Page:EB1911 - Volume 20.djvu/993

Rh sufficient to keep them moist. When any excessive accumulation takes place the condition is known as “hydrops” or “dropsy.” A “transudate” is a liquid having a composition resembling that of blood-serum, while the term “exudate” is applied to an effused liquid whose composition approaches that of the blood-plasma in the relationship of its solid and liquid parts, besides in most cases containing numbers of colourless blood-corpuscles. Exudates are poured out under inflammatory conditions, while none of the truly dropsical effusions are of inflammatory origin; and hence the class of exudates, as above defined, may be rejected from the category of liquids we are at present considering. Where the dropsical condition is more or less general the term “anasarca” is applied to it; if the tissues are infiltrated locally the term “oedema” is employed; and various names are applied, with a local significance, to dropsies of individual parts or cavities, such as “hydrothorax,” “hydro-peritoneum” or “ascites,” “hydrocephalus,” and so on. In “anasarca” the tissues which suffer most are those which are peculiarly lax, such as the lower eyelids, the scrotum, and the backs of the hands and feet. It is invariably the result of some cause acting generally, such as renal disease, valvular defect of the heart, or an impoverished state of the blood; while a mere oedema is usually dependent upon some local obstruction to the return of blood or lymph, or of both, the presence of parasites within the tissue, such as the filaria sanguinis hominis or trichina spiralis, or the poisonous bites of insects. Dropsy of the serous cavities is very commonly merely part of a general anasarca, although occasionally it may be, as in the case of ascites, the sequel to an obstruction in the venous return. Dropsical liquids are usually pale yellow or greenish, limpid, with a saltish taste and alkaline reaction, and a specific gravity ranging from 1005 to 1024. They all contain albumen and throw down a precipitate with heat and nitric acid. None of them, in man, coagulates spontaneously, although they contain fibrinogen. The addition of some of the liquid squeezed out from a blood-clot, of the squeezed blood-clot itself, or of a little blocd-serum, is sufficient to throw down a fibrinous coagulum (Buchanan), evidently by these substances supplying the fibrin-ferment. The proteid constituents are very much like those of blood-serum, although they never come up to them in amount (Runeberg). The quantity of proteid matter in a purely dropsical effusion never amounts to that of an inflammatory exudation (Lassar). Certain peculiar substances, probably degenerative products, some of them reducing copper, are occasionally met with. The liquid of ascites sometimes contains chyle in abundance (hydrops lacteus), the escape having taken place from a ruptured receptaculum chyli.

In a given case of anasarca due to a cause acting generally, it will be found that the liquid of the pleural cavity always contains the highest percentage of proteid, that of the peritoneal cavity comes next, that of the cerebral ventricles follows this, and the liquid of the subcutaneous areolar tissue contains the lowest. The reason of this is apparently that the negative pressure of the pleural, and partly of the peritoneal, cavity tends to aspirate a liquid relatively thicker, so to speak, than that effused where no such extraneous mechanism is at work (James).

The subject of the conditions under which dropsical liquids are poured out opens up a very wide question, and one about which there is the greatest diversity of opinion. It turns in part, but in part only, upon the laws regulating the effusion of lymph, and physiologists are by no means at one in their conclusions on this subject. Thus Ludwig was of opinion that the lymph-flow is dependent upon two factors, first, difference in pressure of the blood in the capillaries and the liquid in the plasma spaces outside; and, secondly, chemical interchanges setting up osmotic currents through the vessel-walls. His results, so far, have been confirmed by Starling, who finds that the amount of lymph-flow from the thoracic duct is dependent upon difference in pressure. It varies with the increase of the intracapillary or decrease of the extracapillary pressure, and is also in part regulated by the greater or lesser permeability of the vessel-walls. Heidenhain, on the other hand, rejected entirely the filtration view of lymph-formation, believing that the passage of lymph across the capillary wall is a true secretion brought about by the secretory function of the endothelial plates. Starling does not accept this view, and cannot regard as an article of faith Heidenhain's dictum that normally filtration plays no part in the formation of lymph. Lazarus-Barlow, again, looks upon the pouring out of lymph as evidence of

the demands of the tissue-elements for nutrition. An impulse is communicated to the blood vessels in accordance with this demand, and a greater or smaller outflow is the result. He traces various local dropsies to the starvation from which the tissues are suffering, the liquid accumulating in excess in accordance with the demand for more nourishment. It may be asked, however, whether a dropsical tissue is being held in a high state of nutrition, and whether, on the contrary, the presence of lymph in excess in its interstices does not tend to impair its vitality rather than to lend it support. According to Rogowicz and Heidenhain, certain substances increase the quantity of lymph given off from a part by acting upon the cells of the capillary wall; they hold, in fact, that these substances are true lymphagogues. Heidenhain recognizes two classes, first, such substances as peptone, leech extract and crayfish extract; and, secondly, crystalloids such as sugar, salt, &c. Starling sees no reason to believe that members of either class act otherwise than by increasing the pressure in the capillaries or by injuring the endothelial wall. The members of the first class influence the endothelial plates of the capillaries injuriously, inducing thereby increased permeability; those of the second class (sugar, &c.), on injection into the blood, attract water from the tissues and cause a condition of hydraemic plethora with increased capillary pressure. The increased flow of lymph is due to the increased pressure in the abdominal capillaries.

It is now coming to be recognized that increase of blood pressure alone is not sufficient to account for all dropsical effusions. Much more important is the effect of the alteration in the amount of crystalloids in the tissues and blood and therefore of the alteration in the osmotic pressure between these. Loeb found experimentally that increase of metabolic products in muscle greatly raised its osmotic pressure, and so it would absorb water from a relatively concentrated sodium chloride solution. Welch produced oedema of the lungs experimentally by increasing the pressure in the pulmonary vessels by ligature of the aorta and its branches, but this raised the blood pressure only about one-tenth of an atmosphere, while in some of Loeb's experiments the osmotic pressure, due to retained metabolic products, was equal to over thirty atmospheres. Thus differences in osmotic pressure may be much more powerful in producing oedema than mere differences in blood pressure.

Now differences in the amount of crystalloids cause alteration in osmotic pressure while the proteid content affects it but little; and of the crystalloids the chlorides appear to be those most liable to variation.

Widal, Lemierre and other French observers have noted a diminution in the excretion of chlorides in nephritis associated with oedema; Widal and Javal found that a chloride-free diet caused diminution in the oedema and a chloride containing diet an increase of oedema. Oliver and Audibert published some cases of cirrhosis of the liver with ascites in which they got results comparable to those of Widal. Some other observers, however, have not got such good results with a chloride-free diet, and Märishler, Scheel, Limbecx, Dreser and others, dispute Widal's hypothesis of a retention of chlorides as being the cause of oedema, in the case of renal dropsy at all events; they assert that the chlorides are held back in order to keep the osmotic pressure of the fluid, which they assume to have been effused, equal to that of the blood and tissues. Certainly not all cases of renal dropsy show diminution in the excretion of chlorides. Bainbridge suggests that a retention of metabolic products may cause the oedema in renal disease, Bradford having previously shown that loss of a certain amount of renal tissue caused retention of metabolic products in the tissues. As sodium chloride is one of the most permeable of crystalloids it seems strange that damage to the renal tissue should impede its excretion. Cushny has shown experimentally that slowing of the blood-flow through renal tissue causes less sodium chloride to appear in the urine while the excretion of urea and sulphates remains unaffected; apparently the chloride, being more permeable, is reabsorbed and so only appears to be excreted in less quantity.

In the dropsy of cardiac disease, owing to the deficient oxidation from stagnation of blood, metabolic products must accumulate in the tissues; also lymph return must be impeded by the increased pressure in the veins and so dropsy results (Wells).

The local oedema seen in some nervous affections might be explained on the hypothesis of increased metabolic activity in these areas due to some local nervous stimulation.

Thus, while increased pressure in the blood or lymph vessels may be one factor, and increased permeability of the capillary endothelium another, increased osmotic pressure in the tissues and lymph is probably the most important in the production of dropsy. This increased osmotic pressure is again due to accumulation of crystalloids in the tissues, either products of metabolism due to deficient oxidation from alteration in the blood or other cause, or, it may be, as in some cases of nephritis, owing to a retention or re absorption of chlorides in the tissues.

Medicine and surgery have never been slow to appropriate and apply the biological facts of pathology, and at no period have