We come now to treat of the different species of dropsy, viz.: First, Anasarca, Fifth, Ovarian Dropsy. Second, Ascites, Third, Hydrothorax, 1. ANASARCA.-CELLULAR DROPSY. DIAGNOSIS. The term anasarca is used to designate that variety of dropsical effusion which takes place from the exhalents of the subcutaneous cellular tissue. The malady first manifests itself in the inferior extremities, particularly after standing or walking for some time, and it gradually extends upwards until the whole sub-cutaneous cellular tissue of the organism becomes involved. The tumefaction is usually soft, doughy, and inelastic, pitting on pressure, and the skin is white, shining, and below the medium temperature. The swelling disappears in great measure, after the patient has been for some time in the recumbent position, but returns again when he has assumed the erect posture. Cellular dropsy may exist for years without causing serious inconvenience, when confined to the inferior extremities; but it is rare that the whole cellular surface becomes involved, unless some vital disorganization exists, or the energies of the system have become dangerously impaired. The cases of anasarca attended with the least danger, are those arising from scarlatina, pregnancy, loss of blood, debility consequent upon convalescence from acute diseases, abuse of arsenic and mercury, enlarged inguinal glands, the pressure of tumors, or any other curable cause which operates to prevent the free return of the venous blood. Effusions of this kind may very properly be termed passive dropsies, for we agree with Dewees, "that there are both active and passive dropsies, or rather dropsies that depend upon an increase of action, or of inflammation, and others where there may be a mere loss of balance between the exhalation and absorption." In cases of dropsy arising from venous obstruction, for example, the venous absorbents below the seat of the obstruction are preternaturally distended with blood, and, as a consequence, their powers of absorption proportionably diminished, while the arterial exhalents exercise their function with the usual activity. In this manner the equilibrium between exhalation and absorption is destroyed, and dropsical accumulations obtain. So in phthisis pulmonalis, and affections of the heart, the blood being but imperfectly decarbonized in its passage through these diseased organs, becomes congested in the venous absorbents, and thus gives rise to diminished absorption, and consequent serous accumulations. Anasarca is not usually attended with much constitutional disturb ance, or with symptoms that are painful. There are present, however, coldness of the surface and diminished secretion of urine and sweat. The countenance is also pale and sallow, and the general appearance indicates ill-health. Not unfrequently the effusion continues to increase until the affected parts become enormously distended, and finally crack and give issue to the accumulated serum. When this happens in erysipelatous or syphilitic subjects, sloughing and gangrenous ulcers sometimes supervene, which prove highly troublesome and dangerous. CAUSES. The pecular condition consequent upon scarlatina, measles, phthisis pulmonalis, chlorosis, and diseases of the heart; venous obstructions caused by the gravid uterus, by the pressure of tumors, enlarged glands, ligatures, and mechanical injuries, sudden and excessive loss of blood, abuse of stimulants, arsenic and mercury. 2. ASCITES.-ABDOMINAL DROPSY. DIAGNOSIS.-Dropsy of the abdomen may arise suddenly in consequence of acute peritoneal inflammation, and be attended with the ordinary symptoms of other febrile diseases, or it may make its appearance in a gradual and imperceptible manner, unattended by any notable constitutional disturbance. During the attacks of peritonitis, there is an increased exhalation from the inflamed serous vessels, from the very commencement of the disease, and so long as the whole organism labors under the exalted action incident upon the fever, the venous absorbents dispose of this superabundance of serum; but after the active symptoms have subsided, a corresponding depression obtains in all parts of the economy, except, perhaps, the affected membrane, in which there still may remain a subacute inflammation and its consequence, a preternatural effusion of serum. In vigorous constitutions the absorbents continue to remove the exhalation as fast as formed; but in feeble, delicate, or scrofulous subjects, the function of absorption often languishes, the equilibrium between the exhaling and absorbing functions is destroyed, and an ascites is the result. The signs which characterize abdominal dropsy, are: gradual en'argement of the abdomen, first observed in the epigastric region, and afterwards extending over the whole abdomen; tenderness on pressure; difficulty of breathing on taking exercise, and some time after lying down; distinct fluctuation on percussion; sallow and unhealthy complexion; dry skin; scanty secretion of high-colored and sedimentiious urine; foul tongue, with a small secretion of viscid saliva; impaired appetite; constipation or diarrhoea, sensation of weight and stiffness, particularly when attempting to move about or bend the body; a general feeling of languor and debility. The only diseases which are liable to be confounded with ascites, are pregnancy and tympanitis; but the history and circumstances of each case will enable us to distinguish with sufficient facility and certainty between the different maladies. In ascites the situation of the swelling, the fluctuation on percussion, the suppression of urine, dry skin, and the previous history of the case, will mark the nature of the complaint; and in pregnancy the gradual swelling at the lower part of the abdomen, the suppression of the menses, nausea and vomiting; the absence of fluctuation on percussion, and the motion of the child, will render our diagnosis accurate. Nor will the acute physician ever mistake tympanitic distention for ascites, for percussion, auscultation, and an absence of the characteristic symptoms of dropsy, will enable him to decide at once in regard to the real nature of the case. Indeed, we can hardly conceive how certain eminent surgeons should have been led to perform the operation of what they have afterwards facetiously termed the operation of "dry tapping," when the distinguishing marks between tympanitic and aqueous distention are so easily recognized. Authors have described several distinct varieties of abdominal dropsy, and have named each according to its precise location; thus, subcutaneous ascites, in which the effusion takes place in a circumscribed cavity or sac in front of the abdominal muscles; vaginal ascites, arising from a puncture or other injury to the aponeuroses of the muscles, and causing effusion into the sheath of the muscle; peritoneal ascites, or effusion within the serous cavity, and in some rare instances, on the outside of the membrane; hydatid ascites, in which the water is closed in one or more thin vesicles; also dropsy of the epiploon, of the mesentery, of the intestines, of the liver, of the spleen, of the gall bladder, and encysted ascites. This minute classification is, however, quite unnecessary for practical purposes, since ascites is so often complicated, not only with several of these varieties, but with hydrothorax, anasarca, and general dropsy. It is so very rare that we find the above-named organs affected separately, that we question the propriety of recognizing in them distinct species of dropsy, although it is of some importance to be aware of the fact that these distinct effusions may occur. CAUSES. The most common causes of ascites are peritoneal inflammation, affections of the liver, and abuse of stimulating drinks. It may also proceed from venous obstruction, general debility in consequence of disease, loss of blood, and abuse of drugs. PROGNOSIS. Our opinion respecting the probable termination of ascites, will be determined by the following circumstanees: old age, and a constitution impaired by previous disease or by excesses, must always render our prognosis unfavorable Dropsies complicated with incurable functional derangement of the liver or other vital organs, and venous obstructions, are for the most part beyond the reach of medicine. On the other hand, ascites consequent upon acute inflammation of the peritoneum, loss of blood, abuse of stimulants and drugs, and the debility arising from fevers and other acute diseases, may generally be set down as curable. When the malady occurs in young and naturally robust constitutions, our prognosis will be still more favorable, and in some instances may afford grounds of encouragement in highly complicated cases. 3. HYDROTHORAX, OR DROPSY OF THE CHEST. Hydrothorax is either idiopathic or symptomatic of some other disease. By far the most common source of the affection, and one which constitutes a serious complication, is organic disease of the heart. Another frequent cause of dropsy of the chest is protracted pleuritic inflammation. Dropsy of the heart generally co-exists with hydrothorax, and it is for this reason that we often find the pulse very irregular. The symptoms are most urgent during the night, after the patient has remained some time in the recumbent posture. The breathing becomes rapid, laborious, and grunting, with frequent sighing, sudden starting during sleep, anxious and distressed expression of countenance, face pallid and wax-like; small secretion of high-colored urine; puffiness of the face and extremities; fullness of the chest; dull sound on percussion; dyspnoea occurring from the slightest exercise, or from lying down; sudden starting up with fright during sleep; and irregular pulsations of the heart, will enable us to recognize the affection without difficulty. Laennec assures us that hydrothorax accompanies many acute and chronic diseases, and that "its presence announces the approach of death, which it often precedes only a few moments." That these effusions do sometimes occur but a short period before death from organic affections of the heart, and possibly other organs, we entertain no doubt, for several cases have come under our observation strongly corroborative of the fact. A dropsy of the heart is so constant an attendant on hydrothorax, and the symptoms of each so constantly simulate each other, that it is unnecessary to enter into a separate description of this malady. When the effusion originates from an affection of the heart, or the pericardium, there will always be a predominance of those symptoms which charac-, terize cardiac disease, and afford us a sure guide in forming our diag nosis. Paracentesis Thoracis may, in some instances, be resorted to with unequivocal advantage, for the relief of purulent collections within the thorax, but very rarely in hydrothorax. We have in two instances saved life by a prompt resort to this operation, where matter had accumulated in the chest and the patients were at the point of death from suffocation; but in thoracic dropsies, very slight encouragement can be offered from its performance, although in extreme cases it is not to be lost sight of, since recoveries have now and then taken place after the operation. 4. OVARIAN DROPSY. In this species of dropsy, the effusion takes place from the internal face of the membrane which encloses the ovarium. The swelling is first observed in the iliac region, in the form of a small elastic tumor, and unattended with pain, uneasiness, or constitutional disturbance. The enlargement generally progresses very slowly, extending upwards towards the kidney of the affected side, then crossing the abdomen to the opposite side, until it comes to occupy the whole abdomen. No serious inconvenience is experienced until the tumor has attained such a size as to encroach upon the bladder, stomach, diaphragm, intestines, and the larger blood-vessels, thus giving rise to difficulty in urinating, sense of weight and uneasiness in the stomach, dyspnoea, colicky pains in the bowels, pains in the side and chest, diminution of the secretions, and oedema of the feet and ankles. The tumor often remains stationary, and almost unnoticed for twenty or thirty years, when some sudden exciting cause will operate, and the swelling rapidly attain an enormous size. The contents of ovarian tumors vary much in their character, being sometimes serous, sometimes albuminous, purulent, sebaceous, or fatty, or composed in part of organized structures. Dr. Clapp, surgeon to Exeter Hospital has reported a case in which the contents of the tumor "consisted of teeth, hair, bony deposit, some transparent masses of a cellular structure, (as examined by the microscope,) serum, sebaceous matter, and granular fat, which were contained in numerous small cysts. Teeth were found in all parts of the tumor, and were counted to the number of forty-three; some were contained in cysts, others were imbedded in the semi-transparent masses, and two or three were growing from the walls of the parent cyst. In one part, a few were imbedded in a mass of bone, bearing a strong resemblance to an upper jaw united in the mesial line." Fluctuation can rarely be perceived in the swelling until it has attained a considerable size, but the location of the tumor, and the absence of pain or other unpleasant symptoms, will enable us to form a correct opinion in the early stage of the disease. For an account of Hydrocephalus or Dropsy of the Brain, we refer to page 719, 724, Vol. II., of this work. |