In attempting to cure Dropsy we are first to inquire whether the disease be primary or symptomatic ; and if we conclude it to be only symptomatic, we are of course to apply our remedies to the removal of the ori ginal disease. But when this cannot be accomplished, or when we are not able to detect any primary affec tion, we must direct our attention to the Dropsy itself ; and the two obvious indications will be, to remove the effused fluid and to prevent its re-accumulation. The effused fluid may be removed by puncturing the cavi ties which contain it, and thus mechanically discharg ing it ; but this seldom affords more than mere tempo rary relief, as, while the same constitutional disposition remains, the water again rapidly accumulates, and it sometimes even appears that it is effused in larger quantity than before, and that the general health is in jured by the operation. It must also be remarked, that dangerous consequences occasionally ensue from the punctures, which, however carefully made, are dis posed to assume the gangrenous state, from the feeble condition of the vital powers. We must therefore at tempt to remove the effused fluid through the inter vention of internal remedies, and of these the most ef fectual are such as produce an increased action of some of the excretory organs, especially the intestinal canal and the kidney. In consequence of that intimate con nexion which subsists between all parts of the system, we find that if by any means we produce an increased discharge from one organ, all the rest seem to be ex cited in the same manner. What is the exact nature of this connexion we arc scarcely able to ascertain, but we are acquainted with the effect, and we have fre quent opportunities of employing it with advantage in the cure of disease. We have stated that purgatives and diuretics are the two classes of medicines which are usually had recourse to for removing collections of serous fluids, when effused into any of the cavities of the body ; and it is accordingly to these substances, and especially to the latter, that we generally look for the cure of Dropsies of all descriptions. When we are able to produce the desired effect upon the kidney, we indeed seldom fail in accomplishing our purpnse, but it unfortunately happens that there is no class of medi cines that is so uncertain and apparently so capricious in their operation as diuretics. The number of articles that have been employed for this purpose is very consi derable, and they are so very different in their nature and sensible properties, that we can scarcely conceive them to act upon the same principle, or even to produce the same effect upon the body. Many of them indeed, it may be concluded, arc entirely inert, and have ac quired their reputation, solely from some accidental circumstai ce ; hut there are others of obvious activity, although even of these it is not easy to say in what manner they act, or how substances of such different qualities can all conduce to the same end. The medi cines that are esteemed the most efficacious diuretics are squills, digitalis. cream of tartar, and certain pre parations of mercury. Of these the squill is the one which is the most certain in its effects, and which seems to be applicable to the greatest variety of cases, so that unless there be some peculiarity in the consti tution, which prevents us from administering the me dicine in proper quantity, or some structural disease which counteracts its operation, it seldom fails in in creasing the flow of urine. The varieties of Dropsy in which the squill is thought to be the most usclul are Aanasarca and Ascites. Digitalis is a medicine which possesses great power over the system, hut which, al though occasionally very beneficial, manifests its dele terious effects, and becomes decidedly injurious, if it be employed improperly or in excessive quantity. When we consider the nature of the primary action of squills and digitalis, we can scarcely suppose that they operate upon the same principle, yet as we are not able with any degree of precision to explain the nature of their operation, we are decided almost entirely by mere experience, in determining upon the individual cases for which they are each of them more peculiarly adapt ed. The variety of Dropsy called Hydrothorax, in which the cavity of the chest is the scat of the disease, has been generally conceived to be the one in which digitalis is most serviceable ; and it is agreed that a languid, or, as it is metaphorically termed, a relaxed habit and a phlegmatic temperament, is better adapted for the exhibition of this medicine than a constitution of an opposite description. The supertartrate of pot ash has been spoken of by many respectable practi• tioners as a powerful diuretic; and there are other neutral salts, principally those into the composition of which the tartaric and acetic acids enter, which are generally supposed to possess the effect of promoting the action of the kidney, bin they are all of uncertain operation. When they prove successful in increasing the quantity of the urine, they commonly, at the same time, act as purgatives ; and it may be questioned whether they are to be considered as any thing more than mild hydragogues, the peculiar property of which is, to cause a copious watery discharge from the mu cous surface of the intestines, in which the urinary or gans may also partake. We have sufficient evidence of the effect of mercury as a diuretic, but it may probably be referred with more propriety to its opera tion as a general stimulant, than to any specific action upon the kidney : and this opinion appears to be coun tenanced by the fact, that the use of mercury in Drop sy is principally as an adjuvant to other substances, for example to squills and digitalis. If the hypothesis be not too mechanical, we may regard mercury as a stimulant to all the secretory organs, probably in pro portion to their degree of vitality, or their connexion with the circulating system ; but that its operation may be more particularly directed to any one of them, by being united with a medicine which acts specifically upon the part ; of this we have an illustration in what we observe with respect to purgatives as well as diure tics. Perhaps the only cases in which we can con sider mercury as having any direct ff..ct in the re moval of Dropsy, is where the disease depends upon the enlargement of some glandular part, either by the constitutional derangement as connected with the di gestive organs, or merely by iis mechanical pressure upon the great trunks of the absorbents; the power which mercury is conceived to possess in discussing glandular tumours, being independent of its action on the kidney. As to the second indication in the cure of Dropsy, to prevent the re-accumulation of the fluid alter it has been removed, all that can be said on this point may be included in the single direction of adopting every means for improving the general health, we must avoid the exciting causes, and we must endeavour to strengthen the digestive organs by temperance, exercise, preserving an open state of the bowels, and by the proper exhibition of tonics.
After these general remarks on Dropsies, as constitut ing an order of diseases, we must proceed to make a few observations upon the different genera. C•nicern ing Anasarca we have little to add to what has been said above, either as to its symptoms or its cure ; for as it is the most universal in its seat, so it presents us with the fewest peculiarities with respect either to its symptoms or its treatment. Purgatives, exhibited ac cording to the strength and constitution of the patient, of which the neutral salts and the hydragogues will pro bably be found the most appropriate, are sometimes alone able to effect the removal of the effusion. It these fail, we proceed to diuretics, of which squiils, in combination with calomel, suggest themselves as the first to be tried. Along with these, or rather to complete the cure after they have accomplished their object, we must have re course to the same kind of tunic treatment which is em ployed in other diseases, where the strength has been much reduced.
Ascites is a more formidable disease than Anasarca, as it generally depends upon a structural affection of some of the abdominal viscera, or upon a local derange ment, which is out of the reach of medicine, or is con nected with some other morbid condition of the sys tem. The disease is characterized by distention of the abdomen, in which the fluctuation of a fluid may be distinctly perceived, and to this local symptom, which properly constitutes the disease, we have always con siderable disturbance of the system generally, loss of appetite, and torpor of all the organs concerned in the function of digestion ; the usual deficiency of urine oc curs, and as the disease advances, the strength fails, the flesh wastes, and ultimately hectic, with complete atrophy, supervenes. Besides other causes of uneasi ness, the patient suffers great distress from the mere bulk of the abdomen, which is often so large as ma terially to interfere with the various vital and organic functions, especially the respiration and the circula tion. The fluid is usually effused in the general cavity of the peritoneum, but in some cases it is contained in a partial cyst ; in these instances the constitutional symptoms are generally less urgent, as the affection may be supposed to proceed from some cause of a more local nature, which, at its commencement, has hut little effect upon the system at large. It is indeed principally from the proportion which the general bears to the local symptoms, that we are to form our judgment respecting the seat of the effused fluid, whether it be encysted or not, a fact of some consequence in the treat ment of the disease, and one of very great importance in its prognosis.
In treating Ascites, the only point to be considered, in addition to the general plincipies which we have laid down above, respects the propriety of discharging the water by an operation. Wnere the tumour is very large, and where it seems, ny its mechanical bulk, to injure the action of any of the functions that are essen tial to life, we occasionally find it necessary to punc ture the sac, but, for the most part, we derive little permanent benefit, and it woultI appear that we not unfrequently bring the disease more rapidly to a fatal termination. Ascites, when it proceeds from a sttuc• tural disease of any of the abdominal viscera, which is One of its most frequent causes, can only be effectually treated by the employment of those remedies which act upon the diseased organ ; and it must be confessed that, in these cases, our prospect of success is very limited. A cautious use of mercury, in combination with squills, is perhaps the best remedy that can be tried ; but it will be °hen found ineffectual, and a va riety of occurrences almost daily present themselves, which will demand our attention, and oblige us to swerve from any regular plan of treatment which we may wish to adopt.
Hy drothorax, or Dropsy of the chest, is characterized by difficulty of breathing, which is increased in the ho rizontal posture, by disturbed sleep. palpitation of the heart, irregularity of the pulse, and frequently by all the symptoms of general Dropsy. Sometimes, by cer tain motions of the body, or by certain postures, the presence of the fluid in the chest may be perceived by the patient himself, and it may be felt by the practi tioner, when he employs a peculiar method of striking the chest, or pressing upon the contiguous parts. The immediate cause of Hydrothorax, like that of Ascites, is generally a disease of some of the viscera ; and as, from its local situation, it is more connected with the func tions which are essential to life, its prognosis is more unfavourable. It has been generally supposed that this species of Dropsy is more peculiarly adapted for the administration of digitalis than any other remedy ; a circurn,tance which, if correct, may perhaps oe ex plained by the power which this remedy possesses over the circulation. When we determine to prescribe this substance, it should always he done with the greatest caution ; and if we do not find it to be useful after it has been taken for a short time, we are not to expect any benefit from the farther continuance of it ; for were we to persevere, we should probably expe rience its deleterious effects. Purgatives are always indicated in Hydrothorax, and the operation of the va rious neutral salts, as being the least stimulating, and at the same time possessing the hydragogue property, we conceive to be the most appropriate. It may be doubted whether blisters or other remedies applied ex ternally to the chest can be of any avail in this com plaint ; and with respect to the operation for discharg ing the fluid by an artificial opening, besides the objec tions that were urged against the analogous practice in Ascites, we have here the additional objection, that it is more difficult and painful, that it is less easy to ascertain the unequivocal existence of water in the chest, and that the subjects of Hydrothorax are more frequently persons 'advanced in life, of a bad habit of body, or debilitated by other diseases, and therefore less likely to derive any benefit from the discharge of the fluid, than many of the subjects of Ascites, so that, upon the whole, we should conceive, that it can only be under a very rare combina tion of circumstances that this operation should ever be recommended.