptom of debility, and 20 Of Universal Dropsy. and depending upon the fame caufes as the difeafe which I am now treating. For inftance, repeated falivations, by in- ducing debility, bring on this difeafe; an obftructed menftruation is produced by the fame caufe. After a falivation, a regular appearance of the catamenia does not take place for feveral months ; not till the fyftem has acquired a confiderable degree of vigour. If this difeafe depended on obflruction, we could not expect a cure till this morbid af- fection was removed, But this is feldom or never the cafe, and it is well known, that the cedematous fwellings difappear a long time before this natural and healthy difcharge is again eftablifhed. I will give one cafe in confirmation of what has been advanced. C-------M-------, a lady of about three and twenty, of a delicate habit, and whofe catamenia had been obftructed for more than five months ; her legs and feet much fwelled, and covered with livid fpots; fhe had a troublefome cough, and at times was a little coftiye. To pleafe her more than myfelf, I ordered a gentle laxative. She made a free ufe of the feveral kinds of dif- fufible ftimuli, as wine, brandy, porter and opiunij Of Universal Dropsy. 21 gpium, as fhe found beft to agree with her ftomach. Her appetite being bad, fhe took but a little aliment for the firfl three weeks, after which, her appetite returned. She then confined herfelf principally to an animal diet, and that of very eafy digeftion; omit- ting the diffufible, as fhe found her ftrength to increafe, and in about fix weeks the cede- matous fwellings entirely difappeared. This plan was purfued till fhe perfectly recover- ed ; though her catamenia did not return for three months from the time I firft faw her. Whether any one caufe to be mentioned, is, of itfelf, capable of producing this, or any other idiopathic difeafe, is uncertain: but, that, part, or the whole of them, when combined, are adequate to this effect, I think, is incontrovertible. The caufes are, cold long applied to the body; this occafions a lofs of appetite, and other fymptoms of debility. A cafe of this kind is related, by Dr. Mon- ro, in which cold alone produced an univer- fal anafarca. Abftinence, or fuch articles of diet, as are not fufficiently nutritive : thefe are all kinds of vegetables, particularly the different kinds of falads. To thefe, the low- er clafs of people, in many countries, are much confined, and it is on this account, together 22 Of Universal Dropsy. together with their other irregularities, that, there are more inftances of this difeafe, a^ mongft them, than perfons of higher fta- tions in life. Thefe afford but a fmall quan- tity of matter from which chyle can be form- ed, confequently, a fmall quantity of blood; as the latter, muft always be in proportion to the quantity of the former, generated in the procefs of digeftion, provided, no im- pediment offers to its being taken up by the abforbents, and carried into the circulating fyftem. Dropfy is often the refult of cold, and watery drinks, when joined to a fedentary life. Thus we have inftances of this difeafe in fome profeffional characters, who, fearful of the vice of intemperance, do not adhere to the paffage, where it is faid; " Drink no longer water, but ufe a little wine for thy ftomach's fake, and thine often infirmities." A large quantity of cold water taken into the body, after exceflive heat or fatigue, has been known to favor the acceflion of this difeafe ; not by increasing the watery parts of the blood, as it has been fuppofed, but, by adding a directly debilitating power to a ftate of indirect debility. Exceffes of all kinds, fuch as heat, drink, watching, venery and Of Universal Dropsy. q.% and the like ; large and repeated evacuations of the vital fluid, either by accident or de- fign, greatly tend to the production of that diathefis, which gives occafion to this generi- cal diftinction. The cold bath has been the caufe of dropfy more frequently than has been generally fuppofed, efpecially, if had recourfe to when the body is in a ftate of debility* An inftance of this lately happen- ed in this city; a gentleman, juft recovering from a fit of ficknefs, as he was walking on one of the wharfs, by accident, fell into the water, though before recovering his health very faft, he was after this immediately feiz- ed with afcites. Certain affections of the mind, as fear, for- row, anxiety, grief, lhame, remorfe, and an indolence and inactivity, greatly contribute to the fame end. Faftidium Animi is likewife very debilitating. It frequently fucceeds difeafes which have continued for a confi- derable time, fuch as intermittents, dyfen- teries, or thofe in which the antiphlogiftic regimen has been too rigoroufly adhered to. Repeated falivations, or when they have been too long continued, are often fucceeded by this complaint ; particularly, if the patient is afterwards expofed to cold and moifture. One 24 Of Universal Dropsy. One of the caufes mentioned, I fear, by fome, will be objected to, as it is recommend* ed by a much celebrated author as one of the moft powerful remedies in the cure of this difeafe. This is the Gold-Bath, Dr. Cullen thus obferves ; " Cold bathing is upon many oc- cafions the moft powerful tonic we can em- ploy ; but at the beginning of dropfy, when the debility of the fyftem is confiderable, it can hardly be attempted with fafety. After however, the water of dropfies has been ve<- ry fully evacuated, and the indication is to ftrengthen the fyftem for preventing a re- lapfe, cold bathing may perhaps have a place. It is, at the fame time, to be admitted with caution ; and can fcarcely be employed till the fyftem has otherwife recovered a good deal of vigour. When that indeed has hap- pened, cold bathing may be very ufeful in confirming and completing it." In this paragraph he fubjoins a caution, and fays, it muft not be ufed till the fyftem has otherwife recovered a confiderable degree of vigour. In this he is certainly right, for now the fyftem is capable of refilling its de- bilitating power; but if we have recourfe to the Of Universal Dropsy. 25 the cold bath when any confiderable degree bf debility is prefent; what will be the event? If facts are to be relied on—an increafe of all the fymptoms, and ultimately death-—But if opinions, which few dare controvert, are to prevail—an increafed tone and ftrength over the whole body. What does he farther obferve? At the fame time he is fpeaking fo highly of the bath, he ftrongly recom- mends a very confiderable degree of exercife, and a free ufe of ftrengthening medicines. Had he omitted the laft mentioned remedies, and tried the effects of the bath alone, it is probable, that the event would have furnifh- ed us with an argument not eafily to be re- futed. It is generally remarked, that, after uiing the bath, unlefs it is foon followed by a glow or warmth, it does harm ; for unlefs this takes place, and the ftrengr.h of the fyf- tem is able to fupport it, the bath ferves no other purpofe than to chill and cool the body, thereby diminifhing the force of the circu- lation, and inftead of promoting, diminifhes the abforption and excretion of the fluids. An antient author, when fpeaking of the effects of the bath, obferves ; Balneum at- que humor omnis alienus eft, Cel.------- D What 26 Of Universal Dropsy* To what is this fenfe of heat owing ? Is it not owing to the vital heat being abftradted from the extreme veffels, and thefe left in a ftate of torpor and inactivity, and foon after being ftimulated from a return of the vital fluid into them a tergo, together with the warm clothes with which the body is immediately covered, and not to the ftimu- lus of the bath ; as it has been commonly ftq> pofed ? This is the moft probable conclufi- on.—From analogy, we Ihould fuppofe it to be the cafe. If a perfon is expofed any length of time to a confiderable degree of cold, he finds himfelf to be ftiff and inac- tive ; but, if he is gradually returned to a warmer temperature, and takes fomething warm internally, he finds, that, from a dozing and depreffed ftate, he has become active and alert, and that, the increafe of excitement has become uniform and uni- verfal. If cold be a ftimulus and heat debilitating as many would infinuate; how are we to account for the beautiful and lively green, when the gentle fpring fucceeds the furly winter and the ravaged vale ? And how are we to account for the many infect tribes, after a temporary death, ftarting into life, under Of Universal Dropsy. 27 under the influence of the penetrative fun? Thefe are queftions which I thought proper to afk; but, as limits are fet to this difler- tation beyond which I cannot proceed, I muft leave this part of the fubject for the confideration of others. From a blind attachment to former cu£ toms, and former methods of thinking, the truth is very apt to efcape us. Had the au- thor, juft quoted, laid afide antient preju- dice, and confidered, that cold was but a negative power; that its apparent effects depended not fo much on the cold itfelf, as on the previous ftate of the body to which it was applied ; that cold only operated by diminifhing excitement, and keeping the body within the boundaries of vigour: he would not have endeavoured to prove that cold when applied to the body, had not on- ly feveral, but different and oppofite effects; fuch as fedative, ftimulant, tonic, aftrin- gent, &.c. Is it to be fuppofed that any one power can be creative of fuch oppofite ef- fects ? Is it agreeable to reafon ? Can it be explained upon any principles of philofophy whatever ? If this is fuch an ufeful remedy in all difeafes of debility; why does he re- commend it in a difeafe of the higheft de- gree of excitement ? viz. Sthenic Mania. The iS Of Universal Dropsy, The character of Dr. Cullen is fuch, it may be thought prefumption by fome, that a young man fhould dare to contend with fp formidable a perfonage. Yet, however great a man's authority, or however diftinguifhed his abilities, if he delivers things contrary to truth, we are not paflively to receive them. A phyfician ought to be ftudious to examine into the legitimacy of every fact, to fcruti- nize with diligence every circumftance rela- tive to his profeflion; and though many times he may not be able to offer any thing new or improving, it is frequently of fervice even to dare to doubt. If we may judge from the fpirit of enquiry that now prevails \ the defire of fearching into the Hidden recef- fes of nature, and inveftigating her fecret o- perations ; we may expect, that the period will foon arrive, when medicine will be no longer a fubject of reproach, but nature's paths fo clearly pointed out, that the meaneft capacity may trace her through her labyrin- thian courfe, wipe away every offending caufe, and drive every enemy from hermo- lefted habitation : and that the time will come, when thofe difeafes, which now re- main the approbria medicorum, may be as eafily cured as the moft fimple difeafes with which we are at prefent acquainted. I will relate Of Universal Dropsy. 29 relate feveral cafes in which the cold bath was ufed, which cafes I noted at the time. P—— H—---, a young man, who led a fedentary life, was, at the age of eighteen, feized with pneumonia, of which he was cured; but his phyficians, not confidering his former habits, adhered too clofely to the antiphlogiftic treatment; of courfe he was left very low and weak. Soon after he per- ceived a fhortnefs of breath, particularly on lying down; his abdomen was fomewhat fwelled, though no undulation could be perceived. His fhortnefs of breath at laft became conftant; his phyficians gave him feveral cathartics, and between thefe the diuretics ufually recommended. Thefe they found by increafing the general debility, to increafe his other complaints. They then advifed the cold bath; he had ufed this but a few times before he was fo debilitated, that, he could not walk ten rods, though before, he could walk a confiderable diftance without much fatigue. They then defired him to try the fait water; this he found to produce fimilar effects. He then difmiffed his phy- ficians, and confined himfelf to a free ufe of the diffufible and durable ftimuli; he rode every day as much as his ftrength would permit, 30 Of Universal Dropsy. permit, and in two months perfectly reco- vered, notwithftanding he had been trou- bled with this complaint for more than twelve months/ D----T---~, and J----H——H, two boys, one two years, the other two years and fix months old, had been for fome weeks troubled with a lax, which had produced an emaciation of the whole body. They took a variety of medicines, but to no purpofe. They were then put into the cold bath, foon after they began the ufe of this, their legs and feet began to fwell, in one the fwelling advanced as far as the abdomen. They then omitted the bath, but both died in a few days. J---- F----, aged three years and fix months, had a diarrhaea, he took many me- dicines, but getting no better, was put into the cold bath. After he began the ufe of this, he immediately grew worfe, and died in about fix days. J----S----, aged thirty, had the rheu- matalgia, for which he tried the cold bath, but finding his feet and legs begin to fwell, he omitted it; and by the ufe of ftrengthen- ing medicines foon recovered. This pati- ent Of Universal Dropsy. 31 ent took no medicines at the time he was u- fing the bath, purpofely to afcertain its ef- fects. PROXIMATE CAUSE. The true idiopathic dropfy, I fhall conii- der as ever depending on a ftate of debility over the whole body, but predominant in fome particular parts: though it is much contended by fome that this difeafe may arife from different and even oppofite caufes* Thefe are, an excefs of irregular, or a defect of regular action, in the arterial fyftem *. Why this action fhould be termed irregu- lar, when there is an excefs, and not when a defect of action, is difficult to conceive: for a deviation from the ftandard of health either towards a fthenic or an afthenic difeafe, we fhould fuppofe, muft depend on hurtful pow- ers capable of producing fome general mor- bid ftate of the fyftem; of courfe fome ir- regularity in the exercife of the different functions of an animal body< As to the pro- priety of terms little need be faid concern- ing it, for cuftom foon eftablifhes the pro- priety of expreffions, however inconfiftent they Dr. B. Rush. 32 Of Universal Dropsy. they might have appeared at the time they were adopted* If the fymptoms of increafed action fhould fupervene in the courfe of this difeafe; it muft be confidered as a mere accidental cir- cumftance, or from the exciting hurtful powers, either through miftake or fome o- ther means, having been applied in too great a degree, and not depending on the general diathefis, which conftitutes the true nature of the difeafe. It is a fact, I believe, which few will deny, that debility gives a predif- pofition to difeafes of increafed action, and, that powers, which in an ordinary ftate of health, would not have produced any very fenfible alteration, if applied, when the bo- dy is in a ftate of debility, will produce a very confiderable degree of excitement. That an antiphlogiftic treatment is fome- times neceflary in the cure of this difeafe, I readily agree ; when this is the cafe, it muft depend on foreign powers being acci- dentally applied, and not on the general di- athefis, giving occafion to the different phe- nomena which take place. In fuch cafes the difeafe muft be confidered as transferred from a difeafe of debility to a difeafe of in- creafed action; therefore a different plan of Of Universal Dropsy. 33 of cure becomes neceffary. How an increaf- ed action of the arterial fyftem fhould fo o- perate as to produce an uncommon effufion and confequent accumulation of fluid, and the abforbent fyftem lie an idle fpectator, muft with difficulty be accounted for upon the general received opinions with refpect to the animal ceconomy. Can fo important a part of the body, as the arterial fyftem, be affected with an high degree of excitement, and particularly their extreme branches, and their correfponding abforbents not in the leaft partaking of this excitement ? If it be allowed that there is an increafed action of the abforbents cor- refponding to that of the arteries ; how is this to prevent abforption ? Suppofing this increafed action to be predominant in the arteries; would this produce effufion? If the degree of tone in a mufcular fibre depends on the degree of excitement, and the degree of denfity is always in proportion to the degree of the former; if denfity implies contraction, or a tendency in the conftituent particles of a mufcular fibre to be brought nearer each other, thereby being better enabled to refill any diftending power; if this denfity takes place in thofe fibres which encircle the ex- E treme 34 Of Universal Dropsy. > treme veffels, which cannot be otherwife^ if there is an excefs of action, and this de- pending on excitement. Upon thefe prin- ciples, we fhould fuppofe the diameters of the extreme veffels would be diminifhed and not enlarged, and inftead of an increafed, that there would be a diminifhed effufion, confequently no dropfy. But as hypothefes never yet led to any real or ufeful informa- tion, I fhall difmifs this part of the fubject, and proceed to give what I conceive to be the proximate caufe. The proximate caufe of dropfy confifts in a debility of the whole body, but greater in the exhalent arteries, or their correfponding abforbents, or both; than in any other equal parts. Thus we conclude, that thofe powers which act moft urgently on the vafcular fyf- tem, are the moft common in bringing on this difeafe. There is always a quantity of watery parts pafling off from the blood by the feveral outlets*; when this is particular- ly determined to the exhalents, there muft be a diminution of the feveral fecretions and excretions, fo neceffary to the preferva- tion of the healthy ftate; confequently an ac- cumulation and ftagnation of fluids in fome part of the body. Agreeable to the proxi- mate Of Universal Dropsy. 35 mate caufe now laid down, our indications of cure, are, I. To remove the caufes. II. To evacuate the water. III. To regulate the excitement, The fulfilling of our firft indication is not always in our power, for many of the cau- fes have ceafed to act long before this dif- eafe makes its appearance, and are only known to have been prefent from their ef- fects. But if any ftill continue to operate, they are very eafily removed, when once difcovered, and indeed, in fulfilling our third indication, our chief object is to re- move fome of the principal caufes, mentioned in the preceding part, under that head. II. To evacuate the water. For the intention of anfwering this indica- tion, a variety of means has been recommend- ed, and though I fhould not expect much good from the ufe of fome of them, it is pro- per to give them fome notice, as they are by many, confidered very effectual remedies in the cure of this difeafe, Thefe are, a. EME- 36 Of Universal Dropsy< a. EMETICS, b- CATHARTIQS, c. DIURETICS. d. SUDORIFICS. e. SIALAGOGUES. f. ISSUES, g- SETONS. h. SCARRIFICATION& h PUNCTURES, k. BLISTERS. E ME TICS. With refpect to thefe, their ufe appears doubtful: they are known to de- bilitate the organs of digeflion, the ftrength of which is neceffary to the cure of this dif- eafe. Their operation is not confined to the flomach, but extended to the principal abdo- minal vifcera, and the plentiful evacuations from thefe, which they occafion, muft in- creafe that debility on which this difeafe de- pends. The other effects generally afcribed to vomits, cannot in this complaint be very confiderable, and the impropriety of attempt- ing to cure a difeafe of debility, by debili- tating remedies, is too obvious to require a- ny Of Universal Dropsy. 37 Jiy refutation. Whatever has been faid with regard to fpontaneous vomitings curing this difeafe, thence arguing that vomitings, pro- duced by artificial means, might be ufeful, appears quite futile, as the legitimacy of facts cannot always be depended on; though a vo- miting has fometimes taken place, it might have depended on a caufe quite different from that, which produces vomiting, when any foreign matter is thrown into the ftomach. Emetics never fail of occafioning great pain and anxiety during their operation; I have feen them given, but never could perceive any good effects from their ufe; and one pa- tient I faw die during the operation of the emetic. This, I think, is fufficient to deter any man of humanity from a fecond trial. CATHAR TICS, Of thefe, it is faid, if the two or three firft does not have the de- fired effect, it is beft to omit them, and I think, it would be much better, if the ma- jority of them were omitted from the begin- ing; as they tend greatly to increafe that debility on which the proximate caufe de- pends. There is one which may be given, but the action of this is not confined to the inteftines, for it foon fhews its effects in the moft remote parts of the body. This is Mercurius 3$ Of Universal Dropsy. Mercurius Dulcis; it fhould be given in fmall doles and frequently repeated: when given in this manner, it opens every outlet through which an efcape can be made. If we wifh to bring on a falivation, it is beft combined with opium. There are but few cafes of dropfy, which will refill a falivation, if had recourfe to early in the difeafe, DIUR E TICS. To mention all the par* ticular medicines, belonging to this clafs, would be tedious, I therefore refer to the different writers on the materia medica. The fixed vegetable alkali is one of the beft, it has a much better effect when given in an infufion of wormwood or chamomile, the bitters improve its diuretic powers. Emetics and cathartics, when boiled, poffefs a diuretic power, and it is probable that the action of all diuretics upon the fecretories of the kidneys, depend very much on the quantity of liquid taken in. The fpirit, diftilled from the ber- ^ ry of the juniper, combined with fome tonic medicine, is one of the beft diuretics I have yet feen employed. The digitalis purpurea has fometimes been of fervice in increafing the difcharge of urine ; this is faid to be more ufeful in the hydrothorax than in any other fpecies of dropfy, but upon what prin- ciple Of Universal Dropsy, jg ciple is not yet determined. And I imagine it is in a great meafure from the difficulty of ascertaining the prefence of this fpecies of dropfy, that this medicine has obtained its credit: for, we find, it does not anfwer the intention, as we might expect, confider- ing how much has been afcribed to it by Dr. Withering. SUDORIFICS. The difcharge by the fkin is beft promoted by flimulating drinks and warmth externally. The, antimonial preparations have been recommended, but if the obftructed perfpiration depends upon debility, I fhould fuppofe, that thefe would rather retard than promote a diaphorefis. A gentleman, not long fince, gave me a cafe of a lady of his acquaintance in SoUth-Caro- lina, aged eighteen, who was cured of a dropfy, after the Ufual remedies had failed, by burying her every day in the warm fand on the beach, till a profufe fweating came on. This lady had, previous to the ufe of this remedy, been twice tapped. The hot bath is one of the beft remedies for anfwer- ing this intention; the bath fhould be at lead from 112 to 115 degrees of Farenheit; a perfon in this difeafe will bear a much great- er degree of heat than a perfon in health. The patient 40 Of Universal Dropsy^ patient fhould not be continued in the bath for more than two or three minutes; after being taken out and wiped perfectly dry, he fhould be dreffed in flannel, or put into wool- len blankets; for linen, by conducting off too great a quantity of heat, is apt to become wet and cold. The bath not only cleanfes and deterges the fkin, but gives a general ftimulus to the whole body, particularly the extreme veffels ; and from the confent between the external and internal parts* there is a particular determination to the fe- cretories of the kidneys; this is announced by the profufe difcharge of urine which im- mediately follows the ufe of the bath, J—— P'----, a boy, aged two years, had been for fome time troubled with a lax, which had brought on a general emaciation, he had taken fome medicines, and had tried the cold bath. When I began the ufe of the hot bath, the child had a diarrhaea, an univerfal anafarca, its abdomen consider- ably fwelled, its prepuce fo diftended with water it could fcarce pafs its urine; and that I might rightly afcertain the effects of the bath, I gave it no medicines at the time, except a few drops of laudanum at night to quiet it, for it was very reftlefs. It had ufed Of Universal Dropsy. 41 Ufed the bath but four mornings when the water was entirely evacuated. 1 then gave it a few reftorative medicines, and directed the nurfe to confine it to an animal diet. In a few weeks the child perfectly recovered, and now enjoys a good ftate of health. A fimilar cafe fince occurred, I began the ufe of the bath, after which the child immedi- ately mended, but from an infuperable pre- judice in the parents, I could notpreviil up- on them to continue it; the child, by a fuit- able regimen andexercife, recovered in about two months.— SIALAGOGUES. The moft valuable of this clafs are the different preparations of mercury ; the effects of which havebeenfuf- ficiendy fpoken of under the head of ca- thartics. With refpect to Ijfuesy Sctons, Pur.clarcs, Scarrifications^ and Blifters; if ever they are ufed, it ought to be with great caution, for they are very apt to be fucceeded by gan- grene, particularly in thofe advanced in life. As to the operation called paracentefis: I have omitted faying any thing with refpect to its ufe or manner of performing it, for it be- longs more properly to the practice of forge- ry, than to this place. F It 42 Of Universal Dropsy. It may be obferved here, that, i***e earlier we attempt the cure of this difeafe, the more probability there will be of fuccefs; for when the body has become furcharged with this particular fluid, and any of the large ca- vities filled with water; though we may,by a- ny of the means now recommended, caufe it to be evacuated, if the water has been fuf- fered to remain for a long time flagnant in the body, and the parts a confiderable time over-diftended, and macerated in the water, it is a great chance indeed, if they ever re- cover their proper degree of tone, and the proper and healthy degree of excitement ever eftablifhed in the fyftem. III. To regulate the excitement. u If the force of every power is in propor- tion to the degree of its application, or the fenfibility or extent of the part to which it is applied; we fhould fuppofe our firft object fhould be to reftore the quantity of that flu- id, the prefence of which is fo neceffary to the fupport of tone and vigour over the whole body. But we are fometimes prevented from anfwering this part of our indication by the great debility of the digeftive organs, and their incapability of converting the mat- ters Of Universal Dropsy. 43 ters t * lin, into^ood chyle and blood, for the purpofes of filling and diftending the veffels. Many times the debility is fo great that the matters taken in will not be retain- ed on the ftomach, when this is the cafe, we muft have recourfe to fuch medicines as are calculated to give a proper degree of tone to thofe parts, thereby enabling them to an- fwer the purpofes intended. The medicines beft calculated to give ftrength to the dige£ tive organs, are the whole round of diffufi-* ble ftimuli, bitters, and chalybeates. When this intention is gained, the patient fhould confine himfelf to a well feafoned animal diet of eafy digeflion, and in as large quan- tities as his ftomach will bear, omitting the diffufible, as he finds his ftrength to increafe. He fhould be clad in flannel, ufe friction, and moderate exercife in the open air, as much as his ftrength will permit. It ought to be here remarked, that the convalefcent fhould be gradually returned to his ufual plan of life, and fhould never be confidered as out of danger, or health completely efta- bliflied, till this end is accomplifhed, Principal Errata. 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