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AN
              INQUIRY

                 INTO

     THE NATURE, CAUSES, AND CURE

                  or


      HYDROTHORAX;

              ILLUSTRATED BY

        INTERESTING CASES,

                 AND

MANY LIVING EXAMPLES OF THE SUCCESS OF THE MODE
        OF TREATMENT RECOMMENDED.
W\iVVWWV\*«
BY L. AJACLEAN, M. D.
VWWV wvWV
FIRST AMERICAN EDITION.
        HARTFORD i.

PRINTED AND SOLD BY HALE & HOSMER.

           1814. 
,/•-$ *#<
_V>. i,.- -- *--'
.OH:;
vJ
.;  ct 
to
           niS WORTHY FRIEND,


   M. MACQUEEN,  Esq. M. D. $Ct


     OF RIDGEMONT, IN BEDFORDSHIRE,


                  THE


  FOLLOWING PAGES ARE INSCRIBED,


                 WITH


SENTIMENTS OF SINCERE REGARD JlJrjJ

               ESTEEM,  :,.i »









  SUDBURY,
January 1st, 1810
Bf THE
 ■• * ■ ■       • .......•**


      AUTHOR. 
^vwwvwv^^^wwv^ovwvwwvwv^uxvwwvw
  " At non solumcopia major experimeutorum quaereudaestetprocuran-
da, atque etiam alterius generis, quam adhuc factum est;  sed etiam me-
thodus plane alia, et ordo, et processus, coutinuandae et provehendae ex-
periential, introducenda.  Vaga  enim experientia et  se tantum sequens
mera palpatio est, et homines potius stupefacit quam informat.  At cum
experientia  lege  certa procedet,  seriatim et continenter, de scientiis
aliquid melius sperari poterit."*

                   *  Bacon, Nov. Org. lib. i. { 100.
,MvwWvwvvwvwv\nwnw> 
PREFACE.
     AN the course of Medical experience certain dis-
eases arrest the attention more than others;  insomuch
that every practitioner has, what he terms, his favour-
ite disease, which he fancies he understands better, and
cures more readily than his brethren of the profession :
whether this predilection  and avowed superiority be
well founded or not,  the science of medicine has un-
doubtedly  been  advanced more  by  those who have
thus directed their labours to the investigation  of par-
ticular diseases, than by professors and teachers of me-
dicine,  or systematic writers, who have taken  a more
extensive range :  of the truth- of this the numerous dis-
tinct treatises on  the gout, gravel, and stone, on cancer,
scrophula, consumption, diabetes,-  and other maladies,
afford abundant examples.    The life of man is too  li-
mitted, and the diseases incident to his frame too mul-
tifarious and intricate to  admit of material improve-
ment by  the latter.   But  while  eminent talents and
great industry have been applied to the elucidation of
every other painful affection,  it is a lamentable fact that
this has not been  the case  with the same success in the
disease which forms the subject of the following inqui- 
vi
rncFACEi
ry : It seems to have been in a great  measure  over-
looked, or  so  lightly touched upon as if it claimed no
more notice th?n the common disorders of every sea-
son ; yet, whether  we regard the frequency of its oc-
currence,  the  formidable  aspect k assumes, the ex-
treme sufferings of the patient, or the almost uniformly
fatal termination to  which it leads, few demand inves-
tigation more than dropsy of the chest.   For, if the ob-
servations of the judicious and accurate Withering,
and of the late Dr. W. Hamilton, be excepted, little is
to be  found in the writings  of the physicians of this
island  on the  disease deserving  particular  attention.
While in the works  of the celebrated Morgagni, a body
of evidence, highly  interesting on the history, diagnos-
tic signs, appearances on dissection, or morbid states
connected with it,  has been collected, from various
authors of  acknowledged  celebrity, on the continent.
On the cure, however, foreign writers, it must be con-
fessed, have not been fortunate.
   Impressed with these considerations the author avail-
ed himself of every  opportunity of obtaining  informa-
tion on so important a subject.   At an early period of
his practice, upwards of sixteen years ago, as may be
observed by the  appendix, No.  i. he began to note
down in his report book,  the  history  of every case
which  occurred,  the remedies which were  used,  to-
gether with such remarks as seemed worthy of being
preserved ;  at first,  more for his1 own information, than
with any view' topufjlication: In the7 progress of time,
however, these acquired a bulk far exceeding his ex-
pectations, which induced him  to employ his  lexsurr 
.PREFACE.
vn
 hours in arranging  them into  a more regular form ;
 and he has at length ventured to submit the result of
 his experience to the public in the hope of being useful
 to mankind, and. affording some hints for the cure or
 alleviation of a disease which has been generally regarded
 beyond the reach of medicine.
    In an appendix he has thrown together  upwards of
 eighty well marked cases, pr the materials from which
 his information has been chiefly drawn :  these have not
 been selected for the purpose, but inserted in the order
 in which they occurred, every case having been traced
 from its origin through its progessive changes, stages and
 relapses, to its  ultimate termination in death or perma-
 nent recovery: by this mode of proceeding the list of
 cures is not so long as it might have been, had he conr
 fined himself to first or secqnd editions of these cases.:
 he is confident, however, that the value of  his labours
 will thence be enhanced, if in other respects they should
 be found to possess any merit, since it is only from a
 great number of facts thus carefully collected, faithful-
 ly and impartially related, that the real nature and cure
 of obscure and intricate  diseases is to be ascertained,
 that a correct estimate is to  be formed of the effects of
 remedies, or that a decided inference is to be drawn in
 favour of any  particular mode of treatment—conse-
 quently, that experience can prove really beneficial.
   The few dissections which his own practice has fur.
 nished, owing  to  the prejudice stiU exiting  in the
 country against opening dead bodies, he has endeavored
to supply from Morgagni and other authors, which he 
Viii                  PREFACE.
doubts not will be considered as not the least interesting
part of the work.
  If the lovers of novelty should look for new remedies,
they will be disappointed ; but they will find old medi-
cines, or  those in common use, applied in different
forms and combinations, with different views, and, he
presumes to hope, with a degree of success unparalleled
in the  history of the disease :—they will find that in
every instance it may be relieved, that in a considera-
ble  number it may be kept in check for months, and
years,  with long intervals of  repose, or comparative
ease and comfort to the patient ; and that in some it
may be perfectly and permanently  cured, even under
the most unpromising circumstances.  This, it is pre-
sumed, is more than can be accomplished,  in the present
state of our knowledge,  from any  mode of treatment
hitherto adopted.
  It is obvious that instances will  occur in which the
relief must necessarily be  of short duration, and in
which life can only be held, under a precarious tenure,
in a state of feeble and perhaps comfortless  existence.
If any one should say, and it has been said, that in such
circumstances, the advantages are so trifling as scarce-
ly to  justify the interference of art, since it will only
perhaps be to protract the miseries  of the patient, let
him peruse the following interesting quotation from a
celebrated foreign  writer, which cannot be too much
admired, and the truth  of which  many of the annexed
cases  strongly  illustrate.  "  Those  acquainted  with
" the value of life," says  he,  " know the  importance
" of a year, a day, and even an hour;  and these when 
PREFACE.                     ix
**. spent in the full enjoyment of the vital functions, of,
" how much enjoyment to our whole existence !  what
" events fertile in consequences depend often on one
" hour of our life !   It is therefore an eternal and irre-
^ parable loss when not enjoyed as it ought.—On the
" bed of death, an hour often determines the fate of whole
" families and states.   How many sick die in greater
" peace, because, by having lived an hour longer, they
11 accomplish one of their most ardent wishes.—With
" what anxiety do  many dying fathers wish for such
u an hour because they expect the arrival of an absent
" son.  How grateful is this hour to surviving friends
" who have received  from a dying man information
" respecting some important event of his life.  Is any
" thing further necessary to give importance to the art
" of prolonging feeble life ?"  Asthenology, or the art
of preserving feeble life, and of supporting  the consti-
tution under the influence  of incurable diseases,  by C.
A.  Struve, M. D.  translated  from the German by
W. Johnson.
   In  committing these pages to the press  the author
seriously laments that unavoidable avocations have pre-
cluded that precision and accuracy in the arrangement
of his materials as  well as in the dress in which they
 are clothed, which the public have a right to expect.
But since the work  has already been delayed for some
 years from these causes, he  confidently anticipate s the
 indulgence of the candid and liberal reader,  in the hope
 that the errors and omissions which may have in con-
 sequence escaped him, will not meet with that severity
                        b 
X                     PREFACE.

of animadversion, which certain critics of the present
day  seem  to delight in, provided it should be found
that the attention has not been  drawn to the subject
in vain, 
CONTENTS.
                              CHAP. I.

»                               Sect.  i.
                                                         page
       Definition of Hydroihorax                         -    1

                               Sect.  it.

       Precursors, early signs, and general history of the disease   5

                              Sect. hi.

       History of particular symptoms    -       -      *      9

                              CHAP. II.

                               Sect.  i.

       Dropsy of the Pericardium    -      <•      -      -  3$

                               Sect.  ii.

       ISropsy or Anasarca of the Lungs    -                 43

                             CHAP.  III.

                               Sect. i.

       Diagnostics     *      »      -      -       -      • 4G 
XI1
CONTENTS.
Prognostics
CHAP.  IV.
  Sect. i.


  Sect.  ii.
pagu
  55
Dissection    *       -       -       •       -      -57
                      CHAP.  V.
                    Causes in general.
                        Sect.  i.
Prcdisponent causes     -      -      -      -      -  60
                       Sect. ii.
Occasional causes     •      -      -      -           62
                       Sect. hi.
Of the use and abuse of malt liquors as a cause of HydrotKd-
rax
67
Sect. iv.
Pathology ; Proximate cause ; some of the more remarka-
  ble symptoms explained ; Dr. Darwin*s theory of retro-
  gade action of the absorbents examined    -           70
                      CHAP. VI.
                        CURE.
                        Sect. i.
General obsevvathns on the cure                   ,    88 
contents.
ziii
                         Sect. ii..
                                                    page
Indications of cure     -----  100

                        Sect. hi.
Particular remedies     -                               103

                        Sect. iv.
Regimen    ------    132

                         Sect. v.

Conjectures  and observations on the mode of operation of
   the Foxglove     -----     142

                       CHAP. VII.

Of the salutary powers of Digitalis in other diseases  -   165

                       CHAP. VIII.

Of Polysarcia, obesity, or corpulency, as a cause of dropsy
  of the chest     -       -       *       •       -      172

                   APPENDIX, No. I.

Containing near a hundred interesing cases, in which the his-
  tory of every case has been traced from its origin through
  its various stages, changes, and relapses, to its termination
  in death or permanent recovery, together with occasional
  remarks.—Page I, to 149.
                  APPENDIX, No. II.

Containing an  abstract of several  curious and interesting
  cases from various Authors, together with an account of
  the appearances on dissection.—Page 151, to 176, 
 
         NOTE BY THE PUBLISHERS.

  SINCE the following pages  were put to press, the publishers have
been favoured with the following communication, from Nathan Smith,
M. D. Professor of the Theory and Practice of Physic, Surgery, and
Obstetricks, in the Medical Institution of Yale College.  The high stand-
ing, and  character of the Professor, among Medical gentlemen, has in-
duced them to insert it here.
   THE Cantharides  which  is not  mentioned  in  Maclean
on  Hydrothorax, has, in  many  instances, cured that and
other cases of local dropsies.
  The best method of administering this remedy, is in a pill
combined with Squills and Castile Soap, the quantity o*" Can-
tharides should be from half a grain, to a grain :  one pill to
be taken night and morning.
  In some cases  Opium may be added to the pill with ad-
vantage.
  fir.  Squills, 9i.
      Cantharides, 10 gr.
      Castile Soap, 9i.
  Mix and make 10 pills* 
2                   ON HYDROTHORAX.
   " Dyspnoga; faciei pallor; pedum  oedemata;  urina pair-
 ca; decubitus  difficilis; subita et spontanea ex somno cum
 paJpitatione, excitatio ; aqua in pectore fluctuans.#
   In  a  nosological  definition of diseases, such a concise, yet
 sufficiently comprehensive, view of their more prominent fea-
 tures  should  be exhibited as will enable the medical  practi-
 tioner, bearing them in mind, readily to recognize every indi-
 vidual disease as it occurs, and to distinguish it from all oth-
 ers.  Hence it is  obvious, that those symptoms only, which
 are essential to it, or exist in the generality of instances, ought
 to have a place in  such definition.
   In the definition of Sauvages every symptom specified will
 be found occasionally to occur; but any  person looking for
 the "  alterutrius brachii stupor," &c. of this author, and of
 Sagar, as necessary to the disease, would frequently  be deceiv-
 ed, as this symptom is wanting in  by far the greater number
 of  instances:  it was found  to exist in very few of the cases
 specified in the appendix.
   The " efup-io aqua: intra pectus, strepitum concussione in-
 tus facientis," of Vogel, or the " aqua  in pectore fluctuans"
 of Cullen, which implies the same, though apparently  adopt-
 ed  on the authority of the father of medicine, has, however,
 been done on vague and erroneous grounds, probably from
 the analogy of ascites, without considering  the difference  of
 conformation of the abdomen and  chest, which, in the one, is
 such as to admit of easy detection, while in the other it utter-
 ly preciudes it.  Though looked for in every instance which
 occurred in my practice, it has hitherto eluded observation.  If
 the flucl uation of water could as readily be heard  in hydro-
 thorax, as it is felt, against the fingers, in ascites, it  would be
 sufficient of itself to n ark the disease.   But those who will not
 admit the presence of a watery  fluid in the cavities of the
".hest without it, v» ill search for it in vain.
* Cullen cl. iii. or<3. ii. G. lxxviii. 
OX HYDROTHORAX.
3
   The " symptomata ephialtica,"  or ephialtes* in the defi-
nition of  Sauvages and Sagar, are peculiarly characteristic of
the  disease, but as the " subita ex sonino,"  &c. of Cullen, is
generally the consequence of these,  and may be more familiar
to the English  reader, it has  been  preferred in the author's
definition.
   The livid  aspect of the  countenance;  the irregularity of
the pul -e; the high colour and sediment of the  urine, Avhich
have been added, were found, on a  review  and- comparison of
the annexed cases, with few exceptions, to occur.  Palpita-
tion of the heart was very  frequent, yet as  it was observed
more generally  on any  sudden  bodily exertion, emotion of
mind, or on being roused  from sleep, it was judged more  eli-
gible, on due consideration, to follow the example of Dr. Cul-
len,  by joining it ,with the  last symptom, as it for the most
part attended it, in a greater or less degree,  and since the ir-
regularity and intermission  of the  pulse would serve  to give
an idea of the inequality of the heart's action at other  times.
   Influenced  by these considerations, the following definition
is submitted in the hope that it will be found lia]>ie to fewer
objections than  any of those  of the celebrated  writers tran-
scribed.
   Dyspnoea,  decubitu horizontali,  corporisque motu, aucta;
faciei pallor vel livor; urina parca, rubra, sedimentum fur-
furaceo-lateritium, deponente;  pulsus inequalis, intermittens;

  * " Anhelatio difficilis, querula, cum insomnio terrifico."  Sauv. cl. v.
ord. i. G. i. 158.
  " Morbus hie recurrens afficit dormientes cum anhelatione et insomnio
corporis cujusdam pectus opprimentis ; unde respiratio horum  querula,
gemebuuda, et anxia."  Sagar cl. viii. ord. 1. G. i. 245.
  " Respiratio profunda, suffocans, dormientis in dorso cum somnio la-
borioso."  Lin.  cl. viii. ord. i. G. 163.
  It seems singular that hydrothorax should not have a place in the  no-
salogy of Linnieus.                                       , 
4                   ON HYDROTHORAX.
 pedum vel manuum  oedema; subita e somno, cum palpita
 tione, excitatio.
   When  respiration is considerably impeded,  especially  on
 motion, in a horizontal posture, or on ascending an acclivity 5
 when the countenance is at the same time pale and sallow, as-
 sumes a leaden or livid  hue; the urine small in quantity,
 high coloured,  and, on  cooling, deposits a reddish or pink
 coloured  sediment; the pulse irregular or intermitting; the
 feet, ankles, or hands, swell, and are colder than natural; and
 the  patient is suddenly roused from sleep by a sense of suffo-
 cation or extreme anxiety about the prascordia attended with
 palpitation; the most superficial observer will have no doubt
 of the presence of a watery fluid in some of the cavities of the
 chest, and that the person,  thus affected,  labours under the
 disease, termed hydrothorax, or dropsy of the chest.
   The above combination of symptoms may be said to con
 stitute the leading and prominent features of this formidable
 disease;  and were it always  to assume such clearly marked
 characters, it might readily be distinguished from all others.
 Experience, however, teaches that the event is often other-
 wise ; that frequently in the  incipient and early stages, some-
 times in the advanced periods, some of these are either entire-
 ly wanting or so obscurely marked as to elude observation;
 and since it is well known that considerable collections of wa-
 ter have often been found on  dissection in the cavities of the
 ehest, when none was  suspected to exist before death, it be-
 comes an object of importance to point out such circumstanc-
 es c; may lead  to  its early detection, when it will be more
 withui the reach of medical treatment.   With this view the
 most eligible mode appeared to be, first to give a general out-
line of its precursors or early signs, afterwards to deliver the
history of  every individual  symptom in its different forms,
 gradations, and variations, and finally to take such a view of
 the whole as might lead to its early discovery:  in doing this 
ON HYDROTHORAX.
5
©are has been taken to discriminate between those which are
inseparably connected with it, and may be termed pathogno-
monic, and those which are less constant, or seldom occur.

                       SECT. II.

  Precursors, early signs, and general history, of the disease.

  'Although many writers have given a circumstantial histo
ry of its more advanced and latter stages, yet none that has
fallen within my reach appears to have taken a comprehen-
sive view of its precursors and early  symptoms.  The best
and most accurate  I have met with is in Dr. Cullen's inesti-
mable work, his "  first lines," &c.  This, as far as it goes, is
so  faithfully drawn from nature, that I shall  transcribe it
without abridgment in his own words.
   " The disease," says he, « frequently comes on with a sense
 of anxiety about the lower part of the sternum.   This, before
 it has subsisted long, comes to be joined with some difficulty
 in breathing; at first on the person's moving faster than usual,
 upon his walking up an acclivity, or upon his ascending a
 stair-case : but after some time, this  difficulty of breathing
 becomes more  constant and  considerable, especially during
 the night, when the body is in a horizontal situation: com-
 monly, at the same time, lying on one side is more easy than
 upon the other, or perhaps lying upon the back is more easy
 than upon  either side.  These circumstances are usually at-
 tended with a frequent cough, that is at first dry; but which,
 after some time, is accompanied with an expectoration of thin
 mucus."*
    On minutely tracing the history of  the cases of those who
 applied for my advice, to the origin of the disorder, the great-
 er number were found to have laboured for weeks, months, in
* Vol iv. 310. 
J-:
ON KYDKOTHORAX.
 some  instances, even for  years, under particular symptoms,
 generally  such  as  indicated defective energy,  or  morbid
 alteration  of  structure,  of some of the  organs contained
 within  the  cavity of the chest,  especially  of the heart
 and lungs.   Of these,  the peculiar  sense  of  anxiety  men-
 tioned above is  perhaps the  most common: it is variously
 described  by the patient: when questioned respecting his
 complaints, he often places  his hand on the  lower  part of the
 sternum and  epigastrium, or region of the heart, as "  the seat
 of all  his  misery,"  as he terms it: it is sometimes called  a
 sense of sinking, fainting, or fluttering, " as if his life were go-
 ing from him:" at other times, however, a sense of oppres-
 sion, as  if an immense weight were  placed on this  part, is
 complained of; and not  uncommonly by the  same person.
 This symptom is probably not constant at first, but returns at
 certain intervals and from certain causes, such as  those men-
 tioned in the definitions, or sudden emotions or passions.   If
 the pulse be examined, it will often be found irregular, inter-
 mitting, or oppressed, varying in strength and frequency from
 the slightest causes, accompanied with  occasional palpitation,
 or corresponding interruption of the action of the heart; but
 these generally subside on rest, or the abstraction of the caus-
 es which produced theni.   In some instances, however, an in-
 equality of the pulse is one of its first forerunners;  and if this
 has speedily followed acute or violent inflammation of any of
 the principal  thoracic viscera, especially of the left side, or a
 severe  blow on the region  of the heart, the presence of serous
 effusion in the pericardiuni, or sacs of the pleura, is in general
 to be apprehended.
   The breathing is readily hurried or quickened on any sud-
 den emotion of mind, or bodily exertion; and there is some-
 times an irresistible inclination to draw a full,  hut quick or
hurried, inspiration, from a sense of oppression or stricture
 about the prarcordia.   There is an unusual sensibility to cold, 
ON HYDROTHORAX.
t
and the lungs are so tender, that coughs or catarrhal affec-
tions are readily excited by slight transitions of temperature.
The feet are in general unusually cold, with a sense of numb-
ness or imperfect sensibility, especially at night when in bed.
The patient is not only readily " out of breath," as he terms
it, hut much fatigued, by the ordinary exercise of walking or
running;  and the bodily functions are disordered by little ex-
cesses in  eating  and drinking, which  before  were produc-
tive of no inconvenience.  The countenance not unfrequently
at this early period, discovers evident  indications of the la-
tent affection ;  the eye loses its wonted vivacity and expres*
sion; the complexion becomes pale and sallow;  and the nose,
lips, and  eye-lids, assume a livid  hue.   There is probably a
slight degree of oedema about  the feet and ankles, and the
urinary secretion is  irregular,  being sometimes scanty, and
high  colouied, with sediment, while at  others, and in  the
same person, it is in every respect natural. In some of the
cases in the appendix it will be observed, that a very copious
secretion of limpid urine has preceded the disease, and in oth-
ers, alternated  with a scanty high  coloured  turbid water.
Although the appetite be not always impaired, yet respiratioR
is sensibly more impeded  after eating, especially  if the sto-
mach be  overloaded, and the  food be difficult  of digestion,
and the sense of faintness about the pit of the stomach chang-
es to an uncomfortable fulness and oppression,—a proof that
the digestive powrers are  weakened.  The  patient can as yet
lie down in bed, but his sleeps are short, hurried, and disturb-
ed by frightful dreams; he is  obliged, by a peculiar restless-
ness not easily to be described, to change his posture frequent-
ly, and he probably lies already with more ease on one side
than the  other, sometimes the opposite to  that he  has been
accustomed to; in short, although he neither thinks himself,
or is thought by others, seriously indisposed, there is evrrv 
8
<3N HYDROTHORAX.
indication of an impaired state of the functions of some thora-
cic viscus.
   These  symptoms are  seldom constant at first, but return
only at irregular intervals, unless the causes which originally
produced them continue to be applied without intermission,
when they advance  with more  or less rapidity,  until the
disease  assumes its true  form.   If a  state similar  to that
which  has been described, however obscurely marked the
symptoms might be, supervened in persons of a full corpulent
habit, especially if they have been great beer or porter drink-
ers ; in those who have suffered severe or repeated attacks of
cough, catarrh,  asthma, or pneumoniae inflammation; in fe-
males at a certain period of life, that is, between forty  and fif-
ty years of agej or upwards, whose strength had been exhaust-
ed by frequent parturition, the cares, fatigues, and anxieties,
attendant on a  large family, in a certain sphere of life; in
persons whose constitutions had been broken down by frequent
blood letting, inordinate menstruation, or other evacuations;
by intemperance in the use of inebriating liquors; or in those
of a sedentary life, of a thoughtful and studious turn, more
especially if  the transition was sudden from  active occupa-
tions ; I should have no hesitation in concluding that water
began already to  be  effused in some  of the cavities  of the
chest, or that such a morbid condition of the thoracic viscera
existed, as would speedily lead to it.
  In all my patients  these, or the greater number of these
symptoms were observed to precede  its more striking  charac
ters;  and since my attention has been particularly directed to
its investigation, I have more than once predicted its approach
for some time before there was  yet reason to suspect any effu-
sion, as some of the annexed cases will demonstrate.   At this
period, however, it is very  generally mistaken for other disor-
ders ; nor is this to be wondered at, when  it so often eludes
detection in the advanced stages,  and when perhaps   few, if 
ON HYDROTHORAX.
9
any, of the symptoms described by nosologists as peculiar to
it, can as yet be observed.   But the  importance of an early
discovery of its real nature is so obvious, that too much attenr
tion cannot  be paid to its  primary stages, especially if they
arise under the circumstances mentioned above.
   The progress of the disease from this, to the more violent or
confirmed state, is more or less rapid, according to the consti-
tution, and age of the patient,  degree and nature of the re-
mote causes.   It is proper to observe that by removing the
causes when obvious and  within our reach, by attention to
appropriate regimen, and the occasional use of medicine, in-
stances have occurred, in the author's practice, where its fur-
ther  progress has  been checked, and the patient enjoyed to-
lerably comfortable health, for several years, even at an advan-
ced age.  To the  credit of the subject of case 18, and for the
encouragement of others who  may be affected in a similar
manner, be it recorded, that this happened  in  a degree that
was highly pleasing.
   It sometimes steals  on by slow and imperceptible grada-
tions, and assumes a  serious aspect before it has been suspected;
while at others its progress is extremely rapid.   In the follow-
ing history of particular symptoms,  the order of precedency
in which they occur is as much as possible observed.

                       SECT. III.

               History of particular  Symptoms.

   Impeded respiration.—In every case which fell under my
 observation  the breathing was more  or less affected ; even in
 the early stages,  before the nature of the  disease  was sus-
 pected,  this  invariably happened on motion,  or from any
 causes which quickened the circulation.   And  this symptom
 seems to have occurred likewise in all those recorded by the 
10                   ON HYDROTHORAX.

best writers on the  disease.  In  the works of the celebrated
Morgagni,#  where much valuable information  has been col-
lected  on its history,  and the appearances on dissection, two
cases are mentioned, the one by Ruffius, of a virgin, and the
other by Wepfer, of a young man,  which seem at first sight
to furnish exceptions tothis.f   But  as has  been very  justly
observed by Morgagni- himself,, though it be affirmed  in the
first part of the history of these cases, that respiration was not
affected, yet from the subsequent detail, the reverse must ob-
Viously be  inferred.    "For," continues the history,-  "the
young man did these  things when as yet there seemed no wa-
ter effused," but that afterwards, " he  had breathed with
difficulty,  and though he  walked with a slow  pace, he had
taken breath- frequently with  a distended chest;"  and  that
the virgin, " had extended  the alas nasi at the time of expira-
tion, but had not any remarkable  dyspnoea." J  Any instances
of this kind which may be  found in  authors must be attribute
cd to inattention or inaccuracy in the relation.  It is scarcely
possible that a considerable accumulation could exist in any
of the cavities of the chest without corresponding interruption
to respiration, especially on motion.
   It varies materially in degree  and kind, in different cases
and stages; and this  variation sometimes leads to a tolerably
 correct judgment of the seat and extent of the water, as well

   * Letter xvi. p. 397. obs. 27.
   f We are  told, " that the whole thorax of the virgin was filled with a
 ibul and ill savoured water, and that she continued qui'e to death without
 any difficulty in breathing ;" and that " in the right cavity of the chest of
 the young man three pints of serum were found, and one in the  pericar-
 dium ; yet that he was able to the last instant of his life to lie down with
 his head in a low posture, and even ascended steep places  without any
 impediment, and went to the top of iliem rather by running than by walk-
 ing a slow pace."  Sepulchret. Lib. ii. sect. vii. obs. 91. et iu  additam
 obs. 43.
   t Ibid. 
ON HYDROTHORAX.
Ii
-as of the morbid condition of the thoracic viscera which oc-
casioned its effusion.
   It  is sometimes quick, hurried,  anxious, and irregular ;
while at others it is slow and laborious: at times it is perform-
ed with a peculiar wheezing noise as if the air were passing and
re-passing with difficulty through a  narrow straightened, or
as one of my  patients* expressed herself, " through a metaJ
tube."
   Such is often the interruption to the functions of the heart
and lungs, that the aid of other muscles, besides those usually
concerned in respiration, is exerted, in order to elevate the ribs,
and enlarge  the capacity of the chest, and thus  admit of a
more  free circulation of air and blood through them.  With
this view the arms are  frequently  thrown above the head,
while the head itself, the neck,f and indeed  the whole chest,
are suddenly raised erect, and a full laborious inspiration made
at the  same time, with the mouth open,  and the aloe, nasi ex-
panded.  In very urgent cases these asswme the appearance of
convulsive  paroxysms, there being now and then short inter-
vals of repose.
   The patient in  some eases, breathes with most ease stooping,
or with his body  inclined forward.
   If the chest and abdomen be exposed to view, the muscles
which surround them may be observed to labour exceedingly.
 Some of my patients, especially the subject of case 7T,J have
said,  " that   their   breath appeared to come  from  the
lower part  of the body ;"  an observation that serves to con-
 vey a striking idea of the extreme  difficulty with which re-
spiration is sometimes performed.  In some of the worst cases,
 however, the patient enjoys, on rest, or the abstraction of ex-

   * Case 54.  Vide  appendix.
   t This symptom is particularly noticed' by the best writers on the dis-
 ease.
   | Vide appendix. 
12
ON HYDROTHORAX.
 ternal stimuli, a momentary repose, yet the dreadful paroxysm
 described seem to return with redoubled violence afterwards:
 but no well formed case will be found with complete intermis-
 sions as in angina pectoris, which may serve to distinguish the
 one disease from the other.
   Every muscular exertion, or cause which accelerates the cir-
 culation,  aggravates this symptom : hence  running,  quick
 walking, especially up an eminence, talking,  laughing,  and
 singing,  sudden  passions or emotions, are extremely prejudi-
 cial, and seem at times to threaten immediate suffocation ; the
 whole face becoming livid, and even black.   The act of dress-
 ing and  undressing, particularly   of stooping to buckle the
 shoes, is extremely irksome and fatiguing.
   If previously unacquainted with the patient, the breathing
 has been sometimes so hurried on my first visit that some time
 elapsed before he could describe his complaints; and, at all
 times, he expresses himself in short interrupted sentences.
   In a recumbent posture.—The learned author of Zoonomia
 observes* " that dropsy of the chest is attended with an abso-
 lute impossibility  of lying down for a few minutes," and far-
 ther in the same  page he adds " the patient cannot lie down
 for half a minute."  But this observation applies only to the
 worst cases and advanced periods.   In the early stages, when
 the quantity of water is small, the   patient can sometimes lie
 down in bed without inconvenience, though  an elevated posi-
 tion of the chest,  with the head somewhat low,  is generally
 preferred.   I have said sometimes,  because if it be suddenly-
 effused, two or three ounces will occasion as much inconven-
 ience as the same number of pints will do, if gradually collect-
 ed, so that the heart and  lungs have had time to adapt them-
 selves to the pressure.   This is strongly exemplified in case,
 39,f where the heart and .left lobe  of the lungs, were thrust
into the right cavity of the chest.   Hence,  in forming  the

       * Yol. ii. p. 107,                f Vide appendix, 
ON HYbROTHORAX.                  13
prognosis, it is of consequence to ascertain how far the causes
may have been such as to occasion a more or less rapid accu-
mulation.
  But although in some instances the patient be able to lie
down without inconvenience, he is often suddenly roused soon
after going  to sleep by a most distressing sense of suffocation,
oppression, and extreme anxiety, about the prascordia, attend-
ed with palpitation ; and if able to walk, he probably runs to
a window for fresh air, and makes several  laborious inspira-
tions, before he recovers his ordinary breathing.
  Under these most distressing paroxysms the face is generally
livid and even black, and together with the neck and chest, is
Govered with profuse sweats, appearing in large drops, which
are generally followed by a remission of these symptoms, but
not  that complete intermission which usually  succeeds the
asthmatic paroxysm.   The intellectual functions arc, under
these circumstances, much disturbed, the patient talking in-
coherently and labouring under temporary  delirium, which
subsides with the  paroxysm.
   As the disorder advances he is thus immediately attacked
on attempting to lie down ; so that at length he is obliged to
seek repose in a  chair, or in  bed, supported by pillows, in a
sitting posture,  sometimes  with the chest inclined forward:
even in this situation, as the quantity of water increases, he is
suddenly awaked by similar  sensations, and  dreading the re-
petition of this alarming symptom, he has no natural refresh-
ing sleep, though he be overcome by constant drowsiness and
stupor.
   On one side.—As the water is seldom equally diffused in
the cavities  of the chest, so there is in general greater difficul-
ty of lying on one side than on the other ; and, as it is some-
times confined entirely to one side, the  patient can only lie on
this.  Diseases of certain viscera, however,  in some instances
reverse this order, of which a case may be seen in Home's Clin- 
£4
ON  HYDROTHORAX,
ical Experiments,* and in the works of Morgagni.f   And ex*
tensive adhesions of the lungs  with  the pleura costalis, by
preventing the water from passing to the most depending part
of the cavity,  may do the same.   Considerable collections of
water in the pericardium likewise may have some influence in
this respect.
   When both  cavities are equally  distended, the easiest posi-
tion is on the back with the shoulders elevated.
   The cause of this symptom is sufficiently obvious.  Any
considerable pressure on the surface of the heart  and lungs
from  water must necessarily occasion proportionable interrup-
tion of their functions; and  this will  be  increased on motion,
or the application of any causes  which accelerate the circular
tion, because a greater quantity of blood will be  determined
to the lungs than can  readily  pass through them ; in a re-
cumbent posture by the water being determined to the upper
parts  of the chest, and consequently  by its pressure on the
large bronchial tubes, which are more immediately necessary
to respiration than the smaller.  On  lying on the side which
contains the smallest quantity, or none, by the mediastinum,
and in some degree, this lung, sustaining its incumbent weight
and pressure ; whereas on lying on the other side it falls to the

  * The subject of this case was a taylor aet. 45, " Has  been affected,'*
says the author,  " for four years with dyspnoea, uneasiness when he lies
on the right side,  the sensation of something moving in his breast when he
turns  in bed, and pain and swelling about  the liver."  When opened,
" the lungs adhered almost wholly to the pleura ; and in the right cavity
was found a  pint  of fluid, which must have pressed much on account of the
adhesion. We found on  the right lobe of the liver two  contiguous tu-
mours pointing to the ribs.''  p. 358.
   t In the case related by Morgagni, the water was  found on dissection
in the left cavity, " of which  it was full; but she could  not breathe in
bed unless sheiay on the right side.  In the right ventricle of the heart
was a large  polypous concretion, which  extended itself from thence into
the vena cava."  Letter xvj. obs. 12.  Vide case 6.  Appendix No. ii. 
ON  HYDROTHORAX*.                 1$
most depending part, between the lungs and  parietes of the
thorax.
  It is proper to  observe that,  beside adhesions of the lungs
with the pleura, hydatids, tubercular indurations, or cysts
containing a watery fluid within their cavity ;  polypous con-
cretions,  within  thp heart or large arteries; ossifications of
their valves, and other organic affections, may have considera-
ble influence in  interrupting respiration, independent of the
pressure of the water.
   Pallid or livid aspect, and other morbid appearances of the
countenance.—In no instance of chronic disease is the morbid
change of the countenance more strongly marked than in
dropsy of the chest; and it is generally one of the earliest in-
dications of its approach.   The faciei pallor of chlorosis ; the
sallow bloated hue of the bilious habit; the yellow tinge of
jaundice, convey very imperfect ideas of it; even when combin-
ed with this last disease, which sometimes happens, it has cer-
tain appearances peculiar to itself.  As soon as respiration be-
gins to be interrupted, the  lips, nose, eye lids, and those parts
of  the face which are usually florid, begin to assume a livid
hue, while  the rest of the face is pale and sallow.  If the nose
lias before been remarkably red or carbuncled,  the contrast if
now very striking.  As the disorder advances, more  especially
as  it verges on  the last stages ; or if the circulation be sud
denly quickened  by any  of the causes mentioned  above, al!
these increase, the whole face becoming livid and sometimes
black ; and in proportion as it  thus recedes from the healthy
aspect, it loses its natural warmth, the nose in particular being
often extremely  cold.   The eye  by degrees loses its natural
expression and vivacity, as indeed does the whole countenance,
in  which extreme anxiety and suffering are strongly painted.
 The conjunctiva looks dull  and  heavy,  and is at times so yel-
low as to leave no room to doubt the presence  of bile in the
blood.   These appearances afford the strongest evidence of thr
* 
VJ                  ON HYDROTHORAX.
 imperfect oxygenation of the blood, from the great interrup
 tion to its circulation through the lungs, and the diminished
 capacity of the bronchial tubes.   From the same causes the
 veins about the extremities, especially about the hands, may
 be observed distended with dark, sometimes black, blood.
  Diminished high coloured urine.—With few exceptions the
 urinary secretion gradually lessens in quantity, becomes pro-
 portionably high  coloured,  frequently  resembling  that  of
jaundice,  and deposits  on cooling, a copious sediment of a
 deep pink, or yellowish branny colour.   In a few instances  it
 is of a dark or dusky brown hue,  probably without sediment,
 but with an oily film on its surface, which is to be regarded as a
 very unpleasant symptom.  About three cases  occurred in my
 practice in which there was no sensible deviation from the na-
 tural state, till toward the advanced stage.
  Healthy urine when first voided, especially after a tempe-
 rate  meal, emits an odour that is not unpleasant;  but  that of
 dropsy is, for the most part, offensive as soon as it issues from
 the bladder, and becomes still more so in a few hours.
  The period at which these morbid  changes of the  urine
 take  place  is various.  In idiopathic  hydrothorax,  that is,
 where the serous effusion first begins in the cavities of the
 chest, and from causes existing there, the disorder sometimes
 makes considerable  progress before the determination to the
 kidneys is sensibly diminished, or before the quality of the
 urine is altered.   But though the kidneys be at first in a sound
 state, yet  in proportion as the blood conveyed thither is de-
 prived of a portion of its water, their functions will at length
 be impaired, and the urine will  be diminished  in quantity
 and  changed  in quality.  When, however, the  kidneys  or
 other organs are primarily affected, or when the dropsical ha-
 bit had previously existed, as it disposes alike to increased ef-
 fusion in other parts of the body, from the same causes, so the
 secretion of this fluid may be preternaturally changed both in 
ON HYDROTHORAX.
11
 quantity and quality, in the incipient stage  of this disease, or
 even before any watery accumulation has actually commenc-
 ed in the  cavities of tlie chest.  But whether the symptoms
 of impeded respiration  mentioned in the first part  of sect.
 III. have preceded or succeeded this peculiar state, we may
 with certainty conclude  that a fluid is effused in some of the
 Cavities of the chest, though there be no other external sign of
 dropsy.
  When the accumulation is sudden, the urine is quickly af*
 fected; but when it is very gradual, instances have occurred
 where there  was  reason to suspect considerable collections of
 water without any diminution of this secretion.
  The  cause of these  morbid changes in the urine has been
 variously  explained by the writers on dropsy. To refer to their
 real causes the principal  phenomena of diseases is an object of
 the first importance, as on this, in a great degree, will depend
 the successful exhibition of remedies.
   This subject shall be considered in a separate section.
  Palpitation of the heart,• irregularity and intermission of the
pulse,  may be regarded as one of the most frequent attend-
 ants on hydrothorax, and like the interruption of  the impor-
 tant function of respiration immediately connected with them,
 they vary much in degree and kind.   In some instances  the
 palpitation is so violent as not only to be distinctly seen through
 the clothes, but to be heard by a by-stander.  In cases 4f and
 56, this happened in a remarkable degree, and the pulse was
 was proportionably hard, but regular, so as under any  other
 circumstances to have indicated blood-letting: In one  of these
 it was  had recourse to with advantage, the expectoration of
 pure florid blood pointing out the necessity of it;  and had it
 been performed earlier, and with more freedom, it is probable
 the relief  would have been much greater.
  At other times the palpitation  is less violent, and in  some
 "nstances, especially in fat corpulent  or Yery weak  and irrita*
                            3 
13
ON HYDROTHORAX.
ble subjects, it is so obscurely felt as only to be perceived by
aqpther person on placing the hand on the seat of the heart;
and in such cases it is very  aptly termed by the patient, " a
constant working or fluttering."  But although it  be appa-
rently wanting,  or indistinctly perceived, on rest or the ab-
straction of external or internal stimuli, yet on sudden motion
or the application  of these, it is uniformly present with in-
creased violence.
   In  some instances when absent, it was excited on attempting
to lie on one side.   With  few  exceptions  it is acci mpanied
with corresponding inequality of the action of the artery at
the wrist, and the  carotids  shew this in a striking degree.  If
the motus  abnormis, be regarded as essential to palpitation,
those cases only in  which it is accompanied with irreaularity
of the puhe  deserve this appellation ; but  this ought not in
in my opinion to be  considered as necessary to it, for in the
cases  mentioned  above,  and in  many  instances of chlorosis,
there is only  a preternatural increased, and laboured action of
the heart,  without any irregularity in its contractions, or of
the pulse;  yet they are invariably termed, and understood to
be, palpitation.
   I have said above,  with few exceptions, on the authority of
the accurate  Morgagni.  He relates a case  of hydrothorax*
attended  with palpitation, in which he affirms, "  the pulsa-
tions  of the  heart  and  arteries were always observed to be
surprisingly unequal;  those of the arteries were frequent, and
those of the heart, which, when we applied our hands to the
thorax, seemed to palpitate, were  much more frequent; and
this comparison  being often and accurately made, always an-
swered in the same manner."   It is, however, extremely diffi-
cult if not impossible, to conceive that any material irregula-
rity,  or increased frequency of  the heart's  action could exist
 ■% ithout extending its influence immediately to the pulse.
* Case xv. obs.  30,  Vide appendix No. ii. 
ON HYDROTHORAX.
Ifc
   The systole and diastole of the auricles and ventricles suc-
ceeding each other so rapidly might occasion this mistake ; for
on placing one hand  on the region of the heart of a person in
perfect  health, and feeling the pulse with the other, the mo-
tions of the heart appear more frequent.
   When the palpitation was violent, it was observed that the
stroke of the artery at the wrist,  if regular, was proportiona-
lly  full and  hard; and when obscure, or when the patient
complained of the peculiar fluttering already mentioned, the
pulse was likew ise feeble.  In short they seemed to correspond
in every instance.
   The pulse in this disease exhibits every variety of irregula-
rity that has been described by authors.  In some cases, after
a few regular pulsations there is either a complete intermission,
or loss of one stroke, or there is a double stroke much weaker,
and occupying the space of time of a  regular one, as  if the
left ventricle endeavoured by two feeble efforts to make up for
the want of one vigorous  contraction.   These intermissions
and double  pulsations alternate w ith, or succeed, each other so
rapidly that the finger only now and then catches a  regular
stroke:  hence the extreme variation of the pulse in regard  to
frequency, if the intermissions be not numbered, and the dou-
ble pulsations be reckoned as two:  I have found it  to vary
from 60 to 110 in a minute.
   In the numerous interesting cases recorded in the works of
the celebrated Morgagni the state of the pulse is seldom no-
ticed, probably because, there being no fever, it  was rarely
examined;  and when it is mentioned,  it does not appear  to
have been so irregular as I have found  it, or as it has been ob-
served by others. The accurate Hoffman, describing a strong-
ly marked case of hydrothorax, conjoined with asthma, where
he suspected a polypous concretion in the pulmonary artery,
and which proved  fatal, observes, " ut ut  de pulsu, qui ia
■'ali  casu plerumque intermittens et inequalis est,  nihil  rela- 
20
u\ hvdrothora:..
turn mihi fuerit."#  It is hence obvious that this judicious
author regarded irregularity  of the pulse as a common occur-
rence in similar cases, which are very frequent.  It may be
worthy of remark that, except in one instance, the pulse never
returned to its natural state either in those who were perma-
nently cured, or those who experienced only temporary relief,
which 6hew s the power and influence of habit, even in morbid
actions, when once established.
  If relief be obtained  soon  after the irregularity has com-
menced,  by the evacuation  of the effused fluid, the pulse
sometimes returns to its natural state.
  The.palpitation of the heart and inequality of the pulse,
may either precede, immediately attend, or succeed,  the  wa-
tery effusion; and  it is of consequence to ascertain the time of
their appearance: if they precede the symptoms of serous ac-
cumulation, especially in old age, or after acute inflammation
of the chest,  it may be inferred they arise from one  or other
of the organic affections, of, or near the heart, hereafter enu-
merated ;  but if they commence about the same time with,
or soon succeed, these symptoms, it may reasonably be  con-
cluded they  are owing to the pressure of the water on  the
surface of the heart and lungs.  Any cause interrupting  the
flow of blood from the ventricles of the heart will  sooner or
later occasion an irregularity of its action;  but the degree of
this, and the time  of  its commencement are various in differ-
ent constitutions.
  In habits  endowed with a  high degree  of sensibility  and
irritability, after a few efforts more vigorous than ordinary, to
overcome the resisting cause, the contractions become irregular
and more feeble ; and if the cause be not speedily removed,
they remain irregular for life.
  But in constitutions the reverse of these, they not only in-
crease  in strength, but retain their regularity much Longer,
* Obs, viii. de Hydrope 
ON HYDROTHORAX.
n
sometimes to the advanced, and even last stages, of the disease.
Of these facts the cases in the appendix furnish examples.
  (Edematous swellings, coldness, and numbness  of the extreme
itics.—" Quod dein pedum intumescentiam  attinet,"  says
Hoif man,  " sciendum est, hanc fere inseparabile hydropis pec-
toris esse symptoma."*  But although this symptom may be
said invariably to attend the disease at some period or other,
yet the time of its appearance is various.  In idiopathic cases,
especially  if the bodily strength be not much reduced, the
disease makes some  progress before the ankles swell; but un-
der circumstances of great weakness they very soon become
oedematous.
  The swelling first appears about the ankles only at night,
probably  after any unusual exertion, and disappears before
morning.   By degrees, however, it comes on earlier, and at
length soon after getting out of bed, extending upwards, the
thighs, scrotum, and indeed the whole body, becoming enor-
mously distended ;  and in the last stages, suffering very little
or  no alteration by change of posture. The  face, neck, and
hands, in  some instances become oedematous  before the lower
extremities; and the limb of one side is generally more affect-
ed than that of the other; in some cases, probably owing to
the quantity of water being greater in the corresponding cav-
ity than in the other ;  but in others to the interruption to  the
return of the venous blood from lying on one side, more than
on the other.
  Sometimes one of the lower extremities swells earlier, and
more, than the other,  which may be determined by the same
causes. In the case above alluded to by Hoffman, the scrotum,
left foot, leg and thigh only, were swelled ;  in the left cavity
of the chest were found seven pounds of water.
   The anasarcous limbs of genuine hydrothorax are colder,
and more livid, than those of common anasarca ; and this wi!i

                   ' Vol. vii. obs. vii. p. 173 

ON HYDROTHORAX.
be found proportioned to the degree of interruption of respi-
ration.   In a  few instances the blood seemed scarcely to cir-
culate in the lower  extremities for some weeks before death,
and in one case,* this was observed  after the water had been
completely evacuated, and the disposition to further accumu-
lation corrected : from being enormously distended, they be-
came completely emaciated;  were intensely cold, of a dark
livid colour, entirely void of sensibility,  and for several days
before death they were black, and covered with gangrenous
visicles.
  In  the extraordinary  case of Mary Golding,f where the
heart, and left lobe of the lungs were thrust into the right cav-
ity of the chest, the legs were not only extremely cold and of
a livid hue,  but,  to use the mother's  words, " were  dead
nearly up to the hips for a fortnight," before the vital spark
was extinguished in the interior organs;  yet they were at the
same  time considerably  swelled.  The  lips, face, hands and
arms, were likewise intensely  cold, and  equally livid.  The
irregular and feeble action of the heart, the interruption to
the transmission of the blood from the  pressure of the water,
or other causes, and the consequent  imperfect oxygenation of
the blood, afford a satisfactory  explanation of the coldness,
numbness, and livid colour, of the extreme parts.  In the few
cases where the action of the heart was vigorous, and the pulse
regular and full, the legs retained  a considerable degree of
warmth though distended with water.
  The being suddenly roused from sleep by a sense of suffoca-
tion, fyc. is so frequent an attendant on hydrothorax, that it
has been considered by Baglivi, Girolus Piso, Reimannus, and
other respectable authors,J as furnishing a certain diagnostic of

              * Case 14.               f Case 39.
  X Jo.  Jacob.  Vicarius, " believed  he  could swear," says Morgagni,
" that from this symptom in particular, the patient infallibly  laboured
under a dropsy of the thorax ;  yet iu the thorax of a patient who had it 
ON HYDROTHORAX.                   £3
the presence of water in the chest.   But others, and on better
grounds, contend that since it is sometimes observed to attend
disorders unaccompanied w ith serous effusion, no reliance is to
be placed on it  alone, " though it is not to be despised," as
Morgagni justly observes,  « if it be joined.by other symptoms
which indicate the presence of water in the chest."
   This symptom, like every other individually considered, af-
fords no positive evidence  of the presence of water ;  but when
united with the other leading ones mentioned,  however ob-
scurely marked  these may  be, it ought to remove every doubt
as to the nature of the disease.  • But there are certain circum-
stances which determine  its presence or absence, even in the
same person, deserving attention.  The patient,  for  instance,
finding respiration performed with great difficulty in  a recum-
bent  posture, naturally looks for that position  in which he
breathes with the  greatest freedom.   He  goes to bed there-
fore with his shoulders raised up with  pillows; and may thus
for a time escape this dreadful symptom, which before harrass-
ed him.  But if,  forgetting his former sufferings, he should
chance to seek repose without this precaution, especially with
a full stomach ; or if the pillows should slip from under his
chest during sleep, or by the weight of the  body, they should
be compressed so as to place  him nearly in a recumbent pos-
ture, this symptom will probably occur.  Hence it may arise

in a degree, when opened after death, did he find not the least  drachm of
serum or water, either in the right or left cavity; on which be cried out
with an ingenuousness never sufficiently to be commended, and  f'uil of
wonder, Ohhomfallacious sometimes are diagnostics /''  (p. 384, et seq.)
" lie afterwards observes, that this symptom  is not to be depended up-
on, unless the feet swell after it, and not before it, wherefore,"  concludes
Morgagni, " neither this symptom w ill be of itself, and without frequent
hesitation, considered as the  most characteristic mark of the disease,
since it sometimes appears in others also, and since it is even not very
seldom wanting in those who have appeared after death to have laboured
under this disease,"  Letter xvi, obs. 11. 
2i
ON H^D-ROTHORAX.
or not, under different circumstances, in the same psrson.   At
first, it comes on only at certain intervals, after a long sleep ;
by degrees the returns are more frequent, and  the patient is
roused soon  after  falling asleep ;  at length immediately on
lying down, and in the advanced and last stages, it harrasse?
him by day as well as by night, and in every posture: I have
repeatedly  witnessed it, as he  slept or dosed  in his elbow
chair.
   These  may be said to constitute the  leading or character-
istic symptoms of the disease under consideration;  but there
are many others, which, though not essential to it, very fre
quently occur, and therefore no less claim the attention.
   A  cough, that is either hard and  dry, or in which  a copious
yellowish, or what has been termed by authors, a catarrhous
matter, is expectorated, is a fre'quent and distressing attendant
Upon  it,  as every other symptom is thereby aggravated.   Of
this Hippocrates was fully aware. ft A cough," says he, "up-
on those  that are troubled with a dropsy is  bad."*  And
again, "  A dropsy attended with a cough is a desperate dis
ease."f   In fat corpulent subjects, a cough  or catarrhal  af-
fection, if long neglected, improperly treated, or riot relieved
by a copious expectoration, is sometimes followed by serous
accumulation, of which instances may be  seen among the
annexed  oases.j;  Very fat children, of a lax   flabby fibre;
sometimes fall a sacrifice to this disease from similar causes,
without its real nature being suspected, till it  has been  de^
tected on  opening  the body after death.   I have met with
several instances in  which there seemed every  reason to  be-
lieve death arose from this cause.
   In  such habits, the heart and lungs, and indeed the whole
chest, being oppressed by inordinate quantities of fat on the
one hand, and the bronchial tubes  being choaked  up with

   * Hipp. aph. xxxv. sect. 6            f Apb. xlvii, sect. 7.
   | Vide case 19 
                     ON HYDROTHORAX,                  2«i

 viscid mucus on the other, the blood necessarily circulates
 with difficulty through the pulmonary vessels: hence accu-
 mulations in the right side of the heart, distension of the ca-
pillary vessels, diminished absorption, and increased serous ef-
 fusion, (which last is favoured by the laxity of fibre peculiar
 to such constitutions) are the natural consequences. Hence too
 the reason why habitual catarrh, and chronic asthma, so often
 terminate in hydrothorax, especially in such subjects. The fre-
 quent action of coughing likewise causes an unequal  distribu-
 tion of blood through the lungs:  to some parts it is determin
 ed with additional impetus, while others do not perhaps, re-
 ceive it in sufficient quantity, or with  due  velocity.  Several
 patients  applied to me in the spring, or early in the summer,
 labouring under this disease, evidently originating in,a succes-
 sion of severe coughs, or colds, which had probably been ne
 glected, or improperly treated, the preceding winter.
   Blood is sometimes expectorated in great quantity, and is
 always an alarming, if not a fatal symptom.  Some persons,
 however, pass through the disease without a cough.
   Pains in different parts of the chest are common in this
 disease: they vary in  degree, kind, and extent, according to
the causes which produce them,  being sometimes  superficial
and affecting only the intercostal, or other  muscles concerned
 in respiration, while at  others they are deep seated, and may
even be traced to the  heart itself,  causing a most  distressing
sense of constriction,  as  if something were pressing upon, or
closely embracing this  muscle.   The  pericardium has been
distended in some instances to such a degree as to occasion by
its pressure upon the  diaphragm very  considerable uneasi-
ness,  " bearing down, or oppressive weight, in the  lower part
of the chest," extending to the lumbar region in the direction
of the crura of the  diaphragm.  This has also  happened,
though in a less degree, from water in the sacs of the pleura,
The pains are either acute or obtuse, fixed or wandering, or
                            4 
JO
OIN" HYDKOIHORAX..
return at certain intervals; and they move in various direc-
tions, not unfrcquently up to the neck and throat, producing
a sense of constriction, as if a cord were drawn tight round
these parts; as well as to the shoulders and arms  to the ex-
tremities of the fingers, alternating, or attended, with a sense
of numbness.   The brachii stupor,  however, I have not met
with so often as might be expected from the histories given by
the writers  on this  disease, though  the patient was always
questioned as  to its presence; but there is for the most part
a soreness or sense of weariness about the muscles surrounding
the chest.
  External swelling and fluctuation  of water.—A tumour, ele-
vation, or unequality of some part of the chest may sometimes
be  observed;  or if the body  be exposed to view, one  side ap-
pears larger than the other.*  This swelling is  more fre-
quent, and  sometimes very considerable, about the serobicu-
lis cordis, and epigastrium, than any other part.   In some
cases it is occasioned solely by the descent, or protrusion, of
the diaphragm, from  water;  in others by the liver being
thrust downwards, and forward,  from its natural seat,f either
in a sound, but more generally  in a diseased state, by  the
same cause.  Hence  the tumour is either 'soft, smooth, and
elastic, or hard, knotty,  and not yielding; and it is more or
less painful on pressure.
  In regard to the fluctuation, enough, it is  presumed, has al-
ready been said to satisfy the mind that it is a symptom en-
tirely of the imagination, and that the error which Hippocrates
and some  of the earliest writers fell into by  enumerating it
among the  signs of the disease was perpetuated by succeeding
writers copying it from each other.   But though it cannot be

  * Vide case 39. appendix.   Also Cullen's First Lines, vol. Iv. p. 314
  f  Vide Morgagni, letter xvi. obs. 26. Appendix, No. 2. case 14.
  In the case here referred to the liver was so much depressed as to hav*
been taken for the pancreas. 
ON HYDROTHORAX.
27
 * ither heard, or felt against the fingers by the usual tests used
 in ascites, yet the patient sometimes observes that he has the
 sensation as if water were contained in the chest, passing from
 one side to the other on turning, or " as if the heart w ere mov-
 ing in a fluid."   That it may never have been heard on vie-
 lentiy shaking the chest, and holding the ear close to the side
 as advised by Hippocrates, I will not pretend to  determine;
 but as it is here  intended only to record such symptoms  as
 have really been  observed, this cannot be admitted  among
 the number.  The lungs and other organs of the chest fill  its
 cavity so accurately, that it  is difficult to  conceive how the
 agitation of the water could be heard  «« as in  a bladder half
 filled v. ith any fluid," or  as  may be done in the stomach,
 when, together with a watery fluid,  it is partially distended
 with air.  Some  authors, however, were fully aware of this.
 My late worthy and much respected friend Dr. D. Monro,  in
 his excellent treatise on dropsy, has  remarked, " that water
 collected in one or both cavities of the thorax  is with difficul-
 ty discovered, the ribs and tense short intercostal muscles, not
 allowing the water to extend itself outwardly, or the fingers to
.feel any fluctuation."*  " This symptom," says Morgagni,f
 " neither is, nor  indeed can be, perpetual:  for besides that
 you will look for  it in mine  and  Valsalva's observations  in
 vain, the same also happens in most of those  of others -, who,
 it is to be supposed, would not have passed over this clear and
 evident mark of the disease, had it really existed ; and you
 will find it expressly denied by some that it ever existed."
   Natural functions.—The stomach  and alimentary  canal
seem to sutler less in this than in  any other disease in  which
 the functions of organs so essential to  life are so seriously de-
ranged.   In many instances the appetite for  food is not im-
 paired ; but in all it cannot be indulged without more or less
incpnvenience, there being invariably a sense of fulness  and
Page 186,
t Letter xv;  obs. 37, 
28                  ON HVDKOTHOIUA.

distension after eating, attended with increased dyspnoea, and
general suffering, especially if the stomach be  overcharged
and the  food be difficult of digestion, to which a degree of
flatulency, which for the most part occurs, very materially
contributes.  During my visits I had frequent opportunities
of seeing the patient both before and after eating, and the con-
trast was very striking.   In a  few instances the peculiar sense
of faint ness  or sinking at the stomach was  relieved after a
temperate  meal;  but this happened at  an early period.
Wine and other grateful cordials afford considerable, but, for
the most part, only temporary alleviation of this, and indeed
of every other, symptom; insomuch that it was found very
difficult to restrain the inordinate cravings of the patient for
these substances.
  When the disorder is the consequence of exhausted consti-
tution  from repeated excesses in drinking, or other debilitat-
ing causes, as might naturally be expected, the powers of the
stomach are weakened, and the appetite is impaired, from the
beginning.
  As is the case in other dropsies the tongue is sometimes foul
and furred, with more or less  thirst; and these increase with
the disease.   The bowels are various ;  but they are more ge-
nerally bound than otherwise.
  The pressure of the water on the oesophagus sometimes oc-
casions a difficulty in sw allowing: to such a degree did this oc-
cur in one instance* for several days before death, that only
the smallest quantities of liquids could be  conveyed into the
stomach.  Though the craving for food was intolerable, yet the
repeated efforts and struggles to swallow solid food were vain.
In these the patient was more than once nearly suffocated.
  Stupor, drowsiness, and other affections of the head.—From
the inability of lying down in bed, or from the dread of being
suddenly roused and threatened with suffocation on going to
* Vide case 39. appendix 
ON HYDROTHORAX.
^
ileep, the patient seldom enjoys long or natural repose, espe-
cially in the advanced periods of the disease; but he is over-
come by a constant drowsiness  and stupor, to such a degree
at times that when persons are talking  around,  and even to,
him, he is dosing or sleeping, now and  then starting up  sud-
denly ; and talking or muttering incoherent sentences.   But
when his attention is roused he generally becomes sensible, and
talks rationally, but immediately falls into the same state of stu-
por again.  In a few instances there is a delirium approaching to
a maniacal state; and in one case* such was the degree of de-
rangement of the intellectual functions, that the patient, who
had been unable to move for many days from his elbow chair,
walked up stairs in the night, when the family were in bed,
and alarmed them not only by his  unexpected presence, but
by  the positive assurance " that some thieves were breaking
into the house and going to murder him."  The dreams and
reveries are of the horrid and  frightful kind.  The languid
circulation and accumulation of dark,  or imperfectly oxygen-
ated blood, in the head, serve to explain the cause of these
distressing symptoms.
  State of the animal functions, and of those of the habit at
large.—As might be expected from the nature of the remote
causes, this disease is ushered in under  circumstances of gene-
ral or partial debility.  The muscular fibre is for the most
part soft, flabby, and unequal to a vigorous contraction.  If
the blood be examined it will appear generally dark on flow-
ing from the vein, and on coagulating,  the crassamentum will
be  loose and soft, sometimes remaining in an uniform flabby
mass, scarcely separating from the sides of the vessel, the bot-
tom of a dark livid colour; yet the proportion of serum is
large.  In its texture it  resembles that of dropsy in general:
 but is of a much darker colour.   When the disease chances t(
b?  attended with inflammatory symptoms which is to  be r^
" Case 61, 
5C                 ON HYDROTHORAX.
 garded as a rare and accidental occurrence, the blood may be
 otherwise than as here described.*   Even in those cases where
 the pulse was remarkably full and hard the blood exhibited no
 buff on its surface, but was loose in its texture.
   Every  part of the  body shews in a striking manner the ef-
 fect of this morbid change of the solids and fluids, as has been
 in a great  measure already demonstrated.   Not only those
 parts the most distant, but the nearest to the heart, feel the
 influence of a languid, and irregular circulation of dark venous
 blood.   The whole surface is cold and chilly, except  under
 the circumstances mentioned above, w hen profuse sweats break
 out on the upper parts of the body;  the natural perspiration is
 diminished,  and sweat is  with difficulty excited by sudorific
 medicines.
   Progress  and termination of the disease in death.—Many
 diseases have a natural termination in  health without the aid
 of art.  The efforts of nature, or the vires medicatrices nature,
 however they may have been ridiculed by a few modern me-
 dical philosophers, the Brunonians in particular, if their salu-
 tary efforts be not counteracted by the officious interference of
 art, will frequently conduct the patient through the most pe-
 rilous situations, to perfect health.  But in many other  dis-
 eases nature is incapable of affording any effectual assistance ;
 and in  none  is this to be lamented  more than in that  under
 consideration.  Its progress to a fatal  termination is regular
 and uniform, when art has not interposed her salutary aid ;
 and this has  been  too generally the case under medical treat-
 ment, in so much that it is numbered among the incurable dis-
 eases by most medical writers.   In consequence of the increas-
 ed pressure of the accumulated fluid on the heart and lungs,
 the patient may be said to be suffocated ;  or he dies apoplec-

  * Case 5, in  the appendix, taken from  Home's Clinical Experiments,
 an instance of this kind is recorded : the  blood was very buffy, and the
patient seems to have been cured by seven bleedings. 
ON HYDROTHORAX,
31
tic, from the pressure of dark venous blood on the brain, not
unfrequently accompanied with serous effusion, either on its
surface or in its ventricles ; so that death in this disease is some-
times analogous to that  from drowning or hanging.  The fa-
tal event is generally sudden, and sometimes unexpected, pro'
bably when there appeared to be a momentary interval of re-
pose, frequently during, or after a meal, or any sudden bodily
exertion.
   The sudden termination in death is particularly mentioned
by the best authors on the disease.  Dr. Withering, speaking
Of a case which  proved unexpectedly fatal, remarks, " This
case, as well as case vi. is mentioned  with a view to demon-
strate to younger  practitioners, how sudden, and unexpected
the  death of dropsical  patients sometimes happens, and how
eautious we should be in assigning causes for effects."* When
iny  patients refused to pursue the plan of medicine recommend-
ed,  I apprized the friends of this circumstance, and my pre-
 dictions were in general verified.  But in those who conform-
 ed, and in whom the water was repeatedly evacuated, and the
 disposition  to its farther effusion corrected, but who eventual-
 ly died of exhausted constitution, or  decayed organs, the ap
 proaches of death were marked by a slow and gradual pace,
 as in many  other chronic  diseases.  The reason why it should
 terminate  suddenly in  death may be accounted  for  from a
 consideration of the organs affected, the nature of the disease,
 and occasional causes.

   * Case 22.  p. 27.   See the :'<«e6 from Morgagni in appendix No. £\ 
ctiAP.  ii
                        SECT. I.

               Dropsy of the Pericardium.

     .T ROM the belief which has generally obtained, among
the writers on hydrothorax, that the only  certain mode of
evacuating the sacs of the pleura and pericardium of water,
was by artificial outlets, infinite pains were taken to establish
the discriminating characters of each, because in the one, the
operation might be performed  with perfect safety, while, in
the other it was attended with imminent danger, if not with
certain death.  Some  indeed have been bold enough to ad-
vise puncturing the pericardium.*
  When however, it is affirmed that the paracentesis thoracis
is seldom, if ever, necessary, or justifiable, and that the means
hereafter recommended will be found equally  efficacious in
whichever of these cavities the water may be collected, it will
be superfluous to dwell any  longer on this subject.  We shall
therefore proceed to bring into one view some of the opinion."
of the best writers on hydrocardia.
  The celebrated Morgagnif affirms that he  never saw an in.
stance of it unaccompanied with water in some of the other ca-
vities of the  thorax.

  * Senac, who writes ably on this disease, after observing, " that it is
frequent, difficult to be known, and more difficult to be cured," deliber-
ately recommends puncturing the pericardium, with this precaution, and
in such a manner, "that the  mammary artery  may not be wouudcd."
L. iv. C. 5.
  f Letter xvi. obs. 20. 
                   ON HYDROTHORAX.                  33

  The learned Dr. Friend* not only asserts the same, but con-
tends, that it was to be sought for rather among the inventions
of artists  than in the works of nature;" and farther, " that
Galen says not a word upon the subject.   In this, however, he
has committed  an oversight.  The dissections of the antients
were entirely confined to animals, but, from what Galen ob-
served in these,  he concludes, " a  probable conjecture may be
drawn that men are also troubled with similar  disorders."
He  even describes the manner it which it may sometimes arise,
as from hydatids being ruptured within the pericardium ; and
offers some conjectures on  the circumstances that may lead to
its  discovery.  " The palpitation of the heart,"  says he,
" either  happens by  itself or with some indication that the
heart is moved in a fluid ;  nor ought it to seem wonderful,"
continues he, " that so great a quantity of water is accumu-
lated, sometimes, in the coat surrounding the heart, so as to
prevent it from being dilated."!
  Morgagni, from never having observed it alone, naturally
acknowledges the great difficulty of deciding on its peculiar
symptoms; and hence says he,  "  observations  made upon it,
if it be at any time found to be solitary, ought to be very di-
ligently attended to."J
  Grastsius asserts,|| " that he could find scarcely any signs by
which even the most experienced physicians could rightly
distinguish these  two dropsies, the one from the other; unless
one should perhaps say that the fairitings were more frequent
fn this than in the other, and the difficulty of  breathing more
mild."   And, after enumerating several other symptoms com-
mon to both, he thus proceeds: " the pulse grows extremely
small; a weight is felt pressing; or constringing the heart; a slow
fever with thirst  frequently comes on;" and farther, when

  * Hist, de la Med. P. 2,            t De loci Affect, c. 2.
  t Ibid; obs. 20.                   U De Hydrops Per. wet. 4-
5 
j£
ON HYDROTHORAX.
 speaking of a case where the pericardium was so distended as-
 to fill the whole cavity of the thorax, and where the surface of
 the heart was eroded, " the patient," says he, " felt  an op-
 pressive weight in the lower part of the chest," (in the  left
 side it is  presumed) " and  being long  troubled  with other
 symptoms that  generally indicated a dropsy of the thorax, at
 length  died as  if suffocated by  this disease, as was  suppos-
 ed."   In a case* from Valsalva by  Morgagni, where the pe-
 ricardium contained more than half a pint of limpid serum,
 and the two cavities of the chest some fluid, the only  symp-
 toms described, are a slow fever  for many weeks;  a tumour
 of the feet, a dry cough, a dryness of the fauces; short quick
 breathing; and a pulse scarcely perceptible."  A polypus
 was found in one of the ventricles of the heart.
   " A thirst so rarely attends  it," says Morgagni,f "  that I
 would not have  it mentioned among  the symptoms of the dis-
 order, especially as our Saxonia has expressly asserted there is
 no thirst."  Valsalva on the contrary says " that as there was
 neither a thirst or a dryness of the fauces always attending a
 dropsy of the thorax; so it sometimes happens that there is
 none also in this.  Wherefore the absence or presence of thirst
 will not certainly distinguish these two disorders."J
   In the Sepulchretum Anatomicum\\ cases are recorded of this
 dropsy alone, as  well as conjoined with that of the  chest, and
other disorders;  but nothing is found in these histories that is
not peculiar to collections of fluid in other cavities of the tho-
rax.
   Among other  signs, «■ the  sensation, as if the heart were
moving in water," is mentioned.^  A vehement palpitation of
the heart to which the patient  had been subject a  considera-
ble time, and a dyspnoea are the principal symptoms dwelt

  * Appendix, case 3.        f Ibid. obs. 46.       + Ibid
  i] L. ii, s. i. obs. 86.        $ Ibid. s. 8.  obs. 29, 
ON HYDROTHORAX,
35
 ipon in a case where " the pericardium was swelled out to a
 vast tumour."* Boerhaave, who wrote some time afterwards,
 expressly affirmed, " that from the hydrops pericardii won-
 derful palpitations of the heart are brought on."f
   On the other hand, however, R.eimanus observes that pal-
 pitation is sometimes wanting.J   Diemerbroeck also denies
 that  in any of those he had dissected there had been any pal-
 pitation, though they had  a dropsy of the pericardiumj| and
 affirms " that  he found the pulses  very languid and few ;
 and that palpitation was excited rather by any kind of liquid,
 although small in quantity, so that  it could lfut irritate the
 heart by any veilicating quality." Nor does Barrere mention
 this symptom in the history of five cases related by  him.
   Many other well authenticated instances are to be found in
 medical  writings  of this disease, even with considerable ero-
 sions  of the surface of the heart jn which no mention is made
 of palpitation ;§ and since  numberless instances are  to be met
 with  of palpitation of the heart without any water in the per-
 icardium, this  symptom alone, it is obvious, is not to be reli=
 ed  upon, but ought invariably to be had in view before we de-
 cide on the nature of the disease.
  Stalpartlf gives the history of the case of a girl who was cur-
 ed  by him,  " whose face was pallid, very much swelled, and
 had never menstruated, in whom he could very distinctly hear
 the agitation of the water in the pericardium when  the heart
 was beating, (for she laboured  under a palpitation  of the
heart.")   But I perfectly coincide in opinion with  the accu-
rate Morgagni, in  his comments on this case: he very justly
observes that as the real nature of the disease was not confirm-

  * S. 8. of 21. § 4. 10.           f Prelect, ad Instit.
  % Act. N. C. Tom. I. obs. 170.   [| Sepulch. sect. ead. 8. obs. 22.
  J Vide Centuriae Cesar. Acad. obs. 141, Sepulchret ■ L, 2. S. 2. obs
3. cum Schol.
  ? Cent* I. obs. 36, 
So
ON HYDROTHORAX.
 ed by dissection, and since it so readily admitted of a perfect
 cure,  no certain inference could  be deduced from it.  It is
 probable that it was no more than a case of confirmed chloro-
 sis, in which disease, not only all the symptoms he has enume-
 rated but the addition of osdematous ankles and indeed oedema
 of almost every part,  even the face, are frequently observed to
 occur.
   In the case of a boy, by Vieussens,* «« from a lively, brisk,
 and well coloured youth, he became sad, slothful, and pallid,
 with his eyes less vivid than usual, and hi6 lips and eyelids
 verging to a leaden colour.  If he walked a little faster than
 usual, or went up stairs, his respiration became difficult, and
 the  palpitation  of his  heart with which he was  constantly
 troubled, more violent.  The disorder then greatly increasing
 he lost his appetite for food, and  his bodily strength, the ex-
 tremities  were  constanly  somew hat cold,  and his feet very
 much swelled  ; but his pulse was always very soft, weak, small,
 freepuent, and somew hat irregular.  Finally, being taken with
 a slow fever, he  died."
  Another,!  in which the  collection of water was much more
 considerable, " was a man  of a melancholic temperament w ho
 had always been extremely well in  health till  a year before,
 when he began to labour under a difficulty of breathing which
 had so encreased by degrees, that at length, for three or four
 months together, he  was  forced to sit up in bed night and
 day,  for fear of suffocation.  He was at that time, lean  and
 without any swelling at all.  Hands and legs were for the most
 part chilly ; eyes dull and heavy; face and lips of a dark iron
grey.  He lay with equal  uneasiness on both sides, and on his
back  with still greater  difficulty, and the colour of his face
became more dark;  pulse more small, frequent, and unequal;
and the extreme parts more cold.  This man,  although he
could go from the bed to the fire by himself, yet died the next

  *  Traite du Coeur, ch. i.  Appendix 2. case 11.    f Ibid, case 1.?. 
ON HYDROTHORAX.
37
day at dinner, suddenly."   Vieussens both foretold the dis-
ease and death.   And from comparing these two cases togeth-
er, he was led to distinguish the same disease soon after in an-
other boy;  although it was joined with dropsy of the thorax
and other diseases.
  The symptoms in these two cases are so strongly marked
and so well described, that I could not help transcribing them
at full length.
  But this excellent  author, after  having confessed he  had
been deceived with another great man in distinguishing the
disease in a certain youth, thus ingenuously expresses himself:
" It is not so easy to know the dropsy* of the thorax as some
physicians believe,  who, being ignorant  of anatomy, ascribe
too much to themselves; and  who never imagine they ought
to have dissected bodies, or inspected them when they were
inspected by others;"  and, continues this celebrated writer,
" for those who have inspected many have at least learned to
doubt, when  the others who are ignorant of anatomy, and do
not take  the trouble to attend to it, are in no doubt at all."*
  Barreref from  the cases of five patients  which were found
on dissection to have had a dropsy of the pericardium reck-
ons as diagnostics of this disease, " an oedema of the  feet, a
pale countenance, a small quick pulse, obstructed respiration,
difficulty of lying down in bed,  together with a sensation of
suffocation, recurring from time to time."   He acknowledges,
however, the difficulty of  distinguishing  the one  from the
other.
  SenacJ has with great accuracy enumerated the symptoms
of this disorder, as wrell from his own, as from the observations

  *  To no period did this observation apply more aptly than it does to
the present.
  t  Observat. Anatom. Vide etiam Van Swietens Commentaries,  Sect.
1219. vol.  12. p. 263.
  t De h  Structure du Coeur, L. IV. c 6. Tom. II. p. 356. et seq. 
 38        *        ON HYDROTHORAX.

 of others, and mentions a sign, which, if it always existed,
 would be more certain than any that has been described;  viz
 ft  An undulatory motion between the 3d, 4th, and 5th  ribs
 (of the left side it is presumed) when the heart palpitates."
   Dr. Darwin observes, " if the pericardium is the principal
 seat of the disease, the pulse is quick and irregular.   If only
 the cavity of the thorax is hydropic, the pulse is not quick or
 irregular."*   But  that this assertion is in direct contradic-
 tion to the observations of the best writers on the disease, as
 well as to those which the author's own experience has enabled
 him to make, will appear sufficiently obvious from the preced-
 ing history, and the annexed cases.
   What has been said above on the dropsy of the pericardi-
 um, and a great deal more might be added from  various au-
thors, serves to demonstrate the uncertainty of relying on  any
individual symptom as a diagnostic in either of these diseases,
since it is obvious that no one has as yet been mentioned which
does not occasionally occur in the one as well as the other.
   The great difference of opinion, and contradictory evidence
respecting the presence or absence of palpitation,  and indeed
of some of the other leading symptoms, may be referred to the
causes already mentioned  in delivering the history of hydro-
thorax ;f to which, it may be added, that if the pericardium
be -distended with water, the stroke of the heart will be ob-
 scurely or perhaps not at all felt through the side ; and  if it
contain but little, there may be no palpitation; or if there
should be any it may be distinctly seen and felt.   Hence nei-
ther the absence or presence, nor the degree of  this symptom
furnish any certain criteria to depend upon.
   From the foregoing observations, as well as from those fur-
nished by the annexed cases, the following circumstances are
 advanced as  worthy of attention,  and as affording data on
 which a tolerably correct diagnosis may frequently be formed.
* CI. ii. 2= 3.
t Page 19 et seq. 
ON HYDROTHORAX.
39
  In genuine dropsy of the pericardium the breathing is ge-
nerally less affected in all positions and circumstances of the
body ; and it is more of the quick, hurried,  anxious, than of
the slow laborious kind : in other respects there are some pe«
euharities.  Though  the recumbent posture be borne with
less inconvenience, yet if the pericardium be much distended,
and if the other cavities contain but little, or he entirely free
from  water, a sensation as if something were rolling in  the
breast, in the region of the heart, is perceived on turning from
one side to the other, together with an increased difficulty of
breathing, and a sense of weight, on attempting to lie on ei-
ther, especially the right.
  The erect position too is no less irksome, owing to the pres*
sure and bearing down pain of the distended pericardium on
the diaphragm, to relieve which the patient is obliged to sit
up, or walk,  with  his body bent forward, or stooping.  The
greatest ease is in such cases experienced lying  on the back
with the  shoulders elevated and the body inclined to the left
side; this indeed will be found the easiest position in every
stage of the disease.
   The palpitation of the heart, though probably more con-
stant, is less violent, and less distinctly felt, being  of the weak
fluttering kind; and  this  circumstance, added to the more
remarkable variations observed in this respect on change of
position, may serve to account in some degree for the grea#
difference of opinion in medical writings in regard to its pre-
sence or absence.
  The  peculiarities of the  pulse are still more striking: it k
softer, more feeble, frequent, irregular and tremulous, without
those occasional intermissions, now  and then succeeded by a
few regular and full strokes of the  artery, mentioned as occur-
ring in hydrothorax.  It will be obvious, however, that the
palpitation  and pulse  will vary according to the stage of thf 
40                  ON HYDROTHORAX-

disease or  the quantity of water contained in  the  pericardi
urn.
  The peculiar sense of sinking, fainting, anxiety, or constric-
tion, will be more constant, and referred more immediately to
the seat of the heart.
  The countenance is more of the pale, sallow, than of the livid,
hue; and the bodily strength is not only more  impaired, but
there is reason to believe, those of a weak delicate  frame
are more liable to  it than those of strong robust eonstitu-
tions.
  With respect to the swelling of the ankles, defective secre-
tion of urine, coldness of the extremities, and other deviations
from the healthy state, mentioned as common to hydrothorax,
experience does  not  warrant our  reliance on any symptom
which does not occur in the one as well as in the other.
  And it is here to be lamented, that the various  morbid al-
teration of structure of the heart itself, of its valves, large ves-
sels, or other organs within the cavity of the cfcest, with which
these two diseases are generally connected, and by which they
are often  produced, render the diagnosis much more difficult
since the symptoms peculiar to each of these will be obscured
by  being blended together.
  A learned and ingenious  medical friend, of whose judg-
ment I entertain the highest opinion, has favored me with the
following remarks and interesting case: " So far," he observes,
" as my experience enables me to judge, under  the guidance of
ray memory and written notes,  I  refer the dyagnostic symp-
toms of the dropsy of the pericardium to  two only, all besides
being extremely uncertain, I  mean the feebleness and fluttering
of the pulse ;   and the ability of the patient to bear the re-
 cumbent posture.  In the very few cases of this  disease where
 I had an opportunity of inspecting the body,  there was al-
 ways more or less of fluid in the cavity of the thorax, and ge-
 nerally other morbid signs in that cavity. 
ON HYDROTHORAX.                 41 ■
  The last case of this kind which I inspected is more fully
detailed  in my journal.   The subject was a young man 20
years of age :  he had been complaining for some weeks of what
he believed to be  an irregular ague, because he had frequent
returns of chilly fits, with great weakness and loss of appetite
He took an emetic with bitters with temporary benefit.  Af-
terwards he w:as ordered bark, with a corresponding plan of
diet.  By the time he had continued this plan for a week, he
was  seized with  a  severe dyspnoea.  But he said that the
chilly fits had left him the third day after he began to take
bark.  At  the time I saw him the dyspnoea was very great,
the pulse 130, feeble and fluttering, but without any distinct in-
termission : the tongue was white; the countenance sallow and
dejected ;  bowels disposed to costiveness, and a prevailing de-
bility over every function.   The dyspnoea was increased by
action of every kind; but he could lie down without much in-
crease of this symptom: he was free from any oedematous swell-
ing.   Iprescribed moderate purges of calomel, neutreal and di-
uretic medicines, and blisters; all  without the smallest benefit.
The dyspnoea continued to increase; the pulse became more fee-
ble, and  diminished in velocity.  The thirst increased great-
ly ; the tongue and lips became dry, and covered with a dark
viscid crust.   Still he could lie in the horizontal posture, and
the pulse though extremely feeble could not be perceived to
intermit to the last period of his existence.
  On opening the  body we  found the lungs adhering firmly
to all  the neighbouring parts, the sides, the diaphragm, the
pericardium.  The diaphragm seemed to be thickened by the
adhesion, especially on the right side  where he complained
of the most pain.   In  the cavity of the thorax were found
nearly half a pint  of thin bloody serum; it  was chiefly
in the left side.    But  within the pericardium there was
a still larger quantity of a similar  fluid,  by computation
not far short of a  pound.  The heart itself  was  preterna* 
,j.3                  ON HYDROrHORAX.

turally hard in its texture ; the coronary arteries distended;
the whole whole outer surface of it, and also  the  inner sup
face of the pericardium,  had a  carious granulated appear-
ance.
  Here" he very justly remarks, « were seen the effects of a
general  thoracic inflammation, which had taken place proba-
bly some time before the patient began the use of  the  bark;
though  it is equally  probable that the bark and correspond-
ing regimen had contributed to accelerate  the progress of the
disease.   The heart and pericardium seemed to be  affected in
a peculiar degree, and the effusion into the pericardium to
have been the consequence.   The most  striking  symptoms
were, the patient  bearing the horizontal  posture to the end,
the velocity and fluttering of the pulse ; without distinct in-
termissions, the absence of the oedema."
   From Avhat has been said therefore* it will be obvious that
the more distinctly and clearly these symptoms are marked
the. greater probability there will be of the presence of water
in the pericardium;  and vice versa, the more they are eclips-
ed by those mentioned as particularly belonging to hydrotho-
rax the less likelihood there will be of a fluid in this sac. And
again, when they are blended together it may be inierred the
water is contained in all the cavities of the chest.
   But  though those who, to extensive experience, have united
 accurate and attentive observation  of the  symptoms of these
 two diseases, more especially if they have been assisted by dis-
 sections, may in general be enabled to form a correct judg-
 ment of the situation, and extent of the fluid, yet it must be
 confess* d that no one has as yet been fortunate in pointing out
 any individual sign which may be said to belong exclusively
 to the  one more than to the other; "it is  only  by  bearing in
 mind the whole catalogue enumerated, their gradations, pe-
* Ch. II. S,L 
ON HYDROTHORAX.                  4-S
 uliar  combinations, and modifications, that any thing  ap-
proaching to certainty in this respect is to be attained.

                        SECT. II.

             Dropsy or Anasarca of the Lungs.

   Such  is the conformation of  the lungs that water may
be  effused throughout its substance without  any commu-
nication with the air vessels.  The manner in which this hap-
pens may readily be  seen by blowing  air under its external
covering: the cellular substance not only between its surface
and the pleura, but between its lobules may be inflated; and
it has free communication with  the same membrane investing
other parts of the body.
   As an idiopathic disease, or as confined solely to the  lungs,
it is a rare occurrence, but as a symptom of general anasarca,
is very frequent.
   If together with cedematous  swellings of the external parts
just beginning, a difficulty of  breathing presently comes on,
we may, I think, with great propriety, conclude with Alber-
tini that there is oedema of the lungs.*
   Van Swieten justly remarks,  " reason teaches, and the testi-
mony of Hippocr'atesf confirms that respiration will be more
impeded by a small quantity of serum collected in  the inter-
stices of the lungs themselves, than by a much greater quan-
tity extravasated in the cavities of the breast." J  He farther
observes, that  the lungs are more  easily freed from  serum
lodged in their interstices, than when it is in the cavities of
the chest.
   " I always suspected oedema or dropsy of the lungs," says
Dr. Simpson of St. Andrews, " if either the face was turged,

   " Inst. Bonon. T. I. p. 392 et seq.        f  De Intern. Affect.
   ; Aph. sect, 1220 
4-i
ON HiTDROTHORAX.
or there was ever so small a  swelling about the ankles, and at
the same time a  difficulty of breathing, especially if the pulse
was so suppressed that it could scarcely be felt."*
   Dr. Darwin mentions a very irregular pulse as a character-
istic symptom of this disease.f
   With respect  to the pulse my own observations have been
very different, having invariably found it more full and re-
gular in this species than in the dropsy of the chest.
   In a case under  my care while writing thisj where there is
every reason to  conclude the cellular substance of the lungs is
the 6eat of the disease, and is distended to a considerable de
gree, the symptoms are as follow:—Not only the upper and
lower extremities, but the scrotum, penis, integuments of the
abdomen, the face, especially the eyelids, and the  neck at
times, are considerably distended with water.   There is
constant dyspnoea, of the slow laborious kind, increased on first
lying down, but after a certain time  so  much relieved as to
enable him to bear the recumbent posture, and enjoy some re-
pose.   He has a sense of fulness, tightness, or of suffocation,
about the throat and  upper part of the sternum.  Towards
morning as his breathing becomes more free, the throat, neck,
and face 6wcll,  but this decreases and disappears about the
throat, towards  evening,  He is never suddenly roused from
sleep, but his nights are in general restless and uncomfortable.
The pulse is perfectly regular, remarkably full and  slow, be-
ing generally about, sometimes under 60, even  after walking
near a mile to  my house.   His appetite is good, but to use
his own words, " he has not room for  his victuals."   Urine
scaaty, of a dark colour, and  he complains of much pain in the
hypogastric region, a symptom not uncommon in dropsy.
   On the whole then since anasarca  of the lungs may  be re-
garded as a  rare occurrence as a primary disease, and when it

   * Ed:n. Med. Essays. Vol. V.           f Clf i. 2. 3. 16,
   \ Vide case 37. 
ON HYDROTHORAX.                 4$
does occur may readily be distinguished by the swelling of
the face, neck, of one or  both hands, especially if these quick
ly succeed to the difficulty in breathing ; by the slow labori-
ous respiration, increased on first lying down in bed, and on first
getting up in the morning, it seems unnecessary to dwell more
particularly on its symptoms
   It is sometimes combined with dropsy of the chest; or the
water may be contained, partly in cysts within the substance
of the  lungs, and partly in the sacs of the pleura; or it may be
contained in  the  former without any in the latter, a very re-
markable instance of which  is related in the Acad, des Sciences
Ian 1732.  Mem. p. 350 et seq.   The  symptoms were, "a
grievous asthma, together with a slow fever.  The patient
could not lie on his back, or on either side, without great un-
easiness ; hands, arms, legs,  and feet were cedematous."  Sefc
also Van Swieten's Comment 122U.
   Hydatids containing  water  are not uncommonly found in
its substance ; but  unfortunately the symptoms peculiar to
such cases have not been accurately recorded.
   The colour, consistence,  peculiar appearances, and general
properties, of the fluid found  in the cavities of the  chest are
various; but as we are in possession of no tests by which these
may be distinguished it will be useless to enumerate their va-
riety.   In the subject of case 35 the fluid which was thin on
opening the thorax soon coagulated to the consistence of jelly. 
chap. in.
                        SECT. I.

                        Diagnosis.

    IN the early stages, especially if the water has accumu*
lated slowly, it is sometimes difficult to distinguish the disease,
As it may be presumed the symptoms will be obscurely mark-
ed, the practitioner, even if he suspects it, is unwilling to be-
lieve he is to  have so formidable a disease to contend with}
unless there be external signs of dropsy, or some particular cir-
cumstances to rouse his attention.  In the advanced stages,
however, although there may be room for doubt as to the ex-
act seat and extent of the watery effusion, I cannot subscribe
to the opinion of those who contend that the diagnostic signs
are always doubtful,  and to be discovered with extreme diffi-
culty,  the grounds  on which some  of these are  founded be-
ing very erroneous.
   In a dissertation* on  the diagnostic signs of dropsy of the
chest, of which an abstract is given in the  Ed. Medical Com-
mentaries,!  " the  author," say the editors, " sets out with
mentioning the difficulty of distinguishing hydrothorax, and
the importance of doing so.   That Baglivi had pointed  out a
sudden waking from sleep with signs of suffocation as the pa-
thognomonic symptom.   That though this symptom be often

   * D. Joan. Caspari de Rueff, De Hydr. Pect. certa vel incerta diagno-
si.  Vide Act. Nov. Phys.  Med. Acad.  Caesar. Leopald. Carolin. Nat.
Curios. T. IV. Nuremberg.
   f Vol. I. p. 248, 
                    ON HYDROTHORAX.                47

decisive, Vet that sometimes  it is fallacious, occurring where
no water could be found in the thorax after death.  That he
therefore adopts the opinion of De Haen who, from its being
sometimes wanting in the most violent hydrothorax ; at other
times appearing only in the advanced stages, or a few days be-
fore death, concludes, it cannot be considered as a pathogno-
monic symptom.
  " In support of this opinion,"  continue the editors, " the
author adduces  two cases.  The first  is that of a man who
complained of a  dry cough, straightness in the breast, and a
great difficulty of breathing,  with osdematous swellings of the
feet, scanty urine, a nocturnal febrile paroxysm, and the pa-
thognomonic symptom in question.   All these  complaints
were soon removed  by the  use  of squill medicines; but  a
short time after, when he  seemed in  perfect health, he died
suddenly in  the night from suffocation.   Upon dissection
three pounds of limpid serum were found in the thorax which
sufficiently proved the uncertainty of the diagnostic.  In both
ventricles of the  heart was a  polypous concretion, seven inches
in length, to which the author ascribes the immediate cause
of his death."
  Of the weight which ought to be attached to this symptom
in deciding on the nature of the disease; and the circumstan-
ces which  determine its presence or absence, so much  has al*
ready been said that it is unnecessary to add any thing far-
ther in this place.  It wiirbe seen that in this respect our sen-
timents accord.  But why the author should adduce this case
in support of his  position I am unable to assign a satisfactory
reason.
  The disease was very clearly  marked;  it had the pothogno-
monic symptom  mentioned; the man was apparently cured
by squills, very likely means  to reliove  him;  and "he died
suddenly in a short time  after, when he seemed  iit perfect
health."   This last is the only circumstance concerning which 
48                  ON HYDROTHORAX.
any doubt or difficulty arises.   That  a man should seem in
perfect health with three pounds of water in the chest and a
polypus seven inches in length in both ventricles* is not very
probable.  It is much more easy to imagine some inaccuracy
in the statement than to  admit this as a fact.   It is not un.
likely that the  man, finding immediate relief from the  more
urgent symptoms, when as yet only a small quantity of water
was evacuated, might say, comparatively speaking, as I have
repeatedly experienced, that he " felt himself perfectly well."
If  in this case, the original quantity was considerable, say
three, and a half, or four pounds, the patient might experi-
ence so much ease on its  being reduced to three, as to fancy
himself in " perfect health."   In many  of my patients the
transition was so great from extreme difficulty, to perfect free-
dom, in  breathing, even as soon  as the urine began to flow
freely, when I had every reason to be assured  very little wa-
ter was as yet evacuated from the chest, that they repeatedly
expressed themselves in this manner.   The sudden death of
the patient at a time when he seemed to those about him re-
lieved or recovering is mentioned by the best writers as a fre-
quent occurrence.
   " The second case here related," observe the editors, " is
that of a man 60 years of age, who was affected at night with
a degree of dyspnoea, that he could seldom lie in bed.  His
left hand and arm were also much swelled and very torpid;
which is considered by both Hoffnfcn and Baglivi as a sign of
latent hydrothorax.   But notwithstanding this, by proper re-
medies he was soon relieved, and lived till he was 80 years of
age;   he then died without any sympton of hydrothorax."
From all this the author concludes, that this disease can rare-

  * There is, it is presumed, some omission or error here.  Does it mean,
 in one qf the ventricles, or in each  or the ventricles ? for one polypus
could  not possibly extend to both ventricles, yet the  length seems too
great for r?n« 
ON HYDROTHORAX.
49
ly be known while it admits ofa cure ; that when it is known*
it can only be cured by paracentesis;  and that while the na-
ture of the disease is doubtful, we should persist in the reme-
dies adapted to humid asthma, by the effects of which we
may determine whether the disease we dread be present or
not."
  It appears no less singular that this case should be adduced
in corroboration of his opinion.   It is obvious that although
the author might originally have viewed it as a case of hy-
drothorax, he afterwards altered his opinion, from its favoura-
ble termination, or because it admitted of a  cure by medi-
cine, for says he, " it can only be cured by paracentesis," and
because the patient died twenty years afterwards without any
symptom of hydrothorax.   But I own, I am disposed to give
him more credit than he claims.   It seems probable that there
was a collection of water in the cavities of the  chest, and that
it was removed and the cure compleated by the " proper re-
medies" which were used.
   The phenomena of this disease are  so striking, the  horrors
and sufferings of the patient so extreme, as irresistibly to force
themselves on the attention.  The great variety of cases which
have fallen under my care haVe left so strong an impression on
my mind that I think it scarcely possible  to be deceived in any
instance, although as yet in its infancy.   I cannot however in-
dulge the hope that a similar impression will be made on the
minds of my readers, by what has been advanced in these pa-
ges ; yet it is  hoped that something has been added to our
stock of facts on its history, nature, causes and cure; and that
whatever be its fate, it may prove  the means of stimulating
others to the investigation of a disease than which none is to
be found more interesting in the whole catalogue of human
maladies.   With this view, some of the sources from which
much important  information  may be  derived  have been
pointed out to  the young practitioner.   In order to acquire a
                           r 
£0
ojn ii\DR0TH0RAX
 facility in discriminating  with  accuracy  the most commotf
 diseases, it  is  absolutely necessary to be familiar with  their
 striking characters as delineated by the best writers;  for how
 often do we  see  those of daily occurrence mistaken by differ-
 ent practitioners ?   This it is evident, will  be more especially
 requisite in those of a complicated and intricate nature.*


   * " Hence,'* remarks my learned friend on' perusing this passage, " I
 have always been of opinion that of the different branches or departments
 into which the science  of medicine has been  divided, pathology is the
 most essentially necessary to form an able physician.  This branch  which
 includes a previous knowledge of anatomy and physiology, is only to be
 acquired under able and ingenious masters, and at a great expense of la-
 bour and reflection on the part of the student himself.  It is by an appeal
 to his pathological knowledge that  the physician not only distinguishes
 Diorbid from healthy actions in the different functions of the body, but al-
 so discriminates among the morbid symptoms themselves, ascertaining
 which is cause, and, which is effect; in other words, which is primary, and
 which is secondary.   Hence it  is obvious that though the foundation of
 pathological knowledge  is to be laid  in the lecture  room, and in acade-
 mical study, much still remains to be perfected afterwards  by practical
 attention, a close, and correct regard to the early appearances, and  subse-
 quent progress of diseases ;  a deliberate and unprejudiced comparison of
 different cases, and finally  a careful  inspection of dead  bodies.   Still I
 maintain that mere practical labour, even with those who do seriously la-
 bour, will be insufficient, without a   considerable stock of that  precious
 knowledge which is obtained in schools of celebrity,  and  that scientific
 bent, and systematic habit, which the first masters only are capable of
 conferring.  The life of man  is too short and his attention too much di-
 vided to be a  correct pathologist on any other terms.  This  is the de-
 partment, then, in which professional men are more generally deficient;
 and  this the departrr. nt in which the comparative  force and ability of
 professional men are to be discerned.   I  am not afraid to add, that it is
 to a conscious deficiency in  this important and difficult branch of the sci-
ence, we may frequently, though not always, ascribe the shyness and re-
 luctance of maiiy men to enter into any pathological discussion with their
brethren on the cases of <a<ir patients, affecting to rate and estimate such
 tSiscuisions as vague and  useless theories." 
                     ON HYDROTHORAX.                 51

   The disorders with which the hydrothorax is most likely to
be confounded are 1. Empyema.   2.  Asthma.  3. Palpita-
tion  of the  heart.   4. Aneurism.  5. The worst cases of
chlorosis.   6. Polysarcia: Of these in order.
   ].  Empyema is preceded by the ordinary symptoms of
pleurisy or  pneumonic inflammation, receding without  the
signs of resolution, but with those  of  suppuration, such as a
remission  or total cessation of acute pain and fever, changing
however,  into a dull, obtuse sensation, a  sense of weight or
throbbing, attended  probably  with occasional  rigors, suc-
ceeded  by heat, other hectic symptoms, and a copious whitish
or reddish sediment in the urine.   When serous effusion soon
follows either of these acute affections, it is not only not pre-
ceded by  symptoms of resolution or suppuration, but is very
speedily succeeded by other dropsical symptoms, which are in
general very rapid in  their progress.*  In consequence  of in-
flammation of the thoracic membranes and viscera, especially
of the pleura, a considerable exudation of a fluid resembling a
mixture  of pus and  serum, with  whitish filaments or  fibres
floating in it, is thrown out into the cavities of the chest, w hich
sometimes produces the symptoms of hydrothorax, but more
generally  those of empyema.
   Empyema has at times some of the symptoms of this  dis-
ease, such as dyspnoea decubitus difficilis ; pedum oedema ;  urina
parca ;  subita e somno cum palpitatione excitatio.   But from
the absence of others, even sometimes of these, from the hectic
symptoms which generally attends it, and  especially the pe-
culiar circumstances which precede each, the cautious and at-
tentive practitioner, who traces with due  care the history of
the case from its origin, through all its progressive stages, to
the period at which his aid is called, will seldom, if ever, mis.
Ukc the one for the other.
* Vide cas? 10. 
52
Oil HVDROXHORAX.
   2.  Idiopathic asthma unaccompanied with  organic  affec-
tion may be distinguished from  the disease under considera-
tion, by its generally returning  in paroxysms attended with
a dry cough, which, after continuing with more or less vio-
lence for a certain time, gradually go off, or suffer considerable
remission, with free expectoration, proruse perspiration on the
head, neck, and chest,  and for the most part with a sediment
in the urine,  leaving the patient in many instances free from
complaint.
   Respiration is  more generally performed with a peculiar
wheezing noise, and though extremely difficult and laborious,
is  not so quick and hurried as in hydrothorax ; the  stricture
across the chest is greater also.   It is however very frequent-
ly confounded w ith asthma, as may be seen in almost all the
writings on the disease, and as I have repeatedly experienced,
its real nature having been mistaken until, after death, the
quantity  of  fluid found in  the thorax has pointed it  out.
Asthma, if neglected, not relieved  or removed by proper
remedies, for the most part ends in dropsy of the chest.  When
this is the case the interruption to respiration becomes  more
constant;  the secretion of urine which  was before various,
now regularly lessens  in quantity, with the true dropsical se-
diment; the extremities swell, and the other symptoms of the
disease gradually  supervene.  Under these circumstances it is
relieved or cured by the same means.
  3. Palpitation of the heart, if unaccompanied with any
morbid alteration of  its own substance or its appendages, is
seldom constant at first, but returns at irregular periods, ge-
nerally  from obvious  causes; and when it becomes constant,
unless it be attended with some of the other signs of dropsy,
surely no  person will be so rash as to conclude it arises from
water in the  chest.   It frequently arises from  causes which
eventually produce this disease. 
ON HYDROTHORAX.
&d
  4. Aneurismal  dilatations of the  large  vessels near  the
heart may not always  admit  of  early detection, and they
sometimes  occasion many of the symptoms of hydrothorax
before any effusion has as yet taken place.  In general, how-
ever, a pain and throbbing in the seat and direction  of some
of the large arteries, never  entirely ceasing,  aggravated by
causes which accelerate the circulation of the blood, are ex-
perienced, and serve to  distinguish it from this disease.  As
the aneurismal sac increases in size it sometimes leads to serous
effusion in its vicinity.
  Authors haye endeavoured to point out the peculiar symp-
toms occasioned  by polypi in  the cavities of the heart, or
mouths of the large vessels; but no reliance is to be placed
on these, since they have been found when no such concretions
existed; and have been absent when they were present.  " Id
quod dignoscitur," says Hoffman, speaking  of these bodies,
" ex summa compressione pectoris, pulsu intermittente, et in-
equali atque intercurrente, presertim post animi affectum, aut
vehementiorem motum suffocationis  metu.  Interea non ne-
gandum est concurrentibus aliis causis verum hydropem ac
cedere."*
   5. In the cases of  chlorosis which bear a  resemblance to
this disease there is more  or less constant  palpitation on the
slightest motion, and  in general  dyspnoea, but, contrary to
what happens in  hydrothorax, these are invariably relieved,
or subside in the  recumbent posture.   In chlorosis there is of-
ten a cough, oedematous swellings  of the face, legs, and some-
times of the  whole body, scanty high coloured urine,  and
 universal chilliness, but the sex,  age of the patient, which
 w ith  few exceptions is in females about puberty,  or under
 twenty  years of age, while hydrothorax more generally at-
 tacks  males  or  females  at  a much  more  advanced pe-
riod of life, unless from some  previous violent  acute affec-
* Pe Hydrope p 442,  Med. Rat. Syst c. ariv, 
54
ON HYDROTHORAX.
tion; the peculiar  sallowness or yellow colour of the face,
without  any livid hue, while the conjunctiva is remarkably
white, serve as strong discriminating marks between them.
   6. In polysarcia, owing to the quantity of fat surrounding
the heart, and consequently interrupting its free action, many
of the symptoms of this disease, especially difficult  breathing,
palpitation and the sudden starting up from sleep, sometimes
occur.   But if the urine suffer no preternatural diminution,
and there be no  external dropsical  swelling or other sign of
dropsy, the increased bulk of the body will serve to point out
the real cause of these symptoms.   Polysarcia, if improperly
treated or neglected generally ends in watery effusions  in the
chest. 
CHAP. IT
                        SECT. I.

                       Prognostics.

     -T ROM the nature of the remote causes of this disease
the prognosis must necessanly be often unfavourable.  Wheia
it arises from  aneurismal dilatations, or other tumours; from
ossification of the valves or large vessels, from polypi, or from
rimilar morbid alterations of  structure of parts  connected
with or necessary to respiration and pulmonary circulation, all
the aid our art can afford will be of little avail.  The water
may repeatedly be evacuated, and life be protracted, but all:
 hope of a permanent cure will be at an end;  and the progno-
sis will here depend on the probability of ascertaining the pre-
sence or absence of either of these organic affections.   Inde-
pendent, however, of such causes, hydrothorax has uniformly
been regarded as a very, formidable disease, for the most part
leading to a fataf issue, and at best  admitting  butofcasu
al and temporary alleviation.   From  the difficulty which hac
been found of evacuating the serous fluid by the natural out-
lets, trepanning the sternum, or the paracentesis thoracis, ha?
been almost universally recommended, both by  the ancientr
and  moderns, as the only certain means of accomplishing this
object, some have even gone so far as to recommend punctur
ing the pericardium.
   That every species of dropsy is attended with more or less
danger  is a fact which  will not be denied, since, under  the
most favourable circumstances, it evinces a high degree of lo-
cal Or general exhaustion.   But that the cavities of the chm 
56
ON HYDROTHORAX.
may speedily be unloaded of accumulated fluids by the natu-
ral outlets, their farther effusion often prevented, and the di-
sease permanently cured, when none of these morbid states ex-
ist, without being compelled to  resort to either of these ope-
rations, shall be shewn in the course of this  work.  It is  ne-
cessary, therefore, to point out such circumstances as may lead
to the detection of these local evils as guides in delivering our
sentiments in regard to the probable issue of the disease.   A
retrospective view of the cases which occurred in the author's
practice, and of the information Which he has collected from
other sources warrants him in stating the following particulars
as data on which a tolerably correct judgment may be formed
as to a fortunate or fatal result: and first, of those which por-
tend a highly dangerous disease, and in general lead to a fatal
issue.
   1. Palpitations of the heart, steady and constant, appear-
ing early, not subsiding on rest, or on the evacuation of the wa-
ter, together with a pulse in every way corresponding.
   2. Dyspnoea,  or orthopnosa, continuing, with more  or  less
violence, under similar circumstances, and threatening suffo-
cation on attempting to lie down, or on any sudden motion.
   3. Severe pains of the chest, especially about the seat of the
heart, or in the direction of the large arterial trunks, and con-
tinuing with little or no intermission.
  4. The disease suddenly supervening to pneumonia, or other
acute inflammatory affections of the chest, particularly if these
have been neglected in the beginning, or if immoderate bleed-
ings or drastic purgatives  have been used in their advanced
stages.
   5.  The disease coming on in constitutions previously ex-
hausted by intemperance,  especially  by a  constant career of
tipling or dram-drinking;  by the long continued operation of
the depressing passions; in very advanced periods of life; or
from extreme bodily weakness or exhaustion in any age.  ?■ 
ON HYDROTHORAX.
51
  6. Schirrous enlargements, or irregular knotty indurations
of the liver, with confirmed jaundice.
  7. Distortion or malformation of the chest.
  Under these circumstances it behoves the practitioner to be
extremely guarded in delivering his opinion; for although
there may be little difficulty in evacuating the water, he will
either have so  formidable a disease of some important organ to
contend with,  or the constitutional stamina  will be so far ex-
hausted, as probably to preclude the possibility of permanent
restoration under the most judicious treatment.   Perfect re-
covery has,  however, sometimes happened under  these, and
equally unpromising appearances; while it must be confessed,
the patient  has  unexpectedly been carried off when he ap-
peared to be recovering.
  When the disease commences its attacks under circumstan-
ces the reverse of those mentioned; when there is no reason to
apprehend the presence of visceral affection of any magnitude ;
and when all the unpleasant symptoms gradually recede  as the
medicines begin to act upon the kidneys, we may venture to
hold forth  sanguine hopes  of  a happy  issue, provided the
treatment be  directed by skill and judgment, and pursued
with unremitting attention for a due length  of time.

                        SECT. II.

                        Dissection.

   It has been, and still  continues to be, a favourite practice
with some medical writers, to detail minutely the morbid
phenomena  of dead bodies:  to exhibit them in the  form of
preparations in spirits, or expensive drawings on paper,  with-
out the history of the disease which gave rise to them, or of
the remedies which had been used to prevent them.  But if
the object of morbid anatomy be to enable the medical prac«
                            S 
3S
ON HYDROTHORAX-
titioner to detect the same disease whenever it shall again oc-
cur, so as to lead to successful practice, it must be obvious that
no advantage can result from it, Avithout these necessary ac-
companiments : for however minutely and accurately the di-
seased parts may be described, or ingeniously accounted  for;
or however neatly and elegantly injected or represented on
paper, j'et without the history of the symptoms of the disease
which produced them, from their origin through the progres-
sive stages  and changes to the fatal termination, this  impor-
tant end cannot be attained.  A series of dissections ably con-
ducted on such a plan  in diseases  like that under  considera-
tion, whose early stages often pass over unnoticed, and w hieh
assume a serious aspect before their nature be suspected, would
prove a valuable acquisition to the medical practitioner.   The
Opportunities necessary to furnish materials for such an under-
taking are numerous, and the men qualified for it, equally so.
In any of the large hospitals in the kingdom, a very few years
would afford a sufficient number of interesting cases for an oc-
tavo volume; and it is earnestly to be wished the respectable
practitioners who have the superintendance of these excellent
institutions, would make their labors more subservient to pub-
lic utility than has hitherto been done.  In  country practice
the prejudices against  the  inspection of dead bodies are so
strong as to furnish very few opportunities of this kind, a cir-
cumstance which the author has had frequent occasion to la-
ment.
  In the works of the excellent Morgagni, a considerable num-
ber of dissections of subjects who died of hydrothorax are col-
lected from, various authors, besides those which occurred to
himself; but the previous history being extremely defective in
many, and only those symptoms which immediately preceded
death noticed in others; their value is thence materially les-
sened, a circumstance which is pathetically lamented by the
author himself. For although the symptoms indicating the 
ON HYDROTHORAX

presence of water in the cavities of the chest be often tolerably
well ascertained, yet those denoting the nature, seat, and ex-
tent, of the organic affections which occasion its effusion, are
far from being clearly known.   It is only by a sufficient num-
ber of facts thus collected, and faithfully recorded, this desir-
able object can be accomplished.
   In judging of the nature of the disease which was the cause
of death, from the appearances in the dead body there  is of-
ten great room for deception, especially if many days elapse
before the body be opened.  Various parts are discovered in a
state of inflammation, ulceration, gangrene, or sphacelation, or
smeared over  with pus or inflammatory  exudation, without
erosion, to which the  previous disease and death were attrib-
uted, whereas these states were probably  only immediate or
recent consequences of some other morbid condition of these
organs.  This applies more particularly to diseases of the
stomach and upper part of  the intestinal canal;  even where
there has  been no disease the coats of the stomach have  been
found in a state of erosion after death, as illustrated by the late
John Hunter.   Hence the necessity of much discernment and
sagacity in forming a correct judgment in such cases.   The
polypous concretions  found  in the cavities of the heart, or in
the mouths of the large vessels, there is reason to suspect, have
sometimes been of recent date, or were perhaps, formed  in ar-
ticulo mortis.   The degree of density of their texture, and the
nature  of their adhesions, will in general determine whether
they have been of recent or remote origin.
   The most remarkable appearances observed on dissection are
mentioned in  the next chapter sect. ii. among the causes of the
disease; and will be  found  more particularly recorded in the
appendix No. 2.  as  selected from Morgagni and other au-
 thors, and in cases 35 and 39, app. No. 1. 
CHAP. V.
                CAUSES IN GENERAL

                        SECT. I.

                   Predisponent Causes.

     X HAT there are certain circumstances which predis-
pose to watery effusions in the cavities of the chest more than
into other parts of the body, the cases detailed in the appendix
will serve to demonstrate.
   1. Sex.  Of eighty-one well marked cases which occurred in
the author's practice, it will appear that forty-six were males
and thirty-five were  females; hence, as far as his experience
goes,  it  must  be inferred  that the  former are more liable
to the disease than the latter: and on consulting medical wri-
tings the proportion of males will be found still greater: this
is to be accounted for from men being  more exposed to the ex-
citing causes.   Were female constitutions equally  exposed to
their influence it is  probable they would suffer more readily
than those of men, because from their greater delicacy of frame
from the sedentary  life they too generally lead, from their be-
ing " habitu corporis molli, spongioso, minusque  firmis, in-
structo, magis prasditi," they  are naturally more predisposed
to it, to which the  debilitating effects of frequent parturition
and of profuse uterine haemorrhages, they are liable to, contri-
bute in a powerful^ degree.  Men,  however,  have this great
advantage, that  the  exercise they are  using in  the open air
tends often for a great length of time  to counteract the bane.
ful operation of these causes* 
ON HYDROTHORAX.                  61
  2. Age.  Though no age appears exempt from this disease,
yet advanced periods of life are more particularly liable to its
attacks in both sexes, insomuch that when it appears early, it
is for the most part in consequence of some obvious powerful
cause, concurring perhaps with some malformation of the chest
as may be seen in appendix No. 1.,.  Very fat corpulent chh%
dren, who have been pampered with rich food  without  suffi-
cient exercise, are not unfrequently carried off by serous fluids
suddenly effused within the  cavities of the chest, the conse-
quence of pneumonic or catarrhal inflammation neglected or im-
properly treated, though the real cause has not been  suspected
till after death.   A few instances have fallen under my obser-
vation where the fact was ascertained on  dissection, and oth-
ers have occurred where there was every reason to apprehend
death arose from the same cause, though there was no oppor-
tunity of inspecting the body afterwards.  The face in  such
cases is generally pale, sallow, and bloated, som;  times swelled,
and the head seems  preternaturally  large.   The  following
case, however, furnishes a  remarkable exception.
   Miss. P. Cotton, a young lady of a florid complexion, very
fat at so early an age, and of a lax fibre, zet 16;  had for a few
years experienced a sense of  constriction about  the heart as if
something were  closely embracing it, attended with difficulty
in breathing and palpitation at times, especially on running or
on going up stairs.  From her healthy aspect,  and  her lively
disposition these symptoms were disregarded, and even treat-
ed as imaginary by her relatives,  so that  little had been done
for her relief.  She died suddenly; on opening the  chest the
pericardium was found nearly filled with water.
   3. Habit. Of all the circumstances which predispose to this
species of dropsy, a  short,  thick make, with a natural disposi-
tion to corpulency,  especially if proper means have not  been
used to counteract it, is the  most striking.   This is fully  ex-
emplified in the appendix No. 1.   The proportion of cases in 
G2
ON HYDROTHORAX.
habits of this peculiar conformation is very considerable:  it
will be seen that it was so strong in some of these as not to have
required the  ordinary causes to produce the disease.
  When the  disease occurs in persons of a thin slender make,
or in habits the reverse of those mentioned, which was the case
in a few instances, it will be found to happen under the cir-
cumstances stated in 2. of this section.
  I know  of  no particular occupations that  dispose  to this
disease.

                        SECT. II.

                    Occasional Causes.

  It is a fact well known to physiologists and anatomists, that
a subtile fluid is continually exuding from the capillary extre-
mities of certain vessels termed, from their peculiar offices, ex*
halants, into all the cavities and interstices of the human body.
If any  of these  cavities be opened immediately after death
and exposed  to the air, while the body is yet warm, this fluid
will be  seen exhaling in the form of a white vapour, which led
to the erroneous idea that it issued in this form from the ves*
sels.  The fluids thus secreted are intended to answer impor-
tant  purposes in the animal oeconomy.  By constantly moist-
ening the surfaces of these cavities the various motions of the
body are  performed with  facility ; hence their quantity and
quality vary according to the degree and frequency of these
motions.   But  in order to obviate  the inconveniences that
must arise from the accumulation and stagnation of such fluids,
another set of vessels, termed, from their offices also, absorbents,
open by  innumerable mouths into these cavilies, take up and
convey to the blood these fluids as soon as the purposes  for
 which  they were effused are answered. 
ON HYDROTHORAX.
63
  I*hus in health a constant deposition and absorption  are
going on, and a due equilibrium is preserved in every part by
means of these vessels.  It frequently happens, however, from
various causes, that this balance is disturbed, and diseases of
increased or diminished exhalation or of absorption ensue. The
disease termed dropsy may arise either from increased exhal-
ation, or from diminished absorption, or from both; but there
is reason to believe that defective action of the absorbents is the
more frequent cause; but of this more in another place.
  As however, these states are generally connected with, or
arise from, some morbid condition of the solids, and sometimes
also of the fluids, it is necessary to investigate the nature  and
cause of these conditions.
  The most  simple kind of dropsy is that which has for its
cause such a relaxation of the solids, concurring probably with
corresponding tenuity of the blood, that the thinner or serous
parts of the blood are preternaturally exhaled from the capil-
lary extremities of the arteries; and the same  weakness  per-
vading the absorbents, these vessels are  incapable of taking it
up  in due proportion.   Hence accumulation must be the con-
sequence.  That dropsy may,  and does, occasionally arise
from such causes alone  admits of abundant proof.   It  has
been affirmed by authors that dropsy might arise merely from
a superabundance  of water in the  blood, without any other
cause: and instances have  been brought forward in support
of this opinion.   Schultzius produced a dropsy in a dog  by-
causing him to drink largely of water; but it is proper to ob-
serve that he first reduced his strength by bleeding him ad de~
liquiwn ; a very important  part of the experiment, on which,
however, little stress is laid.  An experiment of Dr. Mus-
grave is more to the purpose: he injected four ounces of wa-
ter  into  the right cavity of the  thorax of a d^g; a difficulty
of  breathing, oppression and weakness  immediately ensued.
But these symptoms gradually diminished, and in the course 
01
ON HYDROTHORAX;
of a week entirely vanished,  the animal appearing in perfect
health.   Tlr- eno •■nous quantity of sixteen ounces was inject-
ed into the left cavity of  the chest of the same dog; nearly
similar hymptoins <oilowed, with the  addition of great  heat
and strong action of the heart ; but these again disappeared
in the course of a week.  Had the  vital energy been reduced
by copious bleeding,  as in the first experiment, it is probable
the lymphatics  would  have been incapable of absorbing the
water, and that the animal would have fallen into a dropsy.
   It may therefore be taken for granted lhat a tenuity or wa-
tery state of the blood capable of producing a dropsy, is never
a primary state, but  always  the consequence of laxity of the
solids, and feeble action  of the heart  and  arteries; for in a
healthy condition and vigorous action of these, the absorbents
would  dispose of the superfluous quantity as the experiments
of  Musgrave  sufficiently prove.  The causes more general-
ly  producing  this state  of  the  solids  and fluids  are,  1.
Profuse  haemorrhages  either  from natural  or  artificial out-
lets.*   2. Frequent  copious  evacuations by means of dras-
tic purgatives, especially  if large quantities  of  watery drinks
have been taken  to  repair  the loss.f    3. Profuse  saliva-

   * An instance of anasarca from the  menstrual discharge continuing too
long, is mentioned by Forestus, L. 19. obs. 35.  By vomiting of blood,
ib.  42.  Two cases from  frequent and  long bleeding  at  the nose by
Schenk,  obs. L. 3. obs. 9. De hydrope.  Two cases from frequent blood-
letting, Miscell. Curios. Acad. Nat. Ian. £. obs. 163.  Also from abor-
tion in the third month by Hoffman, chap. xix. De hydrope.   Similar in-
stances constantly occur and may be found iu all the writers on dropsy.
See Monro's excellent treatise on dropsy, passim.
  f Dr.  Fothergill mentions an instance of a person who fell into an in-
curable dropsy, from drinking  twelve pints of barley water daily for a
month, when he was only desired to drink plentifully, in order to remove
his fever.   Morgagni, obs. 43.  gives a remarkable case of a nun of Bo-
logna, who, for  a defluxion upon her gums, was prescribed a  syrupus au-
reus by a physician; it  occasioned fifty motions; these were attended
-*ith intolerable thirst, which large quantities of broth did not allay. Vi- 
ON HYDROTHORAX.
66
tion.*   4.  A  low watery diet, yielding  but little, or a de-
praved nutriment; or a crude, indigestible, unwholesome, ali-
ment.  5. Cold, low,  damp situations, especially if the diet
be such as has been mentioned.f  6. The  use of bad or stag-
nant waters, or the  abuse of mineral  waters.   7. The  long
continued operation  of the depressing passions.   8.  A seden-
tary life, especially if preceded by the  reverse, and if accom-
panied with intense  study or application of the mind.  9. A
weak digestion, and imperfect assimilation of the food.   10.
Large draughts of cold water, or new sinall beer of a bad qua"
lity, when the body was heated, of which many instances have
fallen within the  author's observation: various  other causes,
which, either by their violence, or long continuance, exhaust
 the vital pbwers, might be enumerated.
   Effusions thus arising,  will first shew themselves in parts
which have  been previously weakened  by disease, or  other
causes.  Hence hydrothorax may appear  in this manner ei-
ther as  a  symptom  of general dropsy, or as a primary affec-
tion.   But since it will be found to have causes  and circum-
stances peculiar to itself,  which destroy more particularly the
equilibrium of the exhalant  and absorbent vessels within the
cavities of the chest, these shall next be considered.

de appendix, No. 2. case  20. where this interesting case  is detailed at
full length.  Vide also Sylvius Tractat. de Morb. Epidem.
  A young woman, a wet nurse,  in order to  increase her milk, drank
night and day  immoderately of  beer,  sometimes by itself,  sometimes
mixed with milk, in consequence of which she  contracted an ascites.
Willis Ph. Rab. part 2. c 3. sect. 3.
  * " Oritur interdum," says Hoffman,  " post perperam institutam sali-
vationera hydropica labes."  De hydrope vol. 7. p. 456.
  t The inhabitants of many parts of Holland and other low fenny coun-
tries, are said, on  the authority of various writers, to be more subject to
dropsy than  those who breathe the salutary dry air of more elevated sit-
uations.  Bontios. 
titf
ON HYBR01HORAX.
   All causes  interrupting the  free circulation of  the blood
through th^ pidmonary artery or  great aorta, or altering its
distribution through the body, so that larger quantities may be
accumulated in, or determined  to the chest, and with greater
velocity than to other organs; while Hs return to the veins is
impeded,  or  such as by altering the organization of the lym-
phatics, or in  any way impairing their functions,  prevent or
impede the absorption of the natural'fluids effused, are the
most frequent agents concerned in its production:  of this de-
scription are, polypi, aneurismal or other tumours, pressing ei-
ther upon  the large  blood vessels, or lymphatic trunks; in-
fractions of the lungs;  obesity, especially when large quanti-
ties  of fat  surround the heart,  or when collections of viscid
mucus are lodged at the same time in the bronchial vessels;
ossifications of  the semi-lunar  valves, of  the coronary  ves-
sels, or fibres of the heart itself, or of the coats of the large
adjacent vessels;  morbid relaxation, or dilatation of  the
heart; paralysis of the lymphatics, adhesions of their sides,
and consequent  obliteration of their cavities, so as to become
impenetrable to injections; rupture of the thoracic  duct, or
of a principal  lymphatic trunk;  enlargements and indurations
of the liver ;* violent blows on  the chest;  frequent or severe
attacks of  pneumonic  inflammation, especially  if  they have
been neglected,  improperly treated, terminate slowly or  im»
perfectly in resolution,  without  expectoration, or if to avert
the urgency of present  danger, copious bleeding Has been re-
sorted to ;f frequent attacks of asthma, or catarrh; acute fe«

  * Vile Morgagni letter 17, obs. 6, 10, 17, 21,23, 25. letter 18, obs. 6,
8, wh« rein instances of morbid dilatations of the heart and large vessels
t-ausing this  disease are mentioned.   Vide also appendix No. 2. where
the particular symptoms and dissections are detailed.
  f Vide case 22, app. No. 1. In the case here referred to, the attacks
of pneumonia were frequent, and the symptoms so extremely urgent that
the most profuse bleedings and other evacuations were absolutely oeces- 
ON HYDROTHORAX.
6.7
vers terminating by  congestions  in  the  thoracic  viscera.
Though  the abuse  of intoxicating liquors in general,  can
scarcely be said to produce dropsy of the chest more than any
other,  yet there are certain kinds which in  particular consti-
tutions possess this  power in a remarkable degree; namely
porter, ale, and beer.  But as this  circumstance does not ap-
pear to have been observed by others,  the subject shall be
considered in a separate section.

                        SECT.  III.

Of the use and abuse of malt liquors as a cause of hydrothorax.

   That  by far the greater number of cases of this disease
which occurred in my practice, especially among males, had
their origin in the free indulgence in  porter and ale, is an un-
doubted fact.  Besides their effects, when  taken to excess, in
undermining the constitution in common with other strong in-
toxicating liquors, they possess properties which may be said
to be peculiar to  themselves^ and which, although operating
more imperceptibly,  are yet no less dangerous in their ulti-
mate consequences.   It is an observation  familiar to  every
one, that great ale or porter drinkers are very fat and corpu-
lent ; so great a disposition to obesity do these rich liquors
produce in certain constitutions, that the most athletic occu-
pations are sometimes insufficient to counteract this tendency.
But it  invariably happens that their peculiar  effects on the
body are unfriendly to exertion.   They furnish lax, soft, flab-
by solids, that  are  not readily acted upon by the ordinary

sary to  save the life of the patient.  While sanctioning this practice, I
more than once observed to the surgeon that hydrothorax would be the
consequence.  But the pracUtioner is often reduced to the alternative of
incurring the hazard of remote evil to obviate present danger.   A5so
Morgagni, letter xvi. art. 12. 
63
ON HYDROTHORAX.
Stimuli, and a dark, rich, thick, blood, that seems to possess.
comparatively little stimulant properties.  Hence instead of
being  endowed  with strength and energy  proportioned to
their increased bulk, such persons are heavy, inactive, and un-
equal to athletic exertions.  A torpor pervades the mental as
well as the bodily functions.  The complexion is either of a
sallow, dark red, or livid  hue.   They sleep  much at night,
and are lethargic in the  day.  If they be seized with violent
Inflammation they have comparatively much less  acute suf-
fering : if it be of any of the thoracic viscera, the breathing will
be extremely difficult and laborious, but the pain in general of
the  dull obtuse  kind, yet on that account not the less  dan-
gerous, because it does  not so readily give alarm.   If blood
be drawn, besides the peculiarities mentioned, it will have,  on
cooling, a large proportion of crassamentumj very dark at the
bottom; the buff on the surface will not be firm or dense, nor
assume the  cup-like form of blood drawn  from the athletic
muscular water drinker,  under similar circumstances, but soft,
flabby, sometimes of a livid hue, and scarcely receding from
the sides of the vessel.   The appearances of the blood in such
cases I have often observed with attention, and have repeated-
ly foretold them to the surgeon before the vein was opened.
  Whether they be owing to the imperfect oxygenation of the
blood consequent upon impeded respiration,  to the weak  ac-
tion of the heart and blood vessels, and general relaxed  state
of the  solids, or to certain properties imparted by  these li-
quors is immaterial to the present  subject; it is probable all
these causes co-operate.
  As the bulk of the body,  especially the quantity of fat, in-
creases, the-functions of those organs most essential  to  life are
impeded.   The  heart, lungs, and muscles subservient to  re-
spiration, being overwhelmed with fat, respiration and pulmo-
nary circulation become more or less interrupted, the venous
blood accumulates in the  right side of the heart, and in the 
ON HYDROTHORAX.
69
head.  This is more distinctly observed on any sudden exer-
tion, or during a fit of coughing, when the breathing is very
sensibly affected; ^nd the face often becomes suffused with a
dark red or livid blood.
   The dark coloured thick blood thus generated being less
stimulant than thin, florid, sufficiently oxygenated blood, may
naturally be supposed to circulate with less freedom through
the capillary extremities of the vessels, and acting at the same
time on a dull, sluggish, or comparatively less susceptible fi-
bre, general torpor must -be the consequence.  The effects of
this are seen in a striking degree in the secretory and excretory
organs, more especially in the lungs, large quantities of viscid
phlegm being  often secreted and accumulated in the bronchial
vessels, so as  in many instances to produce habitual cough,
with copious expectoration, and corresponding dyspnoea.
   In this state of corpulency,  which, has been termed a drop-
sy of fat by some  writers, and which frequently leads to, ge-
neral dropsy, as well as hydrothorax, the body  may be said
to be in a state of constant predisposition to disease, insomuch
that severe colds, catarrhs, or pneumonic inflammation,, are
occasioned by causes which in a  more natural and healthy
condition would,  be  productive of little inconvenience,  and
are with  difficulty subdued,  It will be seen that some of the
subjects of the annexed cases, after struggling with a cough
or cold during the winter months which might have been ea~
sily removed,  had they conformed to  the necessary  restric-
tions, applied  to me the following spring or summer labour-
ing under hydrothorax..
  Fatal instances of apoplexy, orhoemoptoe, from rupture of
vessels, are not uncommon, from such causes; and I have  fre-
quently known a temporary suspension of the sensorial func^
tions amounting to apoplexy, merely from the accumulation of
yenous blood in the head, and consequent pressure upon the
brain,  during  a fit of coughing, 
;o
ON HYDROTHORAX.
  Mr. C. one of the subjects of the annexed cases has had se-
veral such  attacks, in one of which  I lately saw  him.   He
fell from off his chair totally insensible, his face and neck be-
ing suffused with dark blood.   Not aware that he had been
subject to them, I remarked to a gentleman who  was in the
room, that all was over with him:  he however soon recover-
ed, and by a proper course of medicine and regimen, has re-
mained  free from these alarming attacks, and his cough is
much relieved.  He  had a confirmed hydrothorax about six
years before.
  In short, there is so little room for the ordinary circulation
through the lungs under such circumstances,  that whatever
occasions an extraordinary determination thither,  or impedes
its passage, is productive of more or less inconvenience.

                       SECT. IV.

Pathology ; Proximate cause ; some of the more  remarkable
  symptoms explained ; Dr. Darwin s theory of retrograde ac-
  tion of the absorbents examined.

  It has already been observed, that the immediate cause of
dropsy was generally allowed to be an increased exhalation, or
diminished absorption, or both of the natural fluids secreted
in cavities, arising from some defect  in the vessels concerned
in performing these functions.   But although the fact itself be
admitted, medical men of high character are divided as to the
precise nature of the  morbid condition of these vessels.  Dr.
Darwin in particular has stepped out of the common path to
explain these, and some of the other  principal  phenomena of
dropsy.  After giving a general view of the absorbent system,
vol. i. sect. xxix. 1. p. 302, et seq ;  he thus proceeds to urge
his objections to the generally received opinion, and to advance
his own, vol. ii. p. 305. 
OH HYDROTHORAX.
71
   1. "' The maiiy valves which occur in the progress of the
lymphatic and lacteal vessels, would seem insuperable obsta-
cles to the  regurgitation of their  contents.   But  as these
valves are placed in vessels, which are endued with life, and are
themselves  endued with life also; and are very irritable into
those natural motions which absorb, or propel the fluids they
contain ;  it is possible in some diseases, where these  valves or
Vessels are stimulated  into unnatural exertions, or  are become
paralytic, that during the diastole of the part of the vessel to
which the valve is attached, the valve may  not so completely
close, as to prevent the relapse of the lymph or chyle.   This is
rendered more probable, by the  experiments, of injecting mer-
cury, or water, or suet, or by blowing air down these vessels; all
which pass the valves very easily, contrary to the natural
course of their fluids, when the vessels are thus a little forcibly
dilated, as mentioned by Dr. Haller."   (Elem. Phys. T. hi. s.
4.) ibid.
   To  this it may  be objected that as no proof has been given
ofj the return of these fluids, it seems  far more probable that
they would be urged  forward in the natural direction, with
additional force, on  these vessels being stimulated  into unnat-
ural exertions ; and  if their elasticity were not impaired or de-
stroyed by being  " a little  forcibly dilated," that the valves
would prove insuperable barriers to their return.
   2. " The mouths  of the lymphatics  seem to admit water to
pass through them after death,  the inverted way,  easier than
the natural one ; since an inverted bladder readily lets out the
water with  which it is filled;  whence it may be inferred that
there is no obstacle  at the mouths of these vessels to prevent
the regurgitation of their contained fluids."   lb. p. 3G6.
   Before any weight was attached to this experiment, abso-
lute proof  should  have  been  given  that  the water passed
through the channel of the lymphatics; and this done, that
there were valves  between  the  external surface (before inver- 
72
ON HYDROTHORAX.
 sion) and i riternal cavity of the  bladder , for 1. the valves
 which take up fluids from its cavity do not,  it is presumed,
 open and dispose of their contents  upon its external surface,
 but follow the course of its peritoneal covering, and depart
 from it where this membrane is reflected over it at the os pu-
 bis and rectum, and convey their fluids, in common with the
 other abdominal lymphatics to the  ihoracic duct.   Hence it
 will be found, if the ureters only be divided, and the bladdet
inverted before seprration, that no fluid will pass in the direc-
 tion mentioned.   2.  If any have their origin on its  external
 surface and open into its cavities, then the water on  inversion
will pass in the natural channel.   3. As  no communication
has, as far as I  know, been demonstrated between its internal
and external surface,  the only part through which any fluid
 can gain admittance w ill be about its neck, at the place where
it has been separated from its adhesions.   And as arteries and
veins are placed there also, which must necessarily be divided
or lacerated, is  it not  more probable that the  water passed
through them ? Is it not the only channel through  which it
could pass ? It  being well known  that  fluids are poured into
the cavity of the bladder by  the exhalent vessels, as well as
absorbed from it.
   3.  " In some  diseases, as in diabetes and scrophula,  it is
probable the valves  themselves are diseased, and are thence*-
incapable of preventing the return of the fluids they should
support,  thus the valve of the aorta, &c."  ib.
   In diabetes there is every evidence of a vigorous  action of
the absorbent system ; indeed a  preternatural action of these
vessels, and determination of blood to the kidneys, seem to
form a principal part of the disease from the  rapidity with
which the enormous quantity of nutriment usually taken in
this disease, is absorbed by the Iacteals, and from the emacia-
tion which generally attends it, 
ON HYDROTHORAX.

  4. 5. G.  7. 8. " There are other valves in other parts cf
the body analogous  to those  of the absorbent system, and
which are liable, when diseased, to regurgitate their contents;
thus the upper  and lower orifices of the  stomach, &c. &c."
ib.  p. 306. et seq.
  The analogy  used here is far fetched  and inadmissible ;
when the valves of the lymphatics are ossified  or diseased, so
as to be incapable of  performing their natural functions, it is
not denied  that their contained  fluids may regurgitate, as the
blood does  into the heart, when  those of the aorta are affected
in a similar manner.   But to judge correctly of the real man-
ner in which they are affected in dropsy, we should take ex-
amples of this disease unaccompanied writh any organic affec-
tion.   We  shall then find that their functions will be restored
sometimes permanently, and the water evacuated from cavities
in the course of forty-eight hours, by the aid of certain sub-
stances hereafter to  be  mentioned.   Hence the  analogy of
what occurs in other  organs and vessels, whose structure is very
different, is vague and inconclusive, since the absorbent system
itself furnishes abundant opportunities of making experiments
both  in the living and dead subject.
   " Many  medical  philosophers,  both  antient and modern,
have suspected that there was a nearer communication between
the stomach and the urinary bladder, than that of the circu-
lation ; they were led into this opinion from  the great expedi-
tion with which cold water when drank to excess, passes off
by the bladder; and from the similarity  of the urine, when
produced in  this hasty manner, with the materjal that was
drank, &c." sect. ib.  iii. p. 3ii8*
   The rapidity with which the bladder is sometimes filled
with  clear  limpid mine  on drinking largely of cold diluting
drink's, such as weak punch, especially if the body be exposed
to a  cold  humid atmosphere, is generally known.  But is it
not more natural to account for  this  through the regular
                            10 
n
ON HYDROTHORAX.
 course of the circulation, than through a channel which the im-
 agination of Dr. Darwin seems to have created, and of which no
 traces can be  discovered by the ablest anatomists.  As to the
 urine being "  similar to the material that was drank," there is
 room for fallacy.  It is well known that according to the qual-
 ity of the substances used far drink and food the urine will ac-
 quire  a particular odour, but  still  there is no reason to infer
 that  its  constituent parts  are  materially changed, but only
their relative proportions.   Unless then the urine mentioned
 in these experiments had been  found on chemical analysis to
 possess peculiar properties,  and that these substances were ac-
 tually found  to be returned unchanged, the evidence of the
 senses is not otherwise to be trusted.   Wine,  or wine and  su-
 gar, or emulsions,  if returned by urine, unchanged, as  men-
 tioned by the author, on the authority of Etmuller, might very
 easily have been detected.
   In certain diseases not only the constituent ingredients, and
properties of the urine,  but of the whole mass  of blood may
be so  altered as even to appear incompatible with the  func-
tions  of life.  As an example of this, I have the authority of
my learned and  ingenious friend Dr. Macqueen,  late of Lon-
don, to insert the following extraordinary case, w hich was  co-
 pied from his journal " as it was taken down at the time it  oc-
curred."
   " In the autumn  of the year 1788 a young woman about 20
years  of age,  was brought to me by her mother.   The girl
looked of a  full habit and healthy, though  her mother raid
she was ofra weak constitution.  About a week before she fell
suddenly  from a stool, on which she stood to reach something
above her, and was  instantly seized with a fit, probably of the
hysteric kind.   Ever since that fit her urine had been either
white, like almond emulsion, or pale like pure water ;  but  whe-
ther milky or pale, it always contained a third part of a strong
rancid oil, which swam on the top.   I have seen a pint vial 
ON HYDROTHORAX.
75
full of both sorts,  the white  and the  pale, each containing a
third part of oil.   About three days after, being seized with a
v ic,nt pain in the side,  I directed that she should lose a few
ounces of bbod from the arm.   This blood was brought to me
in a bason the following  morning : it  was apparently one half
oil, of the same smell and quality with that in the wine.  J.
was informed that as soon as it began to issue from the vein,
the room smelled as if lamp oil had  been poured out.   The
blood gave a  pale red  as it  touched the sides of the bason ;
but the whole appeared  a dirty, turbid oily mixture.  As the
bason laid in my room none of the professional men who came in
could determine what it was.  The young woman  recovered
her usual health in the  course of three weeks, by the aid of
bark, acids, and a tonic  regimen.   After she  appeared well I
had two ounces of blood taken  from her arm, by way of ex-
periment, which exhibited a natural appearance."
   "Dr.  Kratzenstein," continues  the  author ofZoonoraia,
lf put ligdtures on the ureters of a dog, and then  emptied the
bladder  by a catheter ; yet in a little  time  the dog drank
greedily, and made a quantity of water.  (Disput. Morbor.
Haller. T. iv. p. 63.)   A similar experiment  is related in the
philosophical  transactions with  the same event, (No. 65, 67,
for 1670.")  In this experiment too, there is  ample room for
deception.  It is not easily performed with accuracy, and one
or two are not sufficient to justify a general conclusion.  Let
it be fairly made and  repeated, and the nature of the fluid
found in the  bladder ascertained, before any weight be at-
tached to it.
   Nor do  the instances  of urine continuing to pass, after the
suppuration or total destruction of the kidneys, referred to in
Haller (Elem. Phys. T. viii. p. 379-) which are next mention-
ed, appear to favour the author's  hypothesis.   If any fluid
really continued to pass into the bladder after the total destrur«
tion of the kidneys, it must necessarily be by some other chan- 
76
UN HXDROTHOKAA.
nel than the ureters;  and this no anatomist of the present day
will be hardy enough to deny.   But if this fluid should really
be urine, as the author contends, it necessarily follows that
the lymphatics, beside conveying fluids in a retrograde course
to the bladder, must also assume the specific office and func-
tion of the kidneys, by converting their contents into the same
nature with the fluid secreted by these organs, a circumstance
on which the author does not seem to have reckoned.
   There is, however, little room to doubt that the fluid found
in the  bladder was urine,  and that it came from no other
source than the kidneys, and no other  channel than the ure-
ters ; for although the kidneys may  have been found  totally
destroyed by suppuration on dissection, in the dead body, yet
they might have been capable of secreting  some urine a few
hours,  (a few minutes would have been  sufficient,) before
death.   Every person  conversant  with morbid anatomy is
aware of the great difference in the  appearance of the diseas-
ed organs,  when  inspected  immediately after  dissolution, or
when this has been delayed some days, especially  in cases of
suppuration from previous inflammation, in which the parts
pass so quickly through the laws of  inorganic animal matter.
The inference  deduced from these cases,  therefore, seems to
rest on no better foundation :  they are besides extremely rare.
The experiment of the  nitre and asparagus, on which much
stress is laid, is next mentioned.
   " A friend of mine, (June 14,1772,) on drinking repeatedly
of cold small punch, till he began to be intoxicated, made a
quantity of colourless urine.   He then drank two drams of ni-
tre dissolved  in  some  of the punch, and eat  about twenty
stalks of boiled asparagus; on continuing to  drink more of the
punch, the  next urine he made was quite clear, and without
smell;  but  in a little time another quantity was made, which
was not so colourless, and had a strong smell of the asparagus;
he then lost about four ounces of blood from the arm. 
ON HYDROTHORAX.
77
      The smell of the asparagus was not at all  perceptible in
    the blood, neither when fresh taken, nor next morning, as my-
    self and two others accurately attended to; yet this smell was
    strongly perceived in the urine, which was made just before
    the blood was taken from his arm.
      Some bibulous paper, moistened in the serum of this blood,
    and suffered to dry, shewed no  signs of nitre by its burning.
    But some of the same paper, moistened in the urine, and dri-
    ed, on being ignited, evidently shewed the presence of nitre.
    This blood and the urine stood some days exposed to the sun
    in the open air, till they were evaporated to about a fourth
    ©f  their original  quantity  and began to stink: the  paper
    which was then moistened with the concentrated urine, shew-
    ed the presence of  much nitre by its manner of burning;
    whilst that moistened by the blood shewed no such appear-
    ances at all."
      " Hence it appears that certain fluids at the beginning of in-
    toxication, find another passage to the bladder besides the
    long course of the arterial circulation; and as  the  intestinal
    absorbents are joined with the urinary lymphatics by frequent
    anastamoses, as Hewson has demonstrated ;  and as there is no
    other road, we may justly conclude, that these fluids pass into
    the bladder by the urinary branch of the lymphatics, which
    has its motions inverted during the diseased state of the ani-
    mal."  p. 319. et seq.
*     If I mistake not the author's meaning in detailing this cu-
    rious experiment, he infers, that the whole of the nitre and as-
    paragus which reached the bladder was conveyed thither " by
    the urinary branch of the lymphatics," and consequently that
    no  part of either entered the circulating mass, as the  blood
    when drawn, and afterwards the serum, by the tests used, af-
    forded no evidence of the presence of nitre or asparagus.  It
    should have been stated whether or not he imagined the whole
    if the fluid found  in the bladder entered  it by the urinary 
 76                  ON HYDROTHORAX.

 branch, or partly by this, and partly by the kidneys ? but,  in
 whichever point of view the question be examined, the solu-
 tion, according to his hypothesis, will be found equally diffi-
 cult : if by the former, all the numberless  mouths of the lac-
 teals and lymphatics which open into the  stomach and intes-
 tines, except those which anastamose with the urinary branch,
 must have remained in a passive  or quiescent state till the
 latter " drank  up," and disposed of  the punch, asparagus,
 and nitre which were swallowed: if he supposed it was part-
 ly by both, those ramifying with the urinary branch must, by a
 wonderful instinct, have selected the whole of the two last sub-
 stances, together with a portion of the punch with which they
 were blended, leaving only the water, acid, sugar, and spirit,
 or at least a part of them, for the other absorbents to be con?
 veycd to the blood, and from thence to the kidneys.  What a
 wonderful accommodation in these vessels! and for what pur-
 pose?
  If the experiment on farther accurate trials, should prove to
 be as here stated, it seems to admit of a satisfactory explana-
tion without going out of the  regular  path, which has  been
so repeatedly explored by the ablest anatomists.   The pow-
erfully diuretic effects of large quantities of cold punch in the
circumstances  mentioned, and on an empty stomach, are well
known.   These will be considerably increased by the enormous
 dose of twodrams of nitre, especially when largely diluted.  As
soon as they enter the stomach and prima vice, they will be quick-
ly taken up by the thousands of mouths of the absorbents which
open into these cavities, and to  which they will prove a pow-
erful stimulus, and as quickly conveyed through them to the
 blood, and from thence to the secretory ramifications of the ar-
 teries.   As soon as the blood thus charged with these sub-
 stances has reached the kidneys, the determination to these or -
 gans, will be still farther increased by the specific stimulus
 they will exert upon them.  Hence the nitre  and the sub* 
QN HYDROTHORAX.
7$
stances in union with it, will of course pass with unusual ra-
pidity through the circulating mass, and the quantity of thi*
salt which may be mixed with the blood, will bear so small a
proportion with, and be so largely diluted by, the whole mass
of the vital fluid, as readily to elude detection without more
accurate tests than those used.   With regard to the  asparagus,,
it has not been proved that  the  peculiar odour imparted to
the urine is communicated to the blood also; it is probable
that this depends upon the combinations it meets with in the
urine, and does not arise till it has passed through  the kid-
neys.
   " A gentleman," continues the  author,  " who had been
some  weeks affected with jaundice, and  whose urine was in
consequence  of a very deep  yellow, took  some cold small
punch,  in  which was dissolved about a dram of nitre; he
then took repeated draughts of the punch, and kept himself in
a cool room, till on the approach of slight intoxication he made
a large quantity; this water had a slight yellow tinge, as might
be expected from a small admixture of bile secreted from the
kidneys; but if the whole of it had passed through the san-
guiferous vessels, which  were now  replete with bile, (his
whole skin being as yellow as gold) would not this  urine also,
as well as that he had made for  weeks before have been of a
deep  yellow ? paper dipped in this urine, and dried, and ig-
nited, shewed evident marks of the presence of nitre."  ib. p
310. et seq.
   If a large quantity of any thin diluting drink  be suddenly
drank and carried to the circulation, and the quantity of urine
be thence very considerably increased, if before of a  high, or
jaundice colour, will it not now become less so in proportion to
the quantity of watery fluid which entered the blood, and of the
urine secreted ?  this  is surely so  self evident as scarcely to re •
quire a serious refutation.   It  may be observed  in health, in
dropsy when the urine is of a very high, or yellow colour, acr 
80
ON HYDROTHORAX.
in jaundice; and if the biliary obstruction be  not removed if
will assume its original colour when the blood ceases to receive
the redundant water, and the urine is lessened in quantity.
  Is it unfortunate for the author's theory that in this expe
riment the urine had " a slight yellow tinge," as it undoubt-
edly proves that the whole of the nitre did not pass through
the new channel, but that some at least, entered the blood and
passed with the bile which imparted the yellow tinge.  Is
not this too a tacit acquiescence in what was denied in the last
experiment ?  namely, that any portion of it had reached the
bldod.
  The celebrated author next proceeds to explain the theory
and phenomena of diabetes, diarrhaea,  and various other dis-
eases  on  the retrograde  action  of the lymphatics, through
which it is not necessary to follow him, presuming, if the ob-
jections  already offered, to which many more might be added,
that the whole of  this subtle  theory must fall to the ground.
  That the functions of the absorbent system of vessels are
variously affected in different cases of dropsy, seems very pro-
bable, since they are restored and the disease is cured, by medi-
cines possessing apparently different, and even opposite effects;
and since diuretic remedies of one class succeed  immediately
after those of another have failed, as well as from the great
uncertainty of any individual medicine hitherto  used  in this
disease.
   On a review and analysis of the theory of retrograde action
of  the absorbents, it appears that he only connects this retro-
grade motion with a diseased state of these vessels; and in or-
der  to  preserve  consistency,  he is obliged to  reduce the
healthy subjects of his experiments  to  " beginning intoxica-
tion," which he  calls a  diseased state, before this unnatural
action commences.  But is he aware that many strong healthy
persons may be found who are incapable of being intoxicated
by weak small punch, but who experience its diuretic effects 
ON HYDROTHORAX.                 81
iri a very considerable degree ; he may however contend that
they are in a diseased state because they labour under tempo-
rary diabetes.
   On the whole then, from  the foregoing observations, the
following conclusions may, I think, be drawn.
   1.  That no proof has been given, by experiment, or by ra-
tional induction^ of a retrograde action of the absorbents, or of
a corresponding motion of their contained fluids.
   2.  That the evidence adduced in support of this opinion is
founded in vague and inconclusive hypothesis.
   3. That the experiments made both on the living and dead
body militate against it.
   4. That if the absorbents be capable of taking  up fluids
and Urging them forward, their valves will oppose insuperable
obstacles to their return.
   5. That no more direct channel has yet been discovered
from the stomach and  intestines, than that of the circulation.
   6. Consequently that the proximate cause of dropsy cannot
be a retrograde action of the lymphatics, but that which hag
been mentioned in the  beginning of this section.
   In some instances of dropsy the watery accumulation is ex-
tremely rapid ; in others it is very slow.   In the first instance
this may be accounted for by a  total, in the second, by a par-
tial suspension of the  action of the absorbents^ even without
taking into the account increased exhalation, which it is pro-
bable may concur in many cases. In those instances  where the
disease is very rapid in its progress  the thirst is generally in-
tense, and  great quantities of  liquids are  suddenly drank,
while very  little water passes off by the kidneys.
   Dr. Darwin's explanation of the state of the  urinary secre-
tion in dropsy seems still more singular.
   1. " Diminished  urine, which is high coloured, and depo-
sits an earthy sediment when cold, is owing," says he," to the
great action of the urinary absorbents.  In some instances the
                            11 
 25J                  ON HYDROTHORAX.

 cutaneous absorbents are paralytic, as well as those opening
 into the  cellular  membrane ;  and hence no  moisture being
 acquired from the atmosphere, or from the cellular membrane,
 great thirst is  excited, and great absorption from  all other
 parts where the absorbents are still capable of action.  Hence
 the urine is small in quantity, and of a deep Colour,with copi-
 ous  sediment; and  the kidneys are erroneou-iy blamed for
 not doing their office ; stimulant diuretic medicines are given
 in vain, and very frequently the unhappy patient is restrained
 from quenching his thirst, and dies a  martyr to false theory."
 vol. ii. p. 39. et. seq.
   Here we perceive, according to this hypothesis, the synchro-
 nous existence of preternatural  action of the  urinary absorb-
 ents ; paralysis of the  cutaneous, and of those opening into the
 cellular  substance, while some are performing 'a retrograde
 movement, and another set their natural action ! To reconcile
 so extraordinary a deviation from the regular course of nature,
 with the known and established laws of the animal ceconomy,
 seems difficult, if not impossible.   That in many diseases cer-
 tain parts or organs  labour under debility or perform their
 functions irregularly or imperfectly, while others perform them
 with additional vigou«- seems very evident; but in no instance
 can  such singular deviations as those  supposed to occur in
 dropsy be discovered.  Something like proof seems  at least
 necessary before assent can  be given to an hypothesis so novel
 however  high the authority which sanctions ii, more especial-
 ly when these phenomena may be accounted for agreeably to
 the known laws of lymphatic absorption and circulation.
  Paralysis of the absorbents has been mentioned as an occa-
sional cause of dropsy; but it is probable that it very rarely oc-
curs, and when it does, that like paralysis of the muscular fibre,
it will be either incurable, or admit only of partial relief; and
that it exists in  those dropsies which are beyond the reach  of
medicine.  If it occurred in every case of dropsy  would it be 
ON HYDROTHORAX.
m
 removed so speedily as is frequently found to be the case ?  by
 the use of digitalis alone, or in combination-with other diuretics,
 the cavities of t he body are sometimes unloaded of very large
 quantities of water in the course of twenty-four  hours; the
 urine is  proportionally increased in quantity, becomes paler,
 Gonietimes limpid, though before it was of a deep red or jaun-
 dice colour.   Here too, if this were the fact, while the cuta-
 neous absorbents, and those opening into cavities, recovered
 their lost action, that of the urinary absorbents must be im-
 paired, for the urine now ceases to be high coloured, or to de-
 posit an earthy sediment.  The cause of the scanty high co-
 loured urine, with a peculiar sediment, must therefore  be
 sought for from a different source, than  " great action of the
 urinary absorbents," and  the inquiry will be found in a prac-
 tical  point of view important.
   " That the kidneys are often erroneously blamed for not do-
 ing their duty;  that stimulant diuretics are given in vain;
 that, the unhappy patient is frequently restrained from quench-
 ing his thirst;  and dies a martyr to false theory,"  is too true.
 But what will be the consequence if the practitioner act un-
 der the influence of this theory ? if he trust to " diluent drinks,
 and warm bathing, the natural cure" affirms the doctor  " of
 this symptom?"  or if he  consider as incurable every case of
 dropsy where the urine is thus affected ?
   The urinary secretion seems liable to  a greater variety of
 changes not only  in this disease, but in many others,  even in
 health, than any of the  other fluids of the body, the perspira-
 tion not excepted.
   It is influenced by the quantity and quality of the food and
 drink; by exercise, and indeed by  every remarkable change
 which the body undergoes, so as to vary frequently in twen-
 ty-four hours in the same person.
   It is sometimes small in quantity, high coloured, and or.
coo'ingJets fall a sediment; while at others  it is increased in 
81
ON HYDROTHORAX.
 quantity, is of a straw colour, pale, or transparent without any
 deposition:  when in  fevers and other disorders it  has been
 without any, the sudden appearance of a copious whitish or
 branny sediment, generally indicates the approach of a favour-
 able change.
   The peculiar appearance the urine frequently exhibits in
 dropsy may be principally attributed,  1- To diminished de-
 termination of blood  and serous fluids to the kidneys, concur-
 ring sometimes with a torpor, weak action, Or inactivity of
 these  organs, more especially of the capillary extremities of
 the emulgent artery.   2. To the introduction of vitiated bile
 into the circulating mass.
   1. In proportion as the blood is deprived of its more aque-
 ous parts by sweating,  by salivation, by purging, or by these
 fluids being copiously effused into cavities, as happens in drop-
 sy, the determination to other parts, agreeably to a law of the
 animal osconpmy, will be  diminished.  In dropsy too the flu-
 ids effused, generally consist of the inert watery parts of the
 blood, holding in solution a portion of the coagulable lymph,
 except when the  disease is the  immediate consequence of in-
 flammation.   As  the  blood going to the various secreting or-
 gans will therefore contain less water, but more of the saline,
 earthy, and  other constituent parts, so the fluids secreted from
 it will  be less in quantity,  more dense, glutinous, and exalted
 in their nature.  Hence apparently, the  cause  of the scanty
high coloured urine, the dryness and clamminess of the fauces,
the thirst, and the diminished perspiration in dropsy.   And
it may reasonably by  inferred that the biliary, pancreatic, and,
Indeed  all the other  secretions, will be  equally influenced.
With  respect to  the  bile we  have the strongest evidence ol
this.
   That " great action of the urinary absorbents" has no share
in the  production of this change  may further be proved by
examining the urine as soon as ithas entered the bladder, before 
ON HYDR0THO*AX.
85
 it has been exposed to the action of these vessels.  If after
 completely emptying the bladder, the patient be again desuv
 ed to void urine, it will assume the same appearances though
 no more than a tea spoonful, or even a few drops be passed :
 this I have repeatedly observed.   If suffered to remain a con-
 siderable time in the bladder, its thinner parts will be taken up
 by the absorbents in dropsy as well as in health; and what re-
 mains will become higher coloured and thicker ; but that the
 diminution in quantity, and high colour, are to be sought for
 from defective secretion  in ihe kidneys owing  to the  causes
 mentioned, and others about  to be pointed out, admits of
 abundant proof.
   Many of the remote causes of dropsy, it  is well known, act
 immediately on these  organs by stimulating them at first to
 excess; but  agreeably to a general law of excessive  stimula-
 tion, their repeated application  will at length be succeeded by
 languor and inactivity.   Hence defective secretion, which will
 be a general consequence, may ocpur early or even precede the
 serous effusion, as has been observed  in the  history, as well as
 succeed it.  It frequently happens, how ever, that there is no
 defect whatsoever of the kidneys in theeariy stages of dropsy,
 and that this symptom  is to be attributed to  the causes al-
 ready pointed out, as  well as to the introduction of vitiated
 bile into  the  blood.
   The great influence of the biliary secretion in the production
 of dropsy seems not to be sufficiently understood, or attended
 to, by modern practitioners.  In this respect the ancient phy-
sicians seemed to have had the advantage.  Though totally
ignorant of the real uses and functions of the liver, they were
 fully aware of its extensive agency in producing dropsy. They
 supposed this viscus to be the elabaratory, as they termed it,
 of the blood, and dropsy to arise " from a cold  temperament
 proceeding from a chronic obstruction of its vessels, by which
 sanguification was vitiated, and the chyle which was brought,' 
66
ON HYDROTHORAX.
as they imagined, " by the ineseraic or mesenteric veins, ia-
stead of being converted into blood, was changed  into that
serous fluid found in cavities in dropsy."
   That a vitiated state  of the blood  is the necessary conse-
quence  of a long continued obstruction of the hepatic vessels
and biliary ducts,  especially  if the bile which finds  its way
into the circulation be morbidly changed in its properties, asig
frequently the case, is a fact too well established to be doubt-
ed ; and which the ancient physicians knew from experience,
however crude  their notions of the oeconomy of this organ
might have been.
   It is however generally supposed that the liver  is concerned
in producing dropsy only in so far as it  prevents,  by its increas
ed bulk, and consequent pressure, the free return  of the blood
of the vena portarum and inferior cava, to the  heart.  But
this is neither the only nor the principal way in  which it dis-
poses to this disease : its influence is often exerted earlier, and
is far more extensive than is generally imagined.
   When the function of the liver is so far impaired by what-
ever cause, that undue quantities of bile are conveyed to the
blood, the urinary secretion and lymphatic absorption, appear
always to be more or less diminished, and there is a correspond-
ing tendency to dropsy ; insomuch that if there  be  a  general
predisposition to  the disease it will frequently take place long
before any schirrous induration, or other enlargement, suffi-
cient  in size  or  degree  to impede the return of the venous
blood, shall have yet occurred.   Though healthy bile be an
active stimulus to the bowels, yet when diverted from its na-
tural channel and mixed with the blood it proves the  reverse
to other organs.
   In jaundice a general torpor and languor pervade the bodily
 and mental faculties; and if in consequence of previous mor-
bid action of the liver the bile should  be vitiated in  its pro-
perties these effects w ill be still more remarkable.  Hence any 
OTS HYDROTHORAX,
 siaferial derangement of this organ, especially if accompanied
 with a languid action of its vessels and absorption of bile, and
 be produced by  the common causes of dropsy, will be suc-
 ceeded by a corresponding inactivity of the kidneys and ab-
 sorbent vessels; and if  these causes be not removed, and a
.proper plan of medicine and regimen  submitted to, either
 chronic  inflammation, schirrus  enlargement of the liver  or
 dropsy, or both, will be the consequence.   As this state, when
 it precedes or  accompanies the disease under consideration,
 ought to influence the practice, it is proper to observe that it
 may be  generally known by the sallow, bloated, or bilious  as
 pect of the countenance, by the high or saffron coloured scanty
 urine, with corresponding sediment,  and by the ordinary
 symptoms of torpor and inactivity of the liver, which usually
 attend it.
   The circumstances which determine  the spontaneous sepa-
 ration of the urine appear  not  to  be sufficiently understood.
 In health,  though the urine be small  in quantity and high
 coloured, in consequence of abstinence from* liquids, or of pro-
 fuse sweating from  exercise, there  is seldom any tendency to
 separation ; nor does this readily take place in the early stages
 of inflammatory disorders, even  though bile be largely taken.
 up and  mixed with  the  blood, as long as the action of the
 heart and arteries continues vigorous;  but no sooner  is the
 strength considerably reduced,  or  exhausted, as happens  in
 the  advanced and last  stages  of these diseases, in hectic, and
 in the crises of other fevers, in jaundice and dropsy, than this;
 separation generally takes place. 
biiAV. vt
                        CUBE.

                        SECT. I.

             General observations on the cure.

     A HOUGH much interesting information may be collect
ed on the history of the disease from the works so often referred
to and quoted, yet it is to be lamented that little is to be found
of any  value, or worthy of being recorded on the most impor-
tant part, the cure.  The disease seems uniformly to have
been regarded, both by the moderns as well as by the ancienti?,
as incurable, admitting, under the most favourable  circum-
stances, but  of  casual and temporary relief from medicine
Under this impression no progress appears to have been madfi
towards a more successful mode of treatment.  In the only for
tunate case of hydrothorax related in the works of Morgagni it
is inferred that it  was a different disease because it terminat-
ed in recovery.   Several successful cases are mentioned in mo*
dern writings, especially in Withering's excellent essay; but
in many of these the disease afterwards returned.  Similar in
stances may be found in detached works, or in periodical pub
lications; but since the  subsequent history has seldom been
traced beyond the short period of a few weeks or months, it is
highly probable the cure was of short duration; and as these
cases are too often published with a view of answering a par-
ticular object, second editions were not to be expected.
  It has already been observed that whatever other circum-
stances might be connected with the disease, it had for its in: 
ON  HYDROTHORAX.
89
mediate cause, either partial or general debility; and the great
desideratum in its cure hitherto has been, a remedy capable
of evacuating the water without increasing this weakness still
farther.   The  means  to which  the ancients resorted, and
which are  not  yet discarded from modern practice, were  ill
calculated to  answer this end.   The cUre was too  generally
trusted to  purgatives  of the most  drastic kind, such as eu-
phorbium, gamboge, hellebore, elaterium, crocus metallorum,
scammony, and the like, termed from their peculiar proper-
ties, hydragogues, while the patient was perhaps at the same
time restrained from quenching his  inordinate  thirst.   The
mild laxatives  were positively said, on the authority of the
great  Sydenham,* to  be either of no use, or even to be preju-
dicial.  It must  be acknowledged, however, that cures are
said to have been performed by these drastic means:  but for
the reasons already mentioned it may reasonably be inferred

   * "  Seri evacuatiohero quod spectat, friagni refert ut diligenter observ-
emus in omnibus  hydropicis  ea cathartica quae vel segnius vel minus po-
tenter operantur,  officere magis quam prodesse."   Tractatus de hydrope,
p. 248. edit. 1685.   And farther;  " Ad hasc in  omnibus hydropicorum
sauationi dicatis,  id diligenter est observandum ut aquae ea maxima cele-
ritate exhauriantur quam aegri vires ferre queant; utpote qui singulis die-
bus expurgari dibeat: nisi quod sire Ob nimiam debilitatem corporis, sive
ob cathai tici praecedentis propter operationem plus satis  violentara dies
unus aut alter nonnuriquam intercalari possit."  ibid. 250.
  The following is a specimen of the cathartics used by this excellent au-
thor.
  " R. Tamarind. §ss. Fol. Sennae 50-  Rhei giss. coque in q. s. aquse
font, ad 3;iij. in colatur. dissolv.  Mannas  et Syr. Ros. Solut. aa fljj. Syr
Sp. Cerv. §<s. elect, e Slice. Rosar. gij. M. ft. potio."   ibid. 252.
  This, however,  he says is only  to be given in strong constitutions when
the milder cathartics have failed  in producing the desired effect.  But the
next, which he calls a milder, would in these days be justly termed a ve-
ry violent one.
  " R. Vini Alb.  fiij.  Jalap  subl. Pulv. Ji. 3ing.  Pnlv. B%%.  Syr. de
Spin. Cervin. %i.  M. ft. potio, summenda summo mane,  repetendaque.
tingulis, vel alteruis diebus pro ratione virtual "
                               12 
00
0*  HYDROTHORAX.
 that these were of short duration.   While the accumulated
 water  has thus been evacuated, and the  disorder apparently
 cured, the powers of life, already much weakened, have been
 still  farther exhausted, so  as to preclude the chance of reco-
 very ;  and  either death has speedily followed, or  the  water
 has again rapidly collected.   It ought to be mentioned, how.
 ever, that some  respectable  authors* have condemned this
 practice, and pointed out the evils resulting from it.

   * Rivei ius, Hoffman, and a few other celebrated writers, observe that
 although in lieucophlegmasia and anasarca it be sometimes necessary to
 give a strong purgative in a larger dose than ordinary, yet it  is highly
 dangerous in ascites.   After many judicious remarks the latter author ad-
 vises them  not to be repeated above once in six or seven vdays.  He de-
 sires to refrain entirely from gamboge, elaterium, coloquintida, and helle-
 bore.
    Arbutbnot is likewise of opinion that violent purges by dissolving the
 blood, have often proved /pernicious.
  Junker tells us that although a great quantitity of water is often carri-
 ed off by strong purges, yet instances frequently occur where they do no
 service,  though  repeatedly administered,  but rather  mischief; for they1
 greatly  irritate the bowels, weaken their tone, and promote the bursting
 of the lymphatics.  See Swan's Sydenham, p. 672.
  In various parts of Hoffman's works the most judicious observations and
 cautions are contained oh the use of purgatives in dropsy. Beside his ex-
 cellent remarks  under this head,  see his Opusc Med.  Pract. Decad. II.
Dissert. V. De Purgantibus fortioi ibus ex Proxi Medica merito ejiciendis.
Also some  valuable observations  on a case that  was very  improperly
 treated by their use.   Consult, et Re-pons. Med, Sect. ii. case 93.
  The whole of this work is highly deserving the attentive perusal'of
 young practitioners.
  " In puigantium administratione," says  Riverius, " observandum est,
omnia purgantia fortiora non esse  fiequentius usuipanda, ubi docet Ga-
lenus, (Lib. ix. de locis.) quia corpus dibilitant,etposteamagoraquarum
 proventus exoriatur ; ideoque roborantia,  et aperientia fiequentius quam
 purgantia erunt prescribenda.  Et experientia nos docet, evacuationem
in hoc morbo, qua? fit per urinam, melius  succedere ea, qua? fit per al-
vum." &.c.  After this excellent admonition it is to be wondered at that
 Sydenham should have goue so much into the opposite extreme 
ON HYDROTHORAX.
91
  In order therefore to obviate these  inconveniences a more
rational mode of cure was adopted by many, namely  by re-
medies  whose operation was chiefly confined to the kidneys,
aided perhaps by the occasional use  of mild laxatives,  with,
now and then, a brisk cathartic. But  though this mode proved
in many instances more successful, the water having been dis-
charged per vias urinas without much loss of strength, or hf
jury to the constitution, yet serious  inconvenience has  some-
times attended  it.  It  has often been found extremely diffi-
cult, sometimes impossible, to determine the operation of these
medicines to the kidneys, without first acting  powerfully on
the stomach, or bowels, or both, and thus failing in the  de-
sired end.   A remedy is yet wanting therefore which may
with more certainty be depended on, and  which possesses all
the advantages of a diuretic, without the inconveniences men-
tioned.  If  I be  not deceived by that self approbation, which
has imposed  on thousands, I have advanced some steps in ob-
 viating these, by means of the combination which is mention-
 ed in this chapter.  Besides evacuating the water more speed-
 ily, and with much greater certainty, the bodily strength is
 not only at the same  time preserved, nay often immediately
 improved, but the cause of the disease is  likewise frequently
 removed.    But  before entering more particularly on the
 means of cure, it may not be improper to  state the  circum-
 stances which led to the use  of a combination that  has been
 employed with so much success in a disease hitherto deemed
 scarcely within the reach of medical aid;  and also to offer  a
 few remarks on the  mode of operation of diuretic  remedies
 in general, a subject acknowledged to be involved still in much
 obscurity.
   By a well known law of the animal osconomy, the blood, in
 order to circulate freely through the capillary ramifications of
 the sanguiferous system, and to furnish the pabulum necessary
 (or the performance of the various secretions and excretion?,, 
y#
ON HYDROIHORAX
 must possess a certain degree of fluidity; or in other words,
 a due portion of water to dilute its more viscid parts: this is
 constantly varying in differejt bodies, and in the same body,
 at  different times;  but nature is endeavouring  to guard
 against a deficiency, or superabundance, and thus to preserve
 a just  equilibrium between the watery and other constituent
 parts.   When, for instance, in consequence of long abstinence
 from liquids, the operation of purgative or diuretic remedies,
 of sweating, or of salivation, the blood is deprived of its serum,
 the loss is made up,  and the balance still preserved by means
 of the absorbents, whose  action is preternaturally  increased
 throughout the  body, in order to answer this important end.
 This is demonstrated by the absorption of fat, and of serous
 fluids effused in cavities, by the  intense thirst, dryness of the
 tongue  and fauces,   and the general emaciation of the body,
 which invariably  follow  the long  continuance  of either of
 these.
  Under such circumstances,  the lymphatics first act upon
 the  more fluid  parts; then upon the fat; afterwards upon
 the muscles; and last of all upon the bones themselves.  No
facts in pathology  are more clearly established than  these,
and by their extensive agency the most important purposes are
effected. By their operation the most corpulent may be speed-
ily reduced within a  moderate compass, the dropsical suffer-
 er relieved of the accumulated water, and the jockey quickly
 reduced to his requisite weight.
  In this way too the operation of purgatives in evacuating the
water in dropsy is readily explained.   By stimulating the in-
ternal surface of the intestinal canal a  considerable quantity
of blood  is determined thither, and as invariably  happens
from similar irritations applied  to  mucus and secreting sur-
faces, the serous  parts, with some portion of the coagulable
lymph,  are copiously thrown out; the determination to other
organs is consequently diminished, and the action of the ab* 
ON HYDROTHORAX.
93
 sorbents, agreeably to this law proportionably augmented.
 When, on the other hand, inordinate quantities of water, or
 watery  fluids, are introduced into the circulating mass, the
 excess speedily passes off by the various outlets of the body,
 but chiefly by the kidneys, together with a portion of the con-
 stituent parts of the blood variously combined and modified.
   Thus we perceive that in health, by the wisest and most sa-
 lutary laws, the evils that must otherwise necessarily arise, in
 the one instance from a defective, in the other,  from a redun-
 dant supply of liquids, are for a time completely obviated, and
 the blood is prevented from suffering any material change in
 its constituent elements.
   From these effects, and more especially from the quick de-
 termination of cold water to the kidneys when drank in large
 quantities on an empty stomach, it  has  very justly  been  in-
 cluded in the class of diuretics.  But it is not only in itself a
 diuretic, but the medium through which all substances known
 to possess a specific operation on these  organs are  conveyed
 thither.   Thus  if any of these, as the crystals of tartar, the
 fixed alkalies, certain neutral salts, &c. be given  in  a solid
 form, the flow of urine will be very little, if at all encreased ;
 but if largely diluted, it will  be very considerably augment-
 ed, the  quantity being much  greater than  if they had been
 separately administered.    If two drams of  crystals  of tar
 tar be dissolved in one pint of water, and  drank in a given
 time, the quantity of urine voided  will  perhaps be twice as
 much as if the 6alt and the water had been administered at
 different and distant periods.
  The principles on which this is to be explained have  been
 beautifully illustrated by Dr. Cullen ; and a knowledge of the
 fact has led to one of the  greatest improvements of modern
practice in the treatment of dropsy ;  for which the  medical
public  owe  much to  those  distinguished  physicians Sir
George Baker, and Sir F. Milraan;  but the sanction and ear- 
31
>K HYDROTHORAX.
nest recommendation of the venerable professor in his public
lectures contributed greatly to give it general currency.
  In certain  diseases, however, especially in that under con-
sideration, the order of things is materially changed.  In by
far the greater number of dropsical cases, the free use of dilu-
ent  drinks is productive of no sensible increase of the urinary,
or any other secretion.  Instead of passing off by the natural
channels, they are thrown out by the exhalent vessels, and ef-
fused in various cavities.   The blood is thus freed from its
superabundant water, and the inconveniences that would oth-
erwise  ensue are obviated.
  With the view of removing such a disposition, the action of
the  kidneys must be excited by such means as are known to
exert a specific operation on them.  As however the absor-
bents may be the organs principally in fault, their functions
also must, if  possible, be restored.   Such remedies therefore
as possess the most extensive operation on  these parts should,
be resorted to.
  On attentively observing the effects of the diuretic remedies
in common use, there is a material  difference m their mode of
operation, insomuch that there appear just grounds for divid-
ing them into three different classes, namely,
  1. Such as act chiefly, if not solely on the kidneys.
  2. Such as act at the same time  on the kidneys, the absorb-
ents, the exhalants, and other secretions and excretions.
  3. Such as act solely on the absorbents.
  Under the  first class nitre is perhaps the only one which
ought  to be  comprehended, especially when largely diluted.
That in certain quantities it  promotes the  flow of urine is ge.
nerally admitted ;  and that this is by a direct specific action
on the  kidneys is rendered probable by its appearing to exert
no sensible stimulus on any other vessels or organs when admin-
istered in haemorrhage in very large doses. 
OH HYDROTHORAX.
9o
  Under the second class by far the greater  number of diur-
etics in daily use may be included.   The crystals of tartar,
the fixed vegetable alkalies, certain neutral salts, the vegetable
acids, squill, the resins, and resinous balsams, seem to exert
an extensive influence over the various secretions and excretions,
as well as the lymphatics.
  The first of these has sometimes cured dropsy without any
sensible increase of the urine, as may  be seen in Dr. Ferriar's
tracts, and in Home's clinical experiments; and its properties in
reducing redundant fat, and causing emaciation of the body,
when persevered in for a great length  of time,  especially in
the grateful but insidious form of imperial drink, as it is term-
ed, in common with vinegar, has frequently, and I fear fatally
been  demonstrated, and serve  to shew its  extensive agenc\
over the lymphatic system.
   The  efficacy of the second in dyspepsia,  especially in com-
bination with bitters, may be attributed probably more to
their power of stimulating the languid absorbents of the stom-
ach, and the first passages to a more healthy action, than to
that of neutralizing superabundant acid.  And their acknow-
ledged  virtues as a  remedy in dropsy seem to imply very con-
siderable effects on  the lymphatics in general, as well as on the
kidneys.
   In  regard to squills I perfectly accord in opinion with  Dr
Cullen, that they do not possess any specific operation on the
kidneys more than  upon every other part or excretory, to
which they seem to be universally stimulants.  " They readi-
ly,"  says  he,  " stimulate  the stomach and prove  emetic.
When managed so  as to pass the stomach they stimulate  the
intestines,  and prove purgative, and when carried into  the
mass of blood,  they are generally, and  I believe justly, sup-
posed to stimulate the mucus glands of the lungs, and to prove
an expectorant."  Mat. Med. vol. ii. p. 465, 
96
ON HYDKOIHORAX
   Analagous in some respects to squills arc the turpentines,
and resinous balsams, though their effects on the stomach and
bowels, in regard to proving emetic or purgative, be different.
Their direct action on the urinary organs is generally acknow-
ledged ; and their stimulant effects on the habit at large, more
particularly on  the mucus glands of the lungs, though differ-
ent in degree from squills, seem no less certain.   Other sub-
stances might be enumerated which possess equally extensive
powers.
   Under the third class I know no substance of which I dare
venture to speak with confidence except the foxglove.   I have
long adopted the opinion, and not on light  grounds, that this
herb exerted no specific diuretic  action on the kidneys; but
since the contrary is, I believe, generally maintained, and since
it  may seem paradoxical to  deny such powers to a substance
which sometimes, without the aid of any other, removes drop-
sical swellings of considerable size and extent, in the course of
a few hours, by increasing the urinary secretion in  proportion,
it  may be necessary to  point out die reasons which gave rise
to it.
   For  some years after I  had been in the habit of prescribing
this medicine, I considered it, in common I presume, with oth-
er practitioners, as one of the most active diuretics in the
whole range of the materia medica; and this by  a direct op-
eration on the kidneys.  Nor had any doubts arisen  in my
mind  in  this respect till it was used in diseases unaccompani-
ed with accumulations of water.   The idea I had been ac
customed to  form of a diuretic power in any substance was,
that this  power would be exerted and the quantity of urine
would be increased under all circumstances of the body, pro-
vided  the kidneys  were in  a sound state; and this by a spe-
cific operation  on these organs, as the substances mentioned
«nder  the first and second classes are generally  believed to
do.  I was surprised therefore that in no instance of  disease 
                     ON HYDROTHORAX.                 $7

 except in dropsy, or where water was effused in some cavity,
 could I discover any sensible increase of urine from the use of
 this herb, though many of my patients were for several weeks   '
 more or less under its influence.   Nor have I observed any of
 those effects which often follow the administration of other
 diuretics, such as thirst, dryness of the mouth and fauces, or
 irritation in the urinary passages.   In some cases the urine
 seemed at first sight to be increased by hybut on minute in-
 quiry, and  attentive observation, this was undoubtedly occa-
 sioned by changes in the diet, in the quantity of liquids used,
 in the temperature and degree of humidity of the atmosphere,
 which would have happened equally in perfect  health, when
 no medicine  was used.  Patients  too, when asked " if the
 quantity of urine was increased," would sometimes answer in
 the affirmative.   Every medical man of observation, however,
 must be aware how apt they are to do this, and how necessary
 it is, in order to obtain correct information, to avoid such di-
 rect questions, but to suffer them to describe their own sensa-
 tions or symptoms.   In some of my consumptive cases, the
 urine was sensibly increased in quantity,  but this happened
 either when there was no  doubt of the- presence of water in
 the chest, when the legs were anasarcous,  or when the colli-
 quative diarrhaa or sweat was lessened or removed by  this
 herb.
   When its operation was very powerful in dropsy, pain  was
 sometimes complained of in voiding  urine,  but this arose evi-
 dently from the efforts used in restraining the sudden and ir-
 resistible inclination to empty the bladder when quickly dis-
 tended, and is what persons in health experience after using
 large quantities of cold diluting drinks, especially weak punch,
 if they be forced for a time to restrain the  inclination.
   On the whole then I am led to conclude that this herb ex-
 erts no diuretic operation on the urinary organs,  but that as a
.successful agent in dropsy its effects are confined to the ab-
                           13 
'Jt
6a HYDROTHORAX.
sorbents, and probably in a certain degree extended to  hit
exhafents.
   The only hint of a similar opinion being entertained by any
other person w hich  I have met with  is the  following; and
this did not fall in my way till  some years after my own had
been  formed.  " In the opinion of Professor  Hecker, of  Er-
fut, Journal der Erfundungen" (say the editors of the Medi-
cal and Physical  Journal, from which this  is copied)  " even
the digitalis, which is perhaps  too generally prescribed in
dropsy, appears  to  possess no  specifically  diuretic  virtues.
This medicine obviously diminishes irritability ,60 that the pulse
becomes slower, while it moderates tensions  and spasms.  Its
re vol vent  and diuretic powers, therefore, must be ascribed
chiefly to those effects.  Hence it will most  probably effect a
cure in spasmodic dropsy, but prove of no service, in that aris*
mg from other causes: and thus we may account for the con-
tradictory opinions which have hitherto prevailed respecting
the efficacy of this medicine."
  I lament not being in possession of the full sentiments of this
learned professor on the subject of digitalis: this is sufficient,
however, to shew  the consistency of his opinion, and that he
does not regard it as possessing two directly opposite effects,
as seems very generally to be done in  this country ; while it
serves to add weight to that which I have advanced, and
which will be more fully stated hereafter.
  The same reasoning applies to its operation on the bowels;
never  having with me acted as a purgative except in dropsy,
or where there was more or less serous accumulation.   If this
opinion should prove well founded, a question naturally aris-
es, how its effects are to be explained, when  it increases  the
urinary secretion with so much promptness and eilect in drop-
sy ?   That this is done entirely by its restoring the impaired
©r lost functions of the absorbing  lymphatics, and probably
by lessening serous effusion at the same time, the reader is re-. 
ON HYDROTHORAX.
9*
quested for the present to take for granted: the farther proofs
will be given hereafter.   lr these vessels be placed in a condi-
tion of  taking up  freely and readily, and  conveying to the
blood fluids effused in  cavities, and the exhalants be at the
same time acted upon so as to throw out no more than the or-
dinary quantity which health requires, they will be determin-
ed to the kidneys as the natural outlets.
  The  practical inferences arising out of these facts and ob-
servations seem  obvious.   If by experience it be  ascertained
that certain substances act chiefly if not  solely on the kidneys;
others  on these, and  the absorbents, and  probably,  at the
same time, on the bronchial glands also; and others again en-
tirely on the  absorbents and exhalants, is it not reasonable
to infer, that by blending and combining these, according to
their known specific powers, so  that only such parts  may be
acted upon as are more immediately diseased, the wished for
end  is  much more likely to be  answered, than if separately
administered, when they are partially applied, and probably
not  to the organ which most needs their aid ? that this will be
fully confirmed by practice I have  no doubt in being able to
prove.
  Hitherto in administering diuretic remedies the only object
which the practitioner had in view was to stimulate  the kid-
neys ;  but the most active of these have been found inadequate
to the purpose of  carrying off the  water, although there was
ample proof of these organs being fully acted upon.  In con-
ducting the cure  of the disease much more extensive  views
have been aimed at by the author of this treatise, with what
success will, in due time, appear.  By the various combina-
tions he has offered, if he be not much deceived, the  water
will often  be speedily evacuated  without  any  unpleasant,
sometimes,  without any sensible, effects on the habit;  when
any one of their  constituent ingredients, even in the largest
doses, will completely fail.  Of this truth the perusal of a few 
100
ON HYDROTHORAX.
 of the annexed cases  will, he thinks, bear ample testimony
 The digitalis may thus be administered with the most perfect
 safety;  w ith greater certainty; and a much smaller dose will
 often be found to answer the proposed end.*

                        SECT. II.

                    Indications of Cure.

   After removing such of the remote causes as may be with-
 in reach, the Indications of Cure  founded on the foregoing
 principles, and on the  view which has  been taken of the dis-
 ease, may be comprehended under the four follow ing heads.
   1. To restore the lost or impaired action of the absorbents,
 so as to enable them to take up and convey to the blood se-
 rous fluids effused in cavities.
   2.  To determine to the kidneys the course of the blood
 charged with the fluids thus absorbed.
   3.  To lessen  inordinate exhalation, by giving tone and en-
 ergy to the whole habit.
   4.  To remove  weakness  or  other disease  of  particular
 organs, and thus by restoring and  preserving the healthy ba-
 lance between  the exhalants and absorbents, prevent farther
 accumulation.
  If  the patient be far advanced in years and his strength
much exhausted by intemperance,  especially in early life, and
 there be reason to apprehend disease of the  liver, or some oth-

  * Dr. Ferriar tells us that the digitalis is much more efficacious in com-
 bination with  other diuretics, than when given alone.  This has been.
 found to be the case w ith respect to squills; and the generality of prac- •
titioners are in the habit of administering two or  more  diuretics  toge-
ther ;  but as this has been done at random and  directed by no  fixed
 principles, the result has not been so favourable as might otherwise have.
happened. 
ON HYDROTHORAX.
101
 er important viscus, a remedy should be selected, of such com-
 bined powers as might answer all  these  indications at once.
 A combination of foxglove, certain tonics, saline diuretics, and
 calomel  in moderate  doses, will be found the best in such
 cases.
   But if the disease occur in delicate  subjects of either sex,
 endowed with a high degree of sensibility and irritability,
 with a soft smooth thin skin, a white shining, or transparent
 appearance of the anasarcous swellings,  if there be any, readi-
 ly pitting on pressure, more especially in females from frequent
 parturition, prof use uterine haemorrhages,  or similar debilitat-
 ing causes, without any organic affection, the digitalis  alone
 will generally succeed; but  its salutary effects will be great-
 ly promoted by mild tonics, steel in particular, and moderate
 doses of the fixed vegetable alkaline salts.   Calomel, squills
and  the crystals of tartar, if at all admissible, must be admi-
 nistered with extreme caution and in very small doses.
   But when it  happens in fat corpulent subjects, of a dull
 phlegmatic habit, and sluggish irritable fibre, with hard ana-
 sarcous swellings, of a livid hue, yielding reluctantly to, and
 not retaining, the impression of the fingers, especially if they
 had indulged freely in the use of porter and beer, such a com-
 bination  as will produce the  most extensive  operation on the
 habit should be prescribed.   The foxglove, calomel, crystals
 of tartar,  and  squills, must  be administered  in full doses.
 Tonics will in general do no good in the beginning; they even
 sometimes do harm ;  nor is the digitalis to be depended upon
 without the aid of the other remedies.
   By proceeding agreeably  to these principles, the  advanta-
 ges are incalculable.  Instead of losing  bodily vigour, ray  pa-
 tients have repeatedly declared, and it was very visible to oth-
 ers, that the appetite and general strength, improved almost
 from the moment of beginning medicine.  Such indeed was
 the rapidity with which some were unloaded of the water,, 
102
ON HYDROTHORAX.
that from the sudden depletion, and want of pressure, on the
lungs, heart, and  large vessels, precautions were absolutely
necessary to prevent syncope ; and  some expressed serious
alarm, to use their own words, " lest they should be drained to
death."

                       SECT.  III.

                   Particular Remedies,

  Blisters.   The  great efficacy of these in procuring almost
immediate relief from urgent symptoms, before other remedies
can possibly act on the absorbents and kidneys, I have repeat-
edly witnessed.   The stimulus exerted on the cutaneous ves-
sels and  nerves seem to be quickly imparted by sympathy to
the absorbents  within the chest, and in a certain degree per-
haps to the heart itself; and thus a more vigorous absorption,
circulation  and free respiration ensue for a time,  and the co-
pious evacuation of serous fluid which soon succeeds doubtless
contributes to the relief almost always experienced.
  In all  urgent cases therefore, with these views, I direct a
large blister to be applied immediately to the breast, pit of the
stomach,  region of the heart, sometimes  between the shoul-
ders, or as near to the seat of pain, oppression or accumulation
of water, as possible;  to  be  repeated afterwards  as circum-
stances may require, or indeed as often as the patient will per-
mit ;  which is  far preferable to a  perpetual blister.   The
breathing is often relieved in a few hours, or as soon as the
cantharides  begin to act upon the skin, which increases in pro-
portion as their secondary or evacuating effects are added to
their  stimulant.   The spasmodic and convulsive  contractions
of the diaphragm, intercostal, and other neighboring muscles,
even of the  heart itself, frequently consequent upon their  la-
borious  exertions to overcome the load with which they are 
ON HYDROTHORAX,
103
oppressed, are likewise greatly relieved by the blisters; and
there is reason to believe that the  irritation they sometimes
excite in the urinary passages, tends to facilitate the operation
of diuretic remedies.   As however their effects are only tran-
sient, so they are only to be resorted to as auxiliaries to more
active and permanent means.
   Digitalis.   In administering  this medicine the principal
circumstances to be regarded are,  the age, strength, peculiar
habit of the patient,  stage of the  disease,  and degree of ur-
gency of the symptoms.   If the disease be far advanced, and
the symptoms  such as to indicate immediate danger, the dose
should be  such as to produce  a speedy effect.   In general an
ounce of the standard infusion* or a grain of the powder taken
three times a day, morning, noon, and night, may be regard-
ed as a full dose for an adult of moderate strength.   If the herb
be genuine, and in perfect preservation, the habit  will feel the
influence of this quantity in a few days;  sometimes in forty-
eight hours the flow of urine has been considerably increased.
In  delicate  female  constitutions,  or in males whose strength
has been much  reduced, this quantity should not be given
oftner than  twice in  the day, evening and morning; and in
young-subjects the  dose must  be reduced  still fait her in pro-
portion to  the age.  The advantage of long intervals is, that
we are seldom taken by surprize by its deleterious effects, and
that it does not so readily disorder the stomach and habit at

                  * STANDARD INFUSION.
   No. 1.—ft- Dig. Pnrp. fot. incis. 3>s. Canells Alb. contus. velZingib
incis £j. Aq. i'erv. $ viij.  Infunde per horas iv. in vase operto ; dein liquc
rem etiunde.
  If the leaves be used as they are suspended  in paper bags in a room in
which a  fire is constantly kept in winter, without farther drying, which
should always be done for infusion, the Ii mor will pour off perfectly clear,
and save the trouble of straining.   The stalks and large fibroid part?
should be separated, and the leaves cut into small piece 
101
ON Hl'DROIHORAX.
 large, while its diuretic effects are more certain.   A very sniai,'
 dose given at  short intervals,  and continued for a  length of
 time,  has been  known to produce the most alarming eifects.
 Before I became familiarized with its various effects, especially
 if the  patient was not within my daily rounds, it was generally
 administered in a moderate dose, and continued  for three
 or four days successively, if in the mean time it produced no
 sensible effect:  it was then discontinued for a day or two, af-
 ter which it was resumed in increased quantity, and  persever-
 ed in  as  before, until  the urine began to flow more  freely, or
 there was some other proof of the habit being affected ; it was
 then judged  prudent  to discontinue  it.   To those who have
 not been in the habit of prescribing it, this method  may still
 be adopted, as any dangerous consequences that might other-
 wise arise, will thus effectually be  obviated, it being well
*xnown that its full effects have appeared some time after it has
 been withdrawn.  Similar precautions are, I perceive, recom-
 mended by an author who deservedly holds a very high rank
 among the  medical philosophers of the present day.   "  Its
 use," says he " should  not be continued for a length of time,
 but  stopped for certain intervals; and it should never be ex-
 hibited for more than five days together."*
   But when  the patient was within my immediate reach, so
 as to be visited  at least once every day,  which ought always
 to be done while he is under a course of this medicine, such
 delays were judged unnecessary,  especially in hydrothorax
 when an hour is in some instances of consequence.  I now di-
 rect  it to be given at once in such quantity as to produce some
 sensible effect in two or  three days : and by long and  frequent

  * Hufeland, Uber die Natur,  &c. der Scrofuln.  From this Essay, io
 ray opinioo, one of the best ever published on Scrophula, tliose who have
 not access to the original  work, will find copious extracts in vol. iii. of
 that valuable repository of medical information, the London Medical Re-
 "■'irvr and Magazine. 
ON HYDROTHORAX.
105
use the habits that are more or less susceptible of its operation
are so familiar to me as rarely to be disappointed,  if the pre-
paration be good.   The first object, namely,  that of evacuat-
ing the  water,  is generally  completely answered  within the
first week, without any untoward circumstance, and sometimes
without any increase of the original dose.
   * In the exhibition  of this herb in dropsy, the urinary se-
oretion is not the only point to be attended to.   He who does

   * In all violent and dangerous affections where the delay of every day,
nay, of every  hour gives additional force to the disease,  the importance
of establishing standard preparations and doses of powerful medicines must
appear sufficiently obvious.  It is equally incumbent  on  the physician to
be circumspect in  not hazarding too large a dose  at first,  whereby danger
might be incurred, as it is in not losing precious  timeby a timid adminis-
tration of weak and ineffectual doses.  In consumption and certain chronfc:
diseases, where the progress  may be slow,  I hold it to be the best plan,
(aud I have on a former occasion given full directions on this head, Medi-
cal and Physical Journal, vol. ii. p. 119) to begin with small doses, so as
to introduce  the medicine in the most gradual manner.   But in certain
acute affections,  and  in  that under  consideration,  unless the  habit be
made to feel its effects speedily it will perhaps come too  late.  These re-
marks are called forth by the language used by authors of high character
on this part of the subject of digitalis.  " Let me observe once for all,"
says Dr. Ferriar, " that nothing is less accurately fixed in medicine, than
one of its most important, the doses of remedies.  The proper dose of a
medicine is undoubtedly that quantity which produces the effect required
 whatever be its numerical denomination.  A full dose of the  foxglove is
therefore merely a relative term," &c.  Essay on the Medical properties of
digitalis  Purpurea p. 8. et seq.
   If Dr. Ferriar thought it an object of so much importance, and every
practitioner must  think the same, to fix more accurately the doses of me-
dicine than has hitherto been done,  it was surely the more necessary for
bim to be particular in pointing out the proper dose of the foxglove which
 was suited to  different ages, and constitutions,  as his experience might
 enable him to do, because more  mischief has avowedly arisen from want
 of knowledge in this respect than from that of any other medicine.  For
 how, it  will naturally be asked, are inexperienced practitioners to know
 this proper dose unless it be pointed out by those who,  like Dr. Ferriar,
                              14 
106-
ON HVDROTKGRA-t
 not attentively watch the state of the pulse, the stomach, the
 bowels, and sensorial functions, should never prescribe it.  But
 if these  be carefully watched, and the medicine withdrawn
 as soon as any of them are materially affected, I hesitate not
 to affirm, that no serious inconvenience will ever ensue from
 it, and that  it  may be administered with as much safety as
 any of the  more active medicines  in daily use.

 are enabled to do- so ? It is surely  of little use to be told Uiat " the pro-
 per dose  is that which will produce the effect required;" for every one
 knows this.  If the writers on the Materia Medica had held forth such Ian.
 guage ; if they had told us tliat the proper dose of ttte muriat and  other
 preparations of mercury, of opium, of emetic tartar,  and similar active
 medicines was " that quantity which produced the effect required," with-
 out specifying its numerical denomination, we should  be as ignorant at
 this time in this respect as many practitioners are  of the  real doses and
 proper management of the foxglove ; and instead of applying them as suc-
 cessful  agents in combating the ravages of disease they would be instru-
 ments of destruction in their hands.   A  full dose of every other medicine
 is a relative terra, so is a medium or small dose.
   " As I have  already observed," says Dr. Mossman  in his Essay on
 Scrophula, '* 1 conceive  the  proper dose of a  medicine  to be  just that
 quantity which will produce the desired effect ; now  the proper dose of
 the digitalis is what will,  by gradually bringing the system under its influ-
 ence, retard Uie motion of the  heart, so as to reduce  its pulsations to a
 given number, and to accomplish this object without inducing any of its
 deleterious or injurious effects."  p.  77 et 78.
  Such  a  dose as will reduce the pulsations of the heart to a given num-
 ber will indeed be  a wonderful one,.and such as I have no hesitation in
 saying, will in many constitutions never be discovered.
  If the best writers on the Materia Medica have deemed it necessary to<
 point out ihe exact doses of the common remedies suited to different ages
and constitutions, surely this is more especially so with  regard to the most
active.
  Under this  impression I shall feel it incumbent upon me to be particu-
lar in specifying the precise doses of the digitalis and other remedies which
have been found succrsful in dropsyv in the  fullest conviction of its neces-
sity to young and inexperienced practitioners 
ON HYDROTHORAX.
107
   The infusion I prefer to every other preparation, both be.
cause, if the herb be preserved as directed, it is liable  to less
variation than the powder, and because it furnishes a ready
vehicle for other active and no less essential ingredients.  The
formula  No.  2.# will be the most proper to  begin with in
simple cases;  but when the disease is complicated, one or oth-
er of those which follow must be had recourse to according to
the particular circumstances of every individual case as shall
hereafter be pointed out.
   If the digitalis be principally trusted to, and the flow of urine
be not increased  within the first week, that is, provided some
part of the habit  be sensibly  affected by it, there will  be rea-
son to suspect such a morbid state of the lymphatics as will on-
ly yield to diuretics of a different class.   These should there-
fore be resorted to; or if they have been already used, they
should be  given in increased quantity.   Such is now my con-
fidence in  the combinations of which various formulas  are
given, that I  have no hesitation in promising a speedy evacu-
ation in the firs't instance whatever may be the probability of
a permanent cure.
   When the medicine acts powerfully on the bowels, although
there be no pain or griping, yet the vital powers are more
speedily exhausted than from the operation of the most dras-
tic purgatives.   Hence this should never be suffered  to take
place,but when it does happen it must immediately be checked.
The operation in general is sudden and unexpected, a number
of copious watery evacuations following one another in quick
succession, attended with extreme faintness, languor, and pros-
tration of strength.   They are easily checked at first, but the
proper remedy should be at hand, and such as to produce an
immediate effect.    The  tincture  of opium in general, will

   * No. 2.—R. Inlus. Dig. Purp. j$j. Aq. Menth. Pip. 3 iij. Kali pp. gr„
x. ad 9j. Sp. JEth. Nitrpsi. vel Sp. ^th. Vitr. C. 3SS. ad 3j. M. ft. haus-
f.us bis terve de  die sum. 
108
OX HYJjROTHORAX,
 succeed, and  is preferable to the  extract in a solid form.
 From ten to fifteen  drops should be given in some  cordial
 water repeated at short or long intervals according to the great.
 er or less frequency of the  evacuations and the consequent de
 bility.   The foxglove should at the same time be discontinued
 for a day or two, though no other effect be as yet discernible.
 When the bowels are too loose naturally, or when it shews a
 disposition to  act upon them  early, five or ten drops may be
 given with each dose of it.
   So apprehensive do the  practitioners of Manchester appear
 to be of its operation on the bowels, (and few are more conver-
 sant with this herb) that they generally begin by combining opi-
 um with it.  In certain cases,  and in inexperienced  hands,
 this may be a necessary precaution, but as a general rule of
 practice it is  inadmissible; because in some instances it will
 counteract its salutary effects.  A lax state of the bowels I
 have uniformly observed to be extremely favourable, nay ah
 most necessary, to the successful exhibition of digitalis and
 other diuretic remedies, while the opposite state is as adverse
 to it.  Hence  when opium retards the natural action of the
 bowels, as it too generally  does, it will prove manifestly pre-
 judicial.
  When the  digitalis  violently  disorders  the stomach and
 produces that  train of alarming symptoms which are only the
 consequence of its unguarded or injudicious use, frequent doses
 of the confeclio opiata, in  the form of pills, with warm cor-
 dials in very small quantity, (for the stomach rejects immedi?
ately every thing in large  draughts) warm volatile, anodyne
embrocations to the epigastrium,* and spirituous fomentations
to the feet, will be found the most effectual means ; and if the

  *  No. 3.—R.  Lin. Camph. gij. Sp. Ammon. C. Tinct. Opii aa. %b.
M. ft. Lin.
   This liniment well rubbed upon the epigastrium or abdomen, I have re-
peatedly prescribed with immediate relief in violent sickness and vomit' 
ON HYDROTHORAX,
109
 stomach should reject every thing, rich broth glysters in small
 quantity, with from 80 to 150 drops of laudanum, may  be
 thrown up, and repeated according to circumstances: if these
 be had recourse to in due time they will assuredly speedily
 quiet these symptoms.
   Although preference be given to the infusion in the first in-
 stance, yet as soon as the water has been evacuated and a slow
 gradual course of the digitalis and other remedies is required
 to keep  up a due action of the absorbents, to determine the
 fluids to the  kidneys, and thus their farther  accumulation is
 intended to  be prevented, the powder  in the form of pills*
 will be found more grateful to the patient and  more conve-
 nient in every respect.
   Squills.  The  use of squills in  dropsy  is of very ancient
 date.   The powder and vinegar of this root were held in high
 estimation by Galen, Caelius Aurelianus,  Celsus, and others
 among the ancients, but more especially when the disease was
 combined with asthma so  as to threaten suffocation; and
 their being in constant use from those periods to the present
 times is the strongest presumption in favour of their superior
 virtues.   Like almost every other active  remedy,  however,
 they  have been warmly commended by some, and  condemn-
 ed by others;  and, as is usually the case, successful instances

 ing, or acute pains of the bowels.  The parts should be covered with hot
 flannel afterwards.
  * No. 4.—R. Dig. purp. fol. pulv. Scillae recent, exsicc P. aa. gr. jx.
 Calom. gr. vj. Myrrhae 9ij. Crystall. tart. Pulv. 9j. teresiraul et extract
 Gent.  q. s. ft. Pil. xxiv. Sum. duas usque ad tres sing. noct. et mat. su-
perbib. liquor, infra praes. cyathum vel librae quadr.
  No. 5.—R. Cryst.  tart. Pulv.  gij. Soly. in Aq. ferv. libj. add. Rad.
Zing, incis. 3's. Sacch. pur. q. s. Sp. Iuniper. ver. §ifs. vel vini rhen. §iij,
 M. Propinat asger quant, hancce vel duplicem quotidie.
  As soon as the patient begins medicine, the free use of this or some di-
luting drink according to former habits, is directed asap absolutely neces-
sary part of the plan 
no
ON HYDROTHORAX.
are brought forward on the one hand, and failures, even fatal
ones, on the other.   This must ever be  the fate of powerful
agents according as they are directed by skilful and judicious
hands, or the reverse.  The enormous  doses which were used
by the ancients, and even by some of the moderns, must have
been generally far too violent to answer the end proposed; and
indeed has been the principal cause of their frequent failure.
  W'hen administered alone it has been  found difficult, often
impossible, to determine their operation to the kidneys.  They
have frequently excited either nausea, vomiting, or.diarrhasa-,
and from their having in a few instances succeeded in curing
the disease in this manner, practitioners have attempted to eva-
cuate the water by keeping up a constant nausea, and sometimel
by exciting vomiting. The action of vomiting determines pow-
erfully the blood to the stomach, lungs, and neighbouring or-
gans, and considerable quantities of the serous parts are mecha-
nically squeezed out from the capillary extremities of their ves-
sels ;  while the lymphatics within the influence of the muscles
concerned are likewise excited.  Thus by a twofold operation
the water in dropsy may sometimes be got rid of, and the dis-
ease cured.   But for the  reasons already  stated the cure of
dropsy of the chest should never be attempted by vomiting.
  Valuable, however, as this  medicine is allowed to be ie
some cases of dropsy, it has  been  far  too indiscriminately
used.  There is perhaps no species  of the disease for which it
is so well adapted as that under consideration,* and there are
certain instances of this for which it is more particularly cal-
culated than others.
  In very fat subjects  at an advanced age, especially when
there is chronic catarrh, asthma, or cough, and the bronchial

  * It is highly probable that  the cases of dropsy,  " pnesertim ubi
asthma ad suffocationis fere metum concurrit," for which  the ancients
found this medicine  more peculiarly adapted, were attended with water
;;> the cavities of the chest.  See Hoffman vol. vy. p. 455. 
ON HYDROTHORAX,
111
 tubes are loaded with large quantities of viscid phlegm, ex-
 pectorated with much difficulty, squills will be found highly
 beneficial both as an expectorant, a diuretic, and by promoting
 absorption.   In such cases they may be given in very full
 doses so  as  even sometimes to keep up nausea, which is con-
 ducive in no small degree towards a free excretion from the
 bronchial vessels.   As this, however, may interfere with the
 principal  object,  that of  evacuating the water, it should not
 be induced until the urine begins to flow with freedom.   The
 preparations best suited for such cases are the oxymel, vinegar,
 or Tincture: the two former I have generally preferred,* be
 cause the other ingredients with which the squill is combined
 seemed to add to its virtues.   But when these urgent symp-
 toms are removed,  or the first object is attained,  and a slow
 gradual operation only is required, the powder in the form of
 pills, No. 4. will be found more convenient.
    In thin, delicate, especially female constitutions, with weak
 irritable stomachs, this medicine should be administered with
 extreme caution ; and it is scarcely adviseable in any  other
 form than that of pills combined with small quantities of opL
 uni; and not even then, unless the bronchial vessels should be
 loaded with viscid mucus.   The stomachs of such subjects are
 extremely susceptible of its action ; and if this organ  be once
 disordered, it will  be found difficult to persuade them after-
 wards to persevere in the use of any medicine.   If they should
 unfortunately produce such unpleasant effects  in those cases
 where they are deemed absolutely necessary, the means re-

   * No. 6.—R. Tinct.tolut. vel Benz. C. 3ss.ad3i. Muc. G. Arab, ve!
Ov. Vit. q. s. ut raiser.   Infus. dig. Purp. §i. mell. Scilke $\. ad 3ij. Sp.
Mlh. VHr. C. gtt. xxx. ad $1  Kali pp. gr. x. ad 9j. M. ft. Haust. ter
 ind. s.
  The author is not ignorant that here a KsJi Acetat may be formed, bvt
the Kali pp. will stiH predominate, 
112
OX HYDROTHORAX.
commended for the noxious effects of the foxglove will br
found the most efficacious.
   Saline diuretics though  precarious and uncertain in their
operation, as they are commonly administered, yet in combi-
nation  with  the other means, and largely  diluted,  will be
found  powerful auxiliaries.  Those in ordinary use are, the
crystals of tartar, Kali  praparatum, or fixed vegetable  alkali,
and Kali acetatum, commonly called the Sal diureticus.
   Crystals of tartar, have  been  much used of late years and
frequently with great success in  dropsy.   Vinfenti Manghini,
an Italian physician, seems to be the first who brought this
medicine  into  repute  in  dropsy.  In  the Comment. Bonon.
Tom. iv. several successful  cases  of this disease are published
by him.  The dose was from four to  six drams daily.  Iu
many of these cases from twenty to forty  days elapsed before
it had any sensible effect on the  bowels or kidneys; but after
wards the bowels became loose, the urine thick,  bilious, and
sabulous.    Many of the patients had  swellings  of the liver
and spleen, which were likewise removed.  The medicine pro-
duced great weakness and emaciation, but the subjects being
young, and the disease generally of a few  months standing, they
soon recovered their strength and flesh.
   These cases appearing to professor Home of Edinburgh au-
thentic and very important, he  put this medicine to the full
test of experiment in  the Royal Infirmary in the year 1769.
In his clinical experiments  published in  1780, the  result is giv-
en in detail.   It was  administered largely diluted in the pro-
portion of from  four  drams to  an ounce of the tartar to ten
and sixteen ounces of water, generally in the morning.   AVith
him it wras  found to increase the urine, thus  diluted, in  at
many hours as days with Manghini;  and on the whole it suc-
ceeded beyond his expectations.
   Dr. Ferriar appears to have been so successful with this re
medy as to prefer it to every other. 
OX HYDR0TII0RAZ.
116
   It has sometimes been given in very large doses undiluted,
 and at other times in moderate and small  quantities largely
 diluted,  and it has succeeded hi both ways.   But in the for-
 mer  mode it has often failed after a long and tedious course
 of it, and when it has succeeded in evacuating the Water  in
 sither way, the patient has sohietimes been left So extremely
 weak and emaciated, as to preclude the hope of recovery from
 other means; and many have thus died  of mere  debility,
 without any evident causey as has been said;  of which Dr.  Mil-
 man  gives instances ;  and many more might be added.  The
 cause of this, however, is sufficiently obvious; it is to be attri
 buted to the peculiar properties which it possesses when per-
 severed in for a great length of time in exciting the action of
 the lymphatics to such a degree as not only to absorb the ef-
 fused thirds, but fat and muscle, and thus producing emacia-
 tion,  marasmus, and  their usual concomitants, debility, and
 universal exhaustion.
   Hence it may be inferred that this sujytance is more partic-
 ularly adapted to certain constitutions and stages of this dis-
 ease  than to others.  These cases are nearly the same with
 those  for which squills are calculated, namely, very fat  sub-
jects, especially when the legs are tense, hard, of  a livid hue,
 and in which the accurate Withering has told us the digitalis
 alone is not to be depended Upon.   It seems, however, to have
 no effect like squills in promoting the bronchial secretion.   In
 these habits the only remedy from which any  material or
lasting benefit can be expected is a combination of crystals of
 tartar, squills, calomel, and digitalis,* together with such oth-
 er auxiliaries as may be suited to the particular circumstances  -
 of the case, continued for  a great  length of time.  On the

  * No. 7 — R. Fol. dig. purp. pulv.  Scilte pulv. aa. gr. i. Calomel, gr,
2s. ad  gr. j. Cryst. tart. 9j. ad 31s. Syr. Zingib. q. s. ft bol.  sing. coct. et
mat. s.  Besides this No. 6. should be given freely
                            15 
ill
ON HYDRO THORAX*
 other hand, iu thin delicate habits, where the complexion is pale,
 the general strength much impaired, with every evidence of a
 tenuity or an impoverished state of the blood, great weakness
 or irritability of the bowels, and where there appeared to have
 existed in health a pre-disposition to emaciation, to inordinate
 lymphatic absorption, and  secretion of pale urine,  if at  all
 administered, it should be given with extreme caution,  in ve-
 ry small doses, blended with warm aromatics, and tonics, and
 be withdrawn as  soon  as the urine is  increased in  quantity.
 Nor should it be resorted  to till other means have been  tried
 in vaiiij  which is  rarely the case, as  the water is in  general
 evacuated with great facility  by the  foxglove  in  combina-
 tion with tonics under such circumstances.
  I have not found it  necessary to prescribe it in any case in
 the large do^es recommended by Manghini, Home, and others.
 Every purpose  will be answered in the proportions of whidi
 formula have been given.
  Dr. Home found that its  success was to be depended on
 most in anasarca, next in ascites and least  in hydrothoraY
 My experience  does not enable me to  speak decidedly on this
 point, but with the precautions laid down, it warrants me in
 recommending  it as a valuable and powerful auxiliary in eva-
cuating the water in every species of dropsy.   But where,  for
 the reasons assigned, its use is deemed equivocal the,
  Kali praparatum may be  administered  with  advantage.
 From long experience, I ara inclined to prefer this  in many
cases,  as  one of the most safe and certain in its operation of ail
the saline diuretics.  It may be used with  advantage in  all
 constitutions, ages, and circumstances of the disease ; and when
 the water is removed it will  be found equally efficacious in
 preventing farther  accumulation and in giving strength and
 energy, in combination with  aromatics, bitters or other  tonic 
ON HYDROTH0RAX>
115
remedies.*1  While it excites the action of the absorbents and
determines to the kidneys, it  seems at the same time particu-
larly  calculated to strengthen the digestive organs; nor does
it ever disorder the stomach or bowels, when prescribed in
moderate doses like many of the other diuretics.   Its opera-
tion seems to be confined chiefly to a certain morbid state of
the absorbents, since when given largely in  diseases unaccom-
panied with watery accumulations it produces  very little,  if
any,  diuretic effect; whereas crystals  of tartar seem  to act
more  readily on these vessels  and on the kidneys in health than
in disease, as may be readily ascertained on trial.  To most
palates however it imparts a pungent bitter nauseous taste,  •
which ought to  be corrected by a  little addition of pepper-
mint  water or  essential oil.   The preparations of aether will
answer this purpose also.
   Broom ashes  have been long recommended as a remedy in
dropsy; as however their virtues evidently depend  on the
quantity of. this substance contained in them, it is scarcely ne-
cessary to remark that the alkali will  be found far  more effica*
cious  when div«sted of the crude substances with which it  ie
combined.
   The dose for adults is from  ten grains to a scruple three
times a day in one or other of the formulas subjoined.
  According to the condition of the first  passages, it wiri be
neutralized for a greater or less time, whereby the alkalescent
quality will not be imparted to the general habit.  It must
therefore  be continued for some time  before  we  pretend to
decide on its efficacy.  Its diuretic virtues are  promoted by

  * No. 8.—R. Infus. Gent. C. 31X. Kali pp. gr. x. ad $j. Tinct. Cort
Aur. £ifs. Sp. Mth. Nitr. gtt. 40 ad  gi.M. ft. haust. ter ind. cum Pi!,
enfra prses. No. ij. s.
  No. 9.—ft. Ferr. Vitr.  Kali pp. aa. 3fs.  Myrrhce 3ij. simul in pulv,
subt-teipet Extract Gent q s-ftpil xxiv 
11G
ouS HYDROTHORAX.
 the nitrous and other aethers,  by the turpentines and certain
 balsams.   During its exhibition  the  patient must be caution-
 ed against the use of saccharine  and all other acescent mat-
 ters ;  also of malt liquors and the like.
   Mther and its preparations, whether we consider their anti-
 spasmodic or diuretic properties, are excellent auxiliaries in
 this disease.  In  full doses they often  afford immediate re-
 lief of the extremely difficult, irregular, and spasmodic breath-
 ing, before other remedies have had time to act.  But as the
 relief  they afford  is very transient they are never to be trust-
 ed to alone, but should always be directed in conjunction with
 the other remedies when the difficulty in respiration  is very
 urgent.
   I have generally preferred  the Sp. Mb.. Vitr. C. or Hoff-
 man's anodyne liquor, fancying that  it possessed superior vir-
 tues to the common vitriolic asther in promoting the efficacy
 of the other remedies; but in the choice of these the practi-
 titioner may use his discretion.
   The Sp. JEtheris Nitrosi will be  found a  valuable medi-
 cine in all cases and stages of hydrothorax.  it seems to pos-
 sess less antispasmodic, but greater diuretic, powers than the
 former preparation.  Both these  substances impart a grateful
 warmth to the stomach, and contribute to relieve the flatulen-
 cy which is often so troublesome.
   The Resins and resinous balsams  will be found useful in
those cases for which squills and  crystals of tartar are parti-
 cularly adapted, in combination with these substances, espe-
cially in what are termed cold phlegmatic constitutions, when
the  lungs are loaded with hard viscid phlegm.   If there be
reason  to suspect great torpor of the liver, if the urine be  very
thick,  of a jaundiced appearance, the eye and countenance
yellow, the turpentines will in such cases  be found highly be-
neficial, both  in stimulating the  vessels  of the liver, and in 
                     OH HYDROTHORAX,                 117

 promoting the action of the alkaline  salts and other diuretic
 medicines.
   The Tinct. Benz. C. the T. et Bals. tolut. I have generally
 preferred ;  but the terebinth. Chios et venet. the Bals. e Mec-
 ca, Cauadens. and Copaibas, may likewise be used with advan-
 tage, incorporated with other substances by means of muci-r
 lage or yolk of egg.
   A Liniment composed of equal parts of the tereb. Venet. or
 chice and sweet oil well rubbed on the region of the liver will
 be found useful in exciting the action of that organ, and when
 mercurial ointment is judged necessary a small portion of tur-
 pentine or camphor may be blended with it with advantage.
   Laxatives.  As purging forms no part of my  curative indi-
 cations in this disease, little remains to be said  on this head.
 Certain circumstances occur, however, which render the exhi-
 bition  of a mild laxative sometimes necessary.   A constipated
 state of the bowels occasionally attends the disease; and con-
 trary perhaps to what nught be expected a priori, is extreme
 ly adverse to the operation of diuretic remedies, as has alrea-
 dy been  observed.   Whilst a constant and violent determina-
 tion to the  bowels by means  of active purgatives, lessens in
 proportion the secretion by the kidneys,  a moderately lax state
 of them contributes in a great degree to increase it.  Hence,
 if the  body be not naturally  open,  the interference  of art
 is absolutely necessary ; and  this should be done by  such
Jaxatives  as are  known to  act  at  the same  time on the
kidneys.
   It is a good plan to. administer a combination  of calomel
and crystals of tartar at night, # and  if necessary, to quicken
their operation the following morning by more active means

  • No. 10.—R. Calomelan. gr. ij. ad iv. Crystallor. tart. p. gr. x. Zing.
Pulv. gr. v. probe simul in pulv. sunt, tere et Syr. Zing. q. s. ft. bolus h
s. s. et sen. Matutino dpglr. yger. Haiut. infra prajs 
118
OH HYDROTHORAX.
 in a liquid form.#   In this way the operation on the kidneys
 is often very considerable; and from the free absorption of
 both these substances which takes place during  sleep, the ac-
 tion of the lymphatics is not only promoted, but, if there be
 disease of the liver, or other  viscus, an additional object is at-
 tained.
   When the patient refused to conform to a plan of medicine
 calculated to effect a radical cure, or when this had been at-
 tempted in vain in certain dropsies, especially ascites, I have
 known the disorder  kept in check for a considerable time by
 means of similar purgatives occasionally  resorted to.   But
 the relief is of short duration, and the water accumulates af-
 terwards with greater rapidity.
  Calomel  and  other preparations  of Mercury.  If there be
 any substance in nature which approximates nearer than  ano-
 ther  to what is termed a specific, this substance is mercury, ju-
 diciously administered.   Not only is its efficacy fully ascer-
 tained in various diseases whose causes and nature are well
 understood, but in several other morbid affections  of  whose
 pathology we still remain ignorant.  After every other reme-
 dy  has been  tried in vain, this mineral  properly used frer
quently performs a cure.   In dropsy, as far as I know, it has
 only  been resorted to in an  irregular and casual way, either
with the view of reduping enlargements of the liver or other
organ, from which the  dropsy was  supposed to arise ;  or in
conjunction with squills, in order to determine their operation
with greater certainty to the kidneys.   But ample experience
has enabled me unequivocally to ascertain that its  efficacy is
far more extensive; and that its salutary  agency is not only
 exerted in the reduction of morbid indurations, but in exciting
 powerfully the  torpid and languid action of the absorbents

  * No. 11.— R. Infus. Senna tart, vel Inf. tamarind, cum Senna? (Ph.
 Ed.)   3x. mannas 5j. Tinct. Sennge vel Jalap, $ij. ad §fs. M. ft.  haust,
mane sumecdus. 
ON" HYDROTHORAX.
119
also, as well as of the whole system of secretory and excretory
Vessels; of removing  disease under which they may labour,
and thus  promoting the operation of all other diuretic reme.
dies.   This, however, will depend in a great  measure on the
quantity, and mode  of exhibition.   If any of its oxyds, or
saline combinations, be introduced into the stomach in their
crude unqualified state even in moderate doses, they will tend
rather to defeat than to promote our wishes.
   The preparation which I have generally preferred is calo-
mel, because it is less liable to  variation of strength, and is
more readily blended with other substances.  Whether it be
intended to act on the bowels as a purgative, or, by entering
the circulation, on the secretions and absorbent vessels, its vir-
tues will be materially increased by previous trituration and
minute division of its particles with some saline substance as
in No. 4—10—13 ; its operation will be more speedy and
certain, at the same time that a much smaller quantity will
be found  sufficient to answer these purposes.   It has been the
practice  of late with many medical  men in this country, for
there is   unfortunately a fashion  in  medicine  as well ag-
in  other  things,  as  has  been  the  case for  some  years in
hot  climates,  to prescribe calomel in  the immense doses of
ten,  fifteen,  and twenty grains even for young subjects; and
I  have   repeatedly   heard  practitioners  boast  of having
given  these  quantities to  children as a  purgative;  but
I  will venture to  affirm that such liberties cannot often be
taken with  the human constitution  without the  most se
rious consequences; and that if we  wish the medicine to
act  upon  the bowels, two grains   will  produce a  more
certain and speedy effect thus prepared and blended thau
ten will  do  in the ordinary way, without any,  or compa*
ratively with very little, pain, irritation, or griping.  If the
bowels be very sluggish or torpid, the addition of an equal
quantity of the resin of Jalap will in general answer the pi;r 
120
OS HYDROTilORAX.
 poses of a  gentle but sufficiently active purgative; for thi;
 substance even gamboge,  is rendered  perfectly mild by the
 same  mode of preparation, without  losing any of its active
 properties.
   In general this medicine will be found adapted for the  same
 cases,  constitutions, and circumstances  with the  crystals of
 tartar and squills,  and the same cautions and restrictions will
 apply to both.#   When unusual languor or torpor pervades
 the whole frame; when the eyes and skin are actually yellow ;
 the urine is thick,  crude, and  loaded with bile ; when there
 is reason to  suspect accumulation of viscid bile in the hephatic
 ducts, and more especially if with these the liver itself or any
 other organ of consequence be enlarged, the bowels  should be
 occasionally stimulated by moderate doses of mercurial purga-
 tives, such as No. 13,f at the same time that one or two grains of
 calomel as in No. 4, may be given every night at bed time with
 the view of charging the habit with it, and persevered in till
 the mouth  be slightly affected.  Frictions with  mercurial
 ointment saturated with camphor, or with a  small addition of
 Venice turpentine, to the region of the liver,  will be found
 useful in such cases.
   In all instances, except those where the disease arises from
 mere  debility,   and  under  the  circumstances   in which
it has been  observed the crystals  of tartar  and  squills are
to be  used  with extreme circumspection,  some  mercurial
preparation must be had recourse to from the beginning, as a
necessary part of the plan of cure.   Even in these^ if there be

  * Vide page 111 et 113.
  f No. 12.—R. TinctrBenz. C. gtt. 40 ad 60 vel Tinct. Tolut. 3i. cum
muc. G. Arab. q. s. redact. Myrrhac gr. x. Aq. M. Pip. £i. Sp. iEth.
Nitr. vel Vitr. C. Ji. Kali pp. gr. x.  M. ft. haust. ter ind. s.
  No. 13.—P.. Resin.  Jalap. Calomehyi. Zingiber. Pulv. aa.gr. ij. adiv.
Crystall. tart.  Pulv. gr. v. ad x. Simul tere et Syr. Zing. q. s. ft. Bolus ft.
s. s. 
On hydrothorax.
121
 organic affection which may  be suspected to have any influ-
ence in keeping up the disease, it  must not be delayed till
the water has been removed.  It will be more prudent, how-
ever, to introduce it through the medium of the surface ; or
if it be given internally it ought to be in small doses blended
with warm aromatics^ and opium if necessary.   The length of
time the mercury is to be continued will depend upon a variety
of circumstances which must be left to the judgment and discre-
tion of  the practitioner*   In those  eases where  a course of
calomel, crystals of tartar,  squills,  and foxglove are particu-
larly recommended, it will not only be necessary to begin with
it, but to continue its  use  for a great length of time after the
water has been evacuated and the disease has been apparently
cured.
  Except where the progress of the disease, or of any organic
affection connected with it, is very rapid, its effects will be
more certain and permanent by a gradual  introduction.   By
this  means the gums may be  kept slightly affected,  and the
habit under its moderate  influence  for a considerable time, a
precaution which is always advisable*   Instances have occur-
red where salivation either accidentally or intentionally induc-
ed has cured the disease;  but unless all other remedies have
failed, and there be some local tumour or disease which may
have resisted its ordinary  mode of exhibition, it should not
be carried so far, since it has been known sometimes to pro-
duce the disease.*  Without  the aid of mercury thus mana-
ged, though the water may be repeatedly  evacuated by the
other remedies, there  will be little  probability  of permanent
relief in most cases ;  even in those apparently arising from
mere debility, it should be directed in small doses internally
in combination  with tonics,  or introduced  into the surface in
the form of ointment saturated with camphor. .

                     Vide page 64 et  seq.
                           tr, 
12k
us hydrothorax.
   Such seems  to  be its extraordinary power over organic a£
 fection of almost every description,  that I have had strong
 grounds for believing,  ossifications of the valves of the heart
 have been considerably relieved or checked  in their progress,
 if not removed by it;  and we ought not! despair of affording
 considerable advantage under the most unpromising and even
 hopeless appearances by a due  perseverance  in  a  course of
 calomel judiciously blended with the other remedies treated
 of, according to the particular circumstances of every indi-
 vidual case.
   The  blue pill made  with turpentine would be  a good pre-
 paration if it could be depended upon-, but it is liable to so
 much variation of strength that I never use it; nor have I tried
 the Hydrarg. Muriat. as recommended by Dr. Cullen,  though
 I am disposed to judge favorably of it on so high  an authori-
 ty :  in solution, however, it is  extremely nauseous, and with-
out great care it is very apt to disorder the bowels in a solid
form.
   Blood letting.  To lay down V. S.  among the remedies  for
the cure of this disease may appear inconsistent with  the  ge-
neral principles held out; but however this may be, cases
will  sometimes  occur where it  may be  absolutely necessary,
and  where the safety,  nay even the life of the patient may
depend upon its timeJy use. Nor will  it be  found contrary on
 due consideration to the general plan recommended.  Such are
the causes  by which the distribution of the blood through the
body are influenced,that the best and most judicious practice of-
ten requires the abstraction of blood from certain parts, while
we are giving tone  and  perhaps stimulus to other parts, and to
the whole habit. Certain cases of apoplexy, asthma, congestions
 in the liver and other abdominal viscera, and of passive inflam-
mation, furnish examples of this.   While we are removing the
local congestion or accumulation by topical, and perhaps gene-
ral venesection and purgatives, and thus giving the vessels an 
OH HYDROTHORAX.
123
opportunity of recovering their contractility, it is perhaps ne-
cessary  to give strength and energy to  the whole  habit by
means of bark and other tonics, and to apply local stimu-
lants.
   In like manner such is the congestions and accumulation of
blood in the right side of the heart and in the head in some
cases of hydrothorax,  owing to the  interrupted circulation
through the lungs, that this operation may be absolutely ne-
cessary  to prevent suffocation.  This will be more  especially
necessary, if, together with a lived swollen aspect,  extremely
difficult respiration, and great distention of the jugular veins,
and those of the hands and  wrists, the pulse be full  and hard,
with strong palpitation of the heart.  A small quantity at a
time will be found sufficient j for very few hydropics will bear
the loss of much  blood.  The repetition will be according to
its effects in relieving urgent symptoms, in reducing the force
of the circulation  and the bodily strength.  The appearance
of the blood will seldom afford any just criterion to judge by,
for how full soever the pulse may be there will be little or no
buff on its surface, but the contrary, its texture being general-
ly loose, as was observed in case 4f.   Had the lancet been used
earlier in this,  and afterwards repeated, and had the patient
conformed more strictly to the plan recommended,  there were
grounds for hoping the event might have  been different,  or at
least that in this as well as the other cases where the pulse was
very full and hard,  life might have been prolonged by  occa-
sional bleedings.   But when these occurred to me  I was not
aware,  or did not recollect, that Hippocrates, and  other cele-
brated  writers had said on V. S. otherwise would  have used
the lancet with more freedom. Their remarks and cautions are
so much to the purpose that I shall transcribe them in this place.
   " Si  hydropicus difficulter spiraverit, et tempus vernura
fuerit, et simul astas viguerit et virium robur adsit. de brachio
sanguinem oportet.'*  Hippocr. de diret, acut. 
lM
OH HYDROTHORAX.
  "Vidimus hydropen viginti  curatura vena? sectionibus,
qui ab exhibitis hydragogis et  diureticis, cujusvis generis,
magis ac magis intumuerit."   Sponius aph.  Nov. Sect,  v,
87.
  " Hydropen anasarca per V. S. curare quandoque opus est.
Si jecur non solum, sed et lien ac ventriculus tumorem ac du-
ritiem habeat, confidenter educ per exiguas missiones sangui-
nem, tantoque id magis, si  vires non prohibeant, et copia san-
guinis in venis manifesta, et aegrotus in flore aetatis constitutus
sit, nee terupus anni magnum frigus aiferat."  Alexandr. Tral-
lian.
  " Curantes initium facimus in anasarca ab evacuatione per
V. S. maxime si ab haemorrhoidum, aut menstrua; purgationis
suppressionero conflata fuerit affectio,"   Paulus jEgineta Lib.
iii. cap. 48.
  " In leucophlegmatia et anasarca, si status adsit plethoricus,
atque ab asthmate sanguineo hax mala prascipuam duxerint
originem.    Venae sectionem ad  curationem momentum  af-
ferre."  Hoffman, Med. Rat. vol. vij. p. 453.  et seq. De hy-
drope.
  In  Home's clinical experiments* a case of dropsy is  men-
tioned  where the patient was cured by seven bleedings in the
course of eighteen days.
  There can be little doubt therefore that circumstances will
sometimes occur where bleeding may be practised with per-
fect safety and advantage.
  If there  be a violent cough with expectoration of blood, a
full hard pulse, great dyspnoea, and more  particularly  if the
strength has not been much reduced a vein may be opened
without hesitation, with every prospect of immediate relief.
  In a few happy instances the cure may be said to be com-
pleted  after the water has  been evacuated.  In  by far the
greater number,  however, the most  important  part of the
'* P. 346. see also Appendix No. ij. case 5 
ON HYDROTHORAX.
125
work remains yet  to  be performed.  The practitioner will
have the mortification of seeing it again accumulate, probably
in no long time after withdrawing his remedies.   Hence the
necessity of nice and  accurate discrimination in ascertaining
all  the causes and  circumstances connected with  its effusion,
since the ultimate  success will greatly depend upon the skill
and judgment displayed in adapting the curative means to the
removal of these after they have been discovered.
  If there be no reason to suspect a fixed disease of any organ,
that weakness and relaxation of the solids, and its usual conco-
mitants, tenuity of  the blood, are  the only remaining evils to,
contend with, the judicious application of tonics and diuretics
together  with appropriate regimen should be persisted  iu
with unremitting atteuiion till the general strength be restor-
ed.  The tonics which appear suited to this disease are few.
Those to which I have given a preference are the light infu-
sions of gention,  or Colombo, in combination with steel and
myrrh as in No. 8  and 9.
   When there is a  hard dry cough with viscid expectoration,
the vegetable decoctions and infusions are scarcely admissible.
Steel  and  myrrh, however, in conjunction with the balsams,
may be had recourse to with advantage.*
   These will indeed be found the best suited as  tonics to all
circumstances and  states of this  disease.  There are a few
cases, however, or rather stages in which experience has ena-
bled me to ascertain they ought not be given.  In those ha-
bits where the complexion was of a dark red before the  at-
tack, where now it  exhibits a  dark livid or purple hue, where
the hands, legs, and feet are livid,  and the latter probably
hard and tense, and the veins appear  distended with  black
blood,  tonics of every description will  prove injurious till
these symptoms have  been removed, which will sometimes
happen when the water in the chest has been carried off, and
* No. 12 and 13. 
120
OH HYDROTHORAX*
the consequent interruption to respiration relieved.  But m>
such subjects have been  generally very corpulent before the
disease, and often continue so after the water has been remov-
ed, the complexion and of course the blood remains of a dark
red colour, a state which, there is reason to believe, is not fa->
vourable to the exhibition of the preparations of iron.   If they
should not succeed, the mineral acids, especially  the nitrous
acid may be tried with the probability of advantage.
  In circumstances the reverse of those mentioned, when the
complexion is unusually pale, the blood is thin, poor, and small
in quantity, the whole body is much reduced, and the skin of
the anasarcous limbs, if there be any swellings, is soft, smooth,
pale, or transparent,  readily receiving and retaining the im-
pression of the finger, and  where probably profuse haemorr-
hages have contributed to the production of the disease, Steel
medicines will prove highly beneficial, and should therefore
have a decided preference over all others of this class.  It is to
be remarked that iu all cases where the  action of the heart
and lungs has been much interrupted, by the pressure of the
water, the complexion is more or less livid and  the  venous
blood is dark; but as soon as the pressure is removed and the
blood circulates with freedom, both will assume their charac-
teristic  paleness in such  delicate subjects, and this medicine
may be used without hesitation.
   The  best preparation is the ferrum Vitriolatum  decom-
pounded by the Kali pp. conjoined with myrrh in the form of
pills.*  The ingredients should be minutely divided and in-
corporated  so that the iron  may be completely disengaged,
and the acid unite with the alkali to form a Kali Vitriolatum.
   This compound, which is now universally used  in this coun-
try, and which appears to have been first introduced into no-
tice by the late Dr.  Moses Griffiths, is  a valuable medicine,
and possesses advantages  in this form which no* other prepara-
* No. 9. 
OS HYDROTHORAX,
127
 Hon of iron does.   The saline impregnation tends to promote
 the urinary secretion, to keep the  body open, and  to  allay
 those febrile irritations under which it is sometimes necessary
 to prescribe this medicine,  and which other tonics  generally
 increase.  It is so extremely nauseous, however, in the form
 of mixture, especially with the addition of myrrh* as recom-
 mended  by Dr. Griffiths,  that  I  very seldom  prescribe it
 The water of  crystallisation soon evaporates during the rub-
 bing,  so that  the ingredients incorporate very readily  into
 pills.
    There is something peculiar in the operation of the prepa-
 rations  of iron, which renders them  better suited to certain
 morbid states of the constitution than other tonics.   When Ave
 wish a sudden change to be made  on the solids, comprehend-
, ing the muscular and nervous parts of our frame, with a view
 of preventing the return of an aguish paroxysm, that of cer-
 tain other affections which come on  periodically, or of stop
 £ing the progress of mortification, the different kinds of cin-
 chona are the  best substances yet known suited to answer our
 Views; but where a slow and gradual change is to be effected
 both on the  solids and fluids, as in chlorosis, various other in-
 stances of cachexia, even in the debility remaining after differ-
 ent acute affections, as well as in that of which I am now
 treating, though they are too frequently resorted to, are  ne
 vertheless very ill calculated  to attain the  ends proposed.
 Unless a certain quantity of the  bark produces these change?
 speedily it will  be vain to persevere in it for a great length of
 time; and indeed it often proves injurious  by laying the
 foundation of those  visceral obstructions and indurations con-
 sequent upon long continued agues that are said to have  re-
 sisted the use of the bark.  It should therefore  be increased
 to the fullest extent the stomach is capable of bearing, and un-
 less it then succeeds in a lew days, it will very seldom succeed
 at all 
128
ON HVDR01H0RAZ
   The operation of steel medicines, however,  is directiy ti.«
reverse : they effect a slow and  gradual change on  the solid*
and fluids, by increasing the tone of the former, and enriching
the  blood and consequently rendering it fitter for the purpos-
es of the animal ceconomy.   Hence the necessity of persevering
in their use for some time before any material advantage is to
be expected.   It will be found more convenient to begin with
a moderate dose and to increase it gradually as may be found
necessary.
   But though I  disapprove  of the bark as a tonic in this  dis-
ease I have thought the bitter iufusions* either in conjunction
with or without  iron  highly  beneficial.   By  imparting their
tonic influence to the stomach more quickly than iron appears
to do, without any of the inconveniences attending the differ-
ent kinds of the  cinchona,  and thereby increasing the  appe-
tite, they may be had  recourse  to with every prospect of ad-
vantage in most  of those cases for which steel is calculated, in
combination with it and alkaline salts, f

  + As No. 8.
  f Here I may be permitted to remark that I have been in the habit of
prescribing the oxyd or precipitate of iron for several years with the best
effects in certain cases and circumstances where the other preparations
of this metal disagreed, or could not, from their nauseous taste, be admi-
nistered.  In many  instances  of chlorosis, for which this medicine ap-
proaches to the nature of what is termed a specific, I found,  in delicate
females with very irritable bowels, that the decompounded ferrum acted
as a purgative, and could not be retained in such  quantities as to do any
good, that the common preparations were resorted to with no better suc-
cess; and it appearing to me that the pills which are called Dr. Austin's
chalybeate pills were an oxyd of iron, I prepared considerable quantities
by dissolving certain portions of the ferrum Vitrioiatum and Kali pp. in
water, mixed them  together, then passed them  through filtering paper
and dried the precipitated iron which remained behind for use.  I  Crst
prescribed  it both in pills, and suspended in  a watery menstruum by
means of mucilage, for the paupers who came for my advice, and  fur-
nished them with the medicine, preferring the latter form because it  was 
ON HYDROTHORAX.
129
   Opiates,   When the cough is  so extremely urgent, as some-
times happens, as to prevent sleep and to aggravate every oth-
er symptom, may be given with advantage combined with
squills and other expectorants.
   Dr. Mead mentions an inveterate case of ascites accompani-
ed with tympanitis  and a very  acute pain in the right hypo-
chondrium, which was cured by  40 drops of Laudanum, taken
at bed time and repeated, octava quaque hora, after the usual
remedies had failed.*   After the water was evacuated, the
styrax pill, Peruvian  bark) and chia turpentine were given to
complete the cure.
   The tinct. opii Camph* will be found a good preparation in
such cases.
   Elaterium.   The  various remedies and combinations of
which I have treated having succeeded in answering all the
purposes which could  reasonably  be expected,  beyond my

more easily prepared. Finding it fully answered my expectations I re*
commended it to some medical friends by a few of whom it was used.
   This medicine is  particularly adapted for young subjects and children
in all those complaints of cachexia and debility for which the prepara-
tions of iron have  been  found  useful, except under the circumstances
pointed out,  from the great  facility with which it may be administered.
It is often extremely difficult, sometimes impossible, to persuade children
to take a quantity sufficient to do any  good, of the tonics or bitters, in or-
dinary use;  whereas the dose of this medicine is so small, that it may
be mixed insufficient quantity in their food without detection, to answer
all the purposes intended.  I have frequently succeeded where there was
reason to apprehend the  child would have been lost without it.  f n rick-
ets, in worms, in the incipient, sometimes in the advanced, stages of me*
senteric obstructions, in those complaints of children accompanied with
either internal or external glandular obstructions, and a tumid abdomen ;
in short in all complaints  of debility where tonics are admissible, this me-
dicine will be found highly useful.  But where a  diuretic effect is at the
same time required, and there is a disposition to constipation  the com-
pound preparation may be preferable.
   * Vide Monit. ct Prsec. Med. p. 141. also append. No. ij
                            17 
130
Oil HYDROTHORAX
most  sanguine  expectations,  I have very seldom prescribed
this remedy, yet from the few trials which I have made I am
inclined  to think might be found useful  in certain cases, cau-
tiously administered  in  combination  with other remedies,
more especially in those in which the digitalis  may have fail-
ed.  In one instance of this kind, Mrs. Chandler's case,* life
appeared to have been protracted for a considerable time by
the immense quantities of water which were carried off by the
bowels every time it was given;  but in this, Hoffman's judi-
cious remark, that the  water would accumulate more rapidly
after drastic purgatives,  was fully  verified.
   Gamboge may be rendered perfectly mild by minute tri-
turation  and union with  the saline laxatives and diuretics al-
ready mentioned, and prove useful under circumstances of ve-
ry great  torpor of the  bowels;  but  without such precau-
tions, it ought  to be rejected from the  catalogue of remedies
suited to this disease.
   Paracentesis.  This operation  being  almost the  only re-
source of the  ancients it was strenuously recommended by
some and boldly performed by others;  while a third class la-
mented and complained  that the patient should be abandon-
ed to certain death when he could be so readily relieved and
cured by drawing off the water: a few, however, have  con-
demned it  from its  proving either generally unsuccessful or
fatal.  Those who are desirous of knowing what has been
said  on this subject both by the ancient and some modern
writers, will meet with curious and interesting information in
Hippocrates,f Bianchi,J  Senac,H Morand,$ Du Verney,1[ La

  * Append. No. 1.
  f De Morbis Lib. II. cap. xxiv. Chart. Tom. vij. pag, 576
  X Histor. Hepat. T. i. p. 662.
  || Traite de la Struct, du Coeur. T.  ii. p. 366.
  5 Mem. de 1'Acad. de Chirurg. T. ii. p. 547.
   I Acad, de Sciences L'An. 1703, Mem. p. 199 
OH HYDROTHORAX.
131
Motte,*  Barrere,f Hoffman,! and others  who  have written
fully upon it.
  From  what has been caid in the preceding observations it
will not be expected that I should be an advocate for this op-
eration when the water can  be so readily removed in almost
every instance by the means recommended.   A few  eases may
occur, however,  such as when the water is contained in a sac,
as in case 39, and in one mentioned by Hoffman|| in  which he
laments the operation was not submitted to; or when there is
reason, from the preceding  history, to  suspect the  fluid is
thick, of a gelatinous or purulent nature, where its absorption
may not  easily be accomplished, in which it may be necessary
to call in the aid of surgery to draw it off.
   I have thus laid down the general indications of cure in this
formidable  disease,  and pointed out the  means by which
these might be fulfilled; and have judged it necessary not on-
ly to enter minutely into the history of particular remedies,
but to  give the formulae or combinations in which they were
found successful.   While this last is intended more immedi-
ately for  young  practitioners, it is hoped men of experience
may derive some useful hints from it.
   To lay  down such minute rules as will apply to every indi-
vidual case which may occur is extremely difficult if not im-
possible.  The kind, combination, and doses of medicines, the
intervals of  repetition, and the length of time they are to  be
continued, must  necessarily be left to  the judgment of the
practitioner.  Hence the results of the same mode of treatment
in this and other diseases will  be different under different
medical men.

  * Traite compl. de chirurgie, T. ii. p. 189.
  \ Obs. Anat. pag. 99,       J Vol. vij. p. 473       || Ibid, 
132
ON HYDROTHORAX.
    The  author is encouraged to hope, from what he has ad«
 vanced  in the foregoing pages, that the practitioner will sel-
 dom be at a loss; and rather than dwell any farther on this
 part of  the subject, he begs to refer the reader to the cases in
 appendix  No.  1. more especially those which  occurred in his
 practice since the year 1796, in which it will be seen the  prii*.
 ciples he has recommended are successfully applied in prac-
 tice.
   One of the principal difficulties he has had to contend  with
 was to persuade the patient that the cure was  not completed
 and  that another disease yet remained after  the water was
 evacuated.  Finding himself relieved from all  his sufferings,
 one or more relapses was sometimes necessary to convince him
 that he must conform  strictly  to a proper course of medicine
 aad  regimen afterwards to insure lasting benefit.  Some of
 those whose cases are annexed, and who ultimately fell victims
 to the disease, might, he is confident, be now numbered among
 the living, and the lives of others protracted, could they have
 been prevailed on to attend to the restrictions enjoined, or to
 abandon the career of intemperance  which gave rise to the
 disorder.
   I now come  to the  consideration of a part of  the subject
 which I deem  of the  first importance in all chronic diseas-
 es, but which  is  often but little attended to, namely, re-
 gimen.

                        SECT. IV.

                        Regimen.

   1.  Diet. Though in many acute diseases, success may de-
pend in a great degree on the judicious application of active
remedies, yet in by  far the greater number of chronic ail-
ments, medicine derives infinite advantage from an appropri- 
ON HYDROTHORAX.
133
ate and judioiously regulated regimen.  The valetudinarian;
he whose  constitution has been broken down by a career of
intemperance, or by repeated  attacks of disease, and who is
perpetually  assailed by a variety of chronic affections, may
derive occasional relief from medicine ; but he deceives him-
self if he look for permanent health without rigid attention to
suitable regimen.  In the disease of u hich  I am now treating,
this will be found particularly necessary.
   That  food which contains the greatest  quantity of  nutri-
ment in the smallest bulk, and which requires, at the  same
time,  the least  effort of the digestive organs to  convert into
animal juices, reason and experience point out as the best in
this disease.   While former habits must to a certain extent
be suffered to influence the choice, light animal food in a solid
form, or,  under extreme weakness of the stomach, its simple
essences in the form of soups or broth.6, will be found the best
suited to the generality of cases and constitutions, when the
presence of fever or other accidental circumstance,  does not
forbid its use.
   Meat preserved in a cool temperature until it becomes per-
fectly tender, is much higher flavoured, easier of digestion, and
consequently more  nutricious than when dressed early: this
is well known to the epicure;  and so convinced I am of it
from ample observation, that to my  dispeptic patients I lay
considerable stress on it.  I have known instances of dispepsia
arise from the  food in" daily use consisting principally of
meat that had been recently killed, and eat without due mas-
tication, in persons engaged in active occupations, who do not
allow themselves sufficient time at their meals;  as well as in
those who have  had the misfortune of losing their teeth at an
early period of life; and the cure has been greatly facilitated
by the use of meat made tender by long keeping, assisted by
diligent mastication.  When the powers of digestion and assi-
milation are weak, and more especially when, with this, there 
134
ON HYDROTHORAX.
is general debilily, every auxiliary ought to be called in.  I
do not mean to infer that meat thus kept acquires any ad-
ditional  nutritive properties;  I only  wish it to be under,
stood that by being in a state more readily acted on by the
solvent powers of the gastric fluid, it will be more completely
converted into animal juices, and  that the habit must neces-
sarily receive a greater supply of nutriment, with less exertion
of the stomach.
   The flesh of animals that have attained their full growth
and  maturity contrary  to the commonly  received opinion,
especially beef, mutton,  venison, and  game, yield much more
nutriment, and  are easier of digestion, than  that of young.
Roasted  meats,  there  is reason  to  believe are  lighter than
boiled ;  and the more they contain of the animal juices, the
more nutritious.  When, by over-roasting, these are  evapor-
ated, and the fibre is dry and hard, it becomes proportionably
less nutritive and  requires a more vigorous stomach to act on
it.   Hence meat under done claims a decided preference,
Pork and veal are only adapted to strong healthy stomachs,
whose gastric juices possess active solvent powers.
   It is supposed by many eminent practitioners that the gela-
tinous or coagulable parts of animals,  extracted by boiling
from the ligamentous and membranous portions of their bo-
dies, are the most nutritious: hence they have been generally
preferred in circumstances of debility, more especially of the
organs concerned in  digestion. • This opinion has long ap-
peared  to me to be erroneous.  That these substances, whe-
ther they be used in their solid, or gelatinous state, are lighter
and more readily assimilated, and converted into animal juices
and that for this reason  they are better adapted for weak de*
licate stomachs which are incapable  of digesting the more  so-
lid,  and stimulating parts of the flesh of animals, I readily ad-
mit.  But if we wish to place the constitution in the most fa»
vourable state for performing long continued laborious mus- 
ON HYDROTHORAX.
135
cular exertion, we shall not, I  presume, advise a course of ani-
mal jellies or the substances from which they are extracted,
but the muscular parts, so prepared that  the nutritive juices
are not evaporated or exhausted.  This fact is well known to
those who are  employed  in training  persons for walking or
running considerable distances in a given time.  They will
allow  their patient no other food than beef steaks  at all his
meals, with no  more liquid than is necessary to their proper
and  ready solution in the stomach, consisting generally of por-
ter or ale, as being at the same time highly nutritious.
   For these reasons then in this disease,  and indeed in all
chronic affections, as soon as the stomach  is capable of receiv-
ing solid  food, I recommend  a diet consisting principally of
the  flesh of animals that have attained their full growth.   It
has this advantage  too, that  by being gradually dissolved in
the stomach, assimulated and  conveyed to the blood, its ef-
fects are more durable ; whereas  when jellies  or broths are
used, by being quickly imparted to the  circulating mass,
their effects are very transient; and a sense of faintness  and
sinking comes on when the stomach is empty which requires
a frequent supply ;  but  from their viscid glutinous qualities
the  consequences too often   are, that they either  clog  the
stomach, disorder the bowels, and by keeping the vessels in a
state of perpetual distention,  dispose so much  to inordinate
biliary secretion, as to prove extremely injuri >us.
   The food should be well masticated, and the free motion of
the  diaphragm never interrupted by  a full meal.  I am not
however an advocate for the practice of, " eating a  little and
often/' so universally inculcated, as well by medical men, as
by nurses and many others, except under certain limitations
and restrictions. 1  have repeatedly observed  serious inconve-
nience from it.   Under circumstances of general debility the
quantity of food introduced  into the stomach  at  one  time
should never be so considerable as to occasion a sense of weight 
J 36
ON HYDROIHORAX.
or oppression ; and if solid, by diligent mastication, it should
be divided, and subjected to the salutary iufluence of the saliva
which is undoubtedly a powerful auxilary to the gastric, and
other juices it meets with in the stomach and P. V.   The sen-
sations of the patient will be the best guide, and not the ar-
bitrary injunctions too generally  imposed by the practitioner.
While the stomach  feels full and oppressed, without any in"
clination  for food,  it  may be  inferred that it  is not in a fit
condition for receiving or digesting any.  Agreeably to a ge-
neral law of muscular action, the stomach, which may be said
to be a hollow  muscle,  should be suffered to empty itself at
certain periods, so as, comparatively, to be under little  or no
exertion  or distention, in order to fit it,  like  other muscles, for
its healthy functions.   If after the food has passed the P. V.
the inclination  do not again return, it will be vain, nay it will
be defeating  the real intention, to  throw any more  into the
stomach.   Nature will in this instance, as on other occasions,
be the best guide.   If this organ be kept continually more or
less on the stretch by the  introduction of some article of food,
be it ever so small, every hour or half hour its powers will be
weakened and the gastric  fluid will possess little activity.  In
general, the best  rule will  be, to eat only  when hungry, or
when inclination prompts to it.
  Vegetables of every  kind should be sparingly used ; and
such as  are of a cold flatulent nature  should be intirely re-
jected.   The farinacious  vegetables, especially rice, may be
fully allowed.
  2. Drink  The advantages  of free dilution in dropsy have
been already mentioned.   As soon as the cure has  been at-
tempted by the means, and on the principles recommended,
the quantity of liquid usually drank should gradually be in-
creased.   The  kind or quality, however, should  be such as is
known by experience to be readily  determined to the urinary
organs; yet, if possible, such as is at the same time grateful to 
ON HYDROTHORAX.
m
the stomach, and not of a cold, debilitating, or relaxing nature.
On these grounds,  therefore, and for the reasons already fully
stated, I never give my sanction to the use of beer or porter.
In all diseases of languid or defective absorption, or secretion,
or where there is  any  tendency, either from these or  other
causes, to glandular obstruction, I am convinced of their per-
nicious tendency, from  ample experience.  But  the interdic-
tion is often unnecessary; for  many of my patients who were
so extremely partial to  their  home brewed ale, that they fan-
cied they could not live without it,  have declared that they
have long been obliged  to discontinue it in consequence of the
sense of oppression it occasioned about the stomach,  or to use
their own words, " because it blows me out so."
   If the  food consist of solid nutritive, chiefly animal substan-
ces, all that will be required in the generality of instances, if
the digestive  organs  be not very considerably  weakened, is
watery drinks to dilute  and convey it to the circulating mass.
But if the stomach have been accustomed to the free use of
strong stimuli, more especially if its tone have been materially
injured and the disease  induced  by their unbounded use, it
must be  gratefully stimulated by a glass or two of old gener-
ous wine, such as madeira, sherry, or hock.
   In the Edinburgh Infirmary  a  very excellent plan has been
for some years  adopted in dropsical cases.  As soon as the cure
has  been attempted the patient is allowed to drink freely of
whiskey punch, from a quart to four pints a day.   This is I
believe, usually audulated with lemon juice.  I generally di-
rect cream of tartar in preference, and a portion of sliced gin-
ger to be added as in No. 5.  To  those who have not been
accustomed to spirits, wine will be more grateful.
   Certain native mineral,  and especially chalybeate, waters
are peculiarly  adapted to dropsical patients; while they im-
part a grateful but gentle stimulus to the stomach they deter-
mine in a powerful degree  to the kidneys and other secretions
                           IS 
138
ON HYDROTHORAX.
also;  and when they can be had at the fountain head may be
used with freedom ;* but as the elastic gases, on which their
virtues  partly depend,  evaporate by  keeping, they may be
well imitated by art.  The soda and artificial seltzer water
prepared by Schwepp ; or that prepared in the common ap-
paratus, with a small portion  of the fixed vegetable or fossil
alkali may be substituted with advantage.   A small quantity
of iron may be added or not as may appear neeessary.
   The virtues attributed to certain  waters,  I  am  persuaded,
depend solely  on their purity ;  for the more they approximate
to a simple  elementary body or the less earthy or other extra-
neous particles they contain, the more  readily are they taken
up by the  lacteals, and the more quickly determined to the
kidneys and other  excretory  vessels.  It is highly probable
that to this circumstance the efficacy  of the Bristol water i»
chiefly to be ascribed, if any  efficacy may  truly be ascribed
to it, as has of late been ascertained with regard to the Ilkley
spaw.  This spring so  long celebrated for the cure of various
disorders has  been subjected to chemical analysis by Dr.
Mossman,  and found to differ from common water only by
being much  purer or  more free from  heterogenous earthy
particles.   Large  quantities  of Jh.ese  waters drank at the
spring have been found to promote in a remarkable degree the
urinary secretion; and on  the same principle that they pos-
sess these effects it may, by parity of reasoning, be concluded
that they pervade in a similar  way the other minute secretory
vessels also, since it is known that no ingredient either in a sim-
 ple or compound  state, enter their composition likely to possess
any specific effects onthe kidneys.   Hence their virtues also in

   * On this subject Dr. Saunders' valuable work on the medical powers of
 mineral Waters may be consulted with infinite advantage.   The Sedlitz,
 the Caroline  or Carlsbad waters in  Bohemia were celebrated in the cure
 of dropsy by Hoffman on account of their diuretic and aperient qualities.
 vol. vij. p. 449.  Some of these increase perspiration as well as all th»
 secretions,. 
ON HVDROTHORAX,
139
sehrophulous and other glandular affections.  Either of these
di.'ut ng substances, therefore, may not only be freely indulged
in during,  but likewise  between meals.   From the prejudice
which still too generally prevails against the frequent use of
liquids in dropsy, sometimes from the uneasiness occasioned by
distention,  I have often  found it difficult to prevail on the pa-
tient to  drink the quantity which was judged absolutely ne-
cessary, experience having  already  assured  him  that " the
more he drank the more he filled" or increased in si?e ;  and
it is not easy to convince him to the  contrary.  To my great
disappointment I have often found on my second visit to the
patient that my injunctions had in  this respect been totally
disregarded.
   As soon as the water  has been evacuated the patient should
return gradually to his ordinary quantity of liquids.
   3. Exercise. Before the evacuation of the water the patient's
situation seldom admits  of much bodily exertion. Much how-
ever may be done  by the diligent use of the flesh brush, or
by friction with flannel all over the body, but especially  over
the chest as near the seat  of the complaint as possible.   Be-
side exciting and preserving a  comfortable warmth in these
parts they  prove excellent auxiliaries in  promoting  lymphatic
absorption, and general  circulation.  They should be usedr at
least every evening and  morning: to  the feet and legs much
oftener, these parts being in general  cold from the languid
circulation of blood through them.
   As soon as the evacuation of the water or the relief of urgent
symptoms will permit,  no day  should elapse without the pa-
tient either walking, riding on horseback or in an open car-
riage.  The frequent but gentle agitation of the body, $nd
the  moderate exertion of the muscles, together with the salu-
tary influence of a pure healthy atmosphere assist  greatly in
giving tone, vigour,  and energy  to the whole frame.   The
lungs of some persons under hydrothorax  are extremely sus- 
140
ON HYDROTHORAX,
ceptible  of a cold frosty air ; it being no sooner respired than
they are  seized with a cough and wheezing, and experience a
painful  sense of constriction  about the chest.   Under such
circumstances it will be better to keep within doors.
  To the steady uniform  perseverance of the subject of  case
18 in the regimen laid down, is  his recovery as much to be at-
tributed as  to medicine;  and many of those whose cases are
recorded, now numbered among the dead, might  have expe-
rienced similar benefit had they conformed to the  restrictions
enjoined.
   The general coldness of the bodies, the languid circulation
in the extremities, of dropsical subjects, and the total want of
perspiration, point out the necessity of warm clothing.  Flan-
nel should always be  used next the body;  and thick woollen
or worsted  stockings will  be found indispensably necessary,
sometimes even with the addition of flannel socks,  in order, if
possible,  to  preserve an  uniform and permanent  warmth
throughout  the body. My patients have repeatedly expressed
the great comfort they experienced  from the change it was
invariably thought necessary to make in their dress, especial-
ly in winter.
   There is no case in which a  flannel covering is  so strongly
indicated, is so beneficial, and so grateful to  the sensations of
the patient  as  in dropsy, especially that of the chest, in
which intense coldness, and languid circulation of the blood
in the lower extremities exist in a greater degree than in any
other.
  In short every means which experience has sanctioned as
likely to  give strength and tone, and to keep up a vigorous cir-
culation  and absorption, should be diligently practised not on-
ly under the  disease, but for  ever  afterwards, if the enjoy-
ment of permanent health be looked for.
   Having now finished  what I  have thought necessary to say
an the cure, I have no hesitation in affirming that if the gene- 
ON H SEROTHORAX.
141
 ral plan which experience has enabled me to recommend, be
 directed with skill and judgment, scarcely a case will occur
 in which the water may not only be evacuated, but a perma-
 nent cure performed, if the constitution be not  already nearly
 exhausted by the causes mentioned, or if the  disease do not
 proceed from certain morbid  alteration of structure, hitherto
 found to be beyond the reach of our art.
   Of Ascites, Encysted dropsy, Anasarca, and  all other kinds
 of dropsy.
   Although the foregoing observations have  been confined
 chiefly to dropsy of the chest, yet the principles and the prac-
 tice inculcated, m ill be found to apply alike to every species
 of dropsy, and with success to the greater number.
   Ascites, and encysted dropsy, acknowledged  to be the most
 difficult of cure, will  generally yield to them in the  early
 stages, and often when far advanced and confirmed.   When
 in ascites the abdomen is  considerably distended, (a circum-
 stance which ought never to  be suffered) as the difficulty of
 evacuating  by the natural outlets will be proportionably in-
 creased, the w ater  should first be  drawn off by tapping, and
 the  cure by  medicine  attempted  immediately afterwards.
 The absorbents will be acted upon at this time with more fa-
 cility than at any other period.
   In encysted  dropsy and ascites a combination  of calomel,
squills, digitalis, and crystals of tartar, as directed in No. 4,
 5, and 7, persevered in for a great length of time, until  the
mouth be fully affected by the mercury,  will insure the best
chance of success; but in these kinds, more perhaps than any
other, the difficulty increases  with  the disease; and no  reli
ance is to be placed on the foxglove alone in either, though it
is more than probable that it assists materially the salutary
operation of the other remedies.   Two cases 5 and 6* of asci-

  * One of the patients is now living and in good health; and the other
was well a few years since ; of late  I have not heard of  her.
  Sept. 1808. 
142
ON HYDROTHORAX.
 tes combined probably w ith encysted dropsy are inserted in
 appendix No. 1. in order to shew the efficacy of the combi-
 nations recommended, without the aid  of digitalis.  They
 occurred early in my practice, in  the  year 1792, before I was
 in the habit of prescribing  this herb  regularly, and before I
 had much experience in dropsy.

                        SECT. V.

  Conjectures and observations on the mode of operation of the
                        foxglove.

   In order to advance our knowledge, and to form a correct
judgment on this subject, it seems necessary, first, to point out
 its obvious and sensible effects on the  body:
   Those which I have observed are as follow,
   1.  On the head or sensorium.   Vertigo or giddiness, head-
 ach, or throbbing of the temples, forehead,  or in the bottom
 of the orbits; stupor, sometimes  delirium, or interruption of
 the intellectual functions; imperfect or depraved vision.
   2.  On the heart, arteries, and vital  organs..  Reduction of
 the number of contractions of the heart, and consequently of
 the pulsations of the arteries; frequently an intermission, ir-
 regularity, sometimes an increased quickness of the same, with
 diminished force.  Relief  at  times  of  difficult, spasmodic
 breathing and cough.
   3.  On the stoinach.  Nausea, sickness, and vomiting of the
 most distressing kind, being usually accompanied with a pecu-
 liar  faintness, and sense of sinking, expressed by  the patientf,
 tf as if his life were going," different  from that experienced
 from any other substance; sometimes  copious water discharg-
 es brought up without sickness or effort to vomit.
   4.  On the bowels.   Under certain circumstances very pro-
 fuse watery evacuations, without  pain or  griping, but with 
ON HYDROTHORAX.
14S
greater and more sudden prostration of strength than happens
from the most drastic purgatives.
   5. On the secretions, excretions, and absorbents.  Increased
flow of urine, sometimes veiy suddenly and profusely; also of
saliva, under the same circumstances which determine its ope-
ration on the bowels, namely in dropsical affections; under oth-
ers, no sensible effect, either on the kidneys, bowels, or salivary
glands, in the largest doses; that is, when there  are  no wa-
tery accumulations.  Restoration  of the functions of  the ab-
sorbents, when  impaired from  certain  morbid  causes, as in
many instances of dropsy ; but no sensible effect on these ves-
sels when impaired by others.  Probably diminished  exhala-
tion of serous fluids into cavities  in  dropsy; but no positive
evidence of this.
   6. On the general  habit.  Great languor, weakness, faint-
ness, coldness, and cold colliquative sweats.
   These were the common effects observed from full doses of
this herb in the various diseased states in  which it was pre-
scribed, which varied in degree, according to the disease, the
constitution, and the quantity administered. It was never tried
on healthy subjects in order to ascertain its effects.  Its con-
stant effects were those on the head, heart and arteries, sto-
mach and animal functions, which will occur under  all cir-
cumstances, in health as well as disease;  whereas those on the
secretions and excretions will arise only in particular circum-
stances, namely, when watery fluids are preternaturally effus-
ed in cavities.
   So contradictory and opposite do these effects  appear that,
as might be expected, the opinions of medical men are no less
at variance as to its mode of action on the body.   This  will be
best shewn by bringing  into one  view the sentiments of the
principal writers on the subject.
   Thus  Dr. Darwin;  " This medicine" meaning  the fox-
glove, "  by stimulating into inverted action the absorbents of 
144
ON HYDROIiioka::
the stomach, increase the direct action of the cellular lympha-
tics."  Art. iv. 2, 3, vol. ii. p. 718.
  " From the great stimulus of this medicine, the stomach is
rendered torpid, with consequent sickness,  which continues
many hours,  and even days, owing to the great exhaustion of
its sensorial power of irritation ; and the actifln of the heart
and arteries  become feeble from the deficient excitement of
the sensorial power of association ; and  lastly  the  ab Gorbents
of the cellular membrane act more violently in consequence of
the accumulation of the sensorial power of  association in the
torpid heart and arteries, as explained in Suppl. i. 12. p. 719."
And farther,
  " But there is reason to believe, that the stronger emetics, as
digitalis, first stimulate the absorbent vessels of the stomach
into greater action, and that the inverted motions of these ab-
sorbents next occur, pouring  the lymph, lately taken up, or
obtained from the other lymphatic branches into the stomach."
p. 740. Art. v. 2.
  And  end  of the same paragraph,—" While the action of
vomiting from digitalis is owing to deficiency of sensorial pow-
er,  which  is previously exhausted by the excess of its stimu-
lus."  p. 741.
  " Digitalis, in carefully regulated doses," says Dr. Beddoes,
" that is, so administered as not to induce sickness or langour,
very regularly increases the momentum of the blood.  In this
view  therefore it is contrary to a sedative.  Of the fact here
stated, I think myself more certain for the following reasons.
It had long,  (as I have publicly stated) appeared to me prac-
ticable to acquire measures of irritability and  sensibility, par-
ticularly of the former.   I  apposed that an instrument might
be so constructed, as when  applied to some artery, to shew the
force of its stroke."   See to the end of the two next sentences,
after which he thus proceeds; " Having observed how great
ly the appetite of many phthisical patients increased  under 
on Hydrothorax.
145
the use of simple digitalis,  I have given  it in several cases of
dyspepsia, and with the best effect.   The appetite having in-
creased in these cases, and the symptoms of indigestion having
disappeared, I conclude, without imputing to it superior quali-
ties of this kind, that digitalis will increase the power of the
stomach.  In the production of languor, of excess of sensibility;
headach, and bilious vomiting digitalis seems greatly to resem-
ble opium.   I have known digitalis occasion an increase of
the pulse from 76 to 120 with heat of the skin, and headach.
In two instances I believed it to  produce feverishness with a
peculiar mottled appearance of the whole skirt.   In one person
a sort of intoxication so repeatedly followed a dose of 14 drops
of the Tincture, taken twice a day, for two or three days, that
I could  entertain no doubt  as to the cause.   If therefore I
were to exhibit the Materia Medica on a map, I should repre-
sent digitalis as not merely  touching on opium, but bordering
upon it for some space.   In another part it should be contigu-
ous to the vegetable tonics or bitters."  And farther,
   " Whatever may be the justness of these ideas, I hope I have
brought together enough to induce those to pause who may be
tempted  to argue from a decreased number of pulsations to a
decrease  of living action, and from  this to the  propriety of
employing digitalis in the height of inflammatory orgasm.  In
pleurisy, if any one should be mad or wicked enough to forego
the so certain resource of the lancet in favour  of the sedative
virtues of digitalis alone, he would I apprehend, increase the
disease, if he confined himself to moderate doses.  If with di-
gitalis, he employs copious  bleeding,  his  practice will not ad
mit of reasoning, as  the benefit from the  operation may  mask
the mischief from  the medicine.  Perhaps  from the peculiar
susceptibility of the system, this mischief will be more than
may be apprehended from  experience of states not inflamma-
tory.  It is possible that immense doses,  by rendering the pe-
riod of excitement evanescent, might produce the desired ef-
                            19 
,115                 ON hydrothorax.
 feet.  On this principle, opium may be sovereign in pleurisy.
 But I know not who would feel himself justified in proceeding
 on such a principle.  If any one bold  enough can be found,
 it is fit that he be clearly given to understand what he is risk-
 ing."  On the management of consumption,
   Dr. Drake in his very judicious remarks prefixed to the two
 interesting cases of Grimes and Marris does not positively say
 whether he regards it as a stimulus or as a sedative, yet when
 we consider the views with which he  preset ibed it, and the
 treatment of the patients in other Fespects, I am disposed to
 infer he considers it. as a sedative.
   " It has been lately maintained " says he" by the most ce-
 lebrated  physiologists  among whom  John Hunter stands
 foremost, that pus is a secreted fluid, the consequence of cer-
 tain diseased motions of the extremities of the blood vessels;
 it has  been  likewise ascertained, that hectic fever arises  only
from the  matter of an open ulcer ; that  what is termed lauda-
 ble pus, when secluded from the air, is neither capable of cre-
 ating fever, nor, except  by its gravity, can  it irritate the parts
 on which it rests.   When  pus, however, is exposed to atmos-
 pheric air,  it rapidly attracts  oxygen ; an acid of a peculiar
 kind is generated, and hectic fever,  the  effect of absorption of
 aerated matter is produced."
  " Mow as an ulcer, of the Jungs is perpetually exposed to a
 stream of air, and of course an  ichorous poison is continually
forming by the union of oxygen with secreted  matter, an im-
 portant^ curative process would seem to arise from promoting
absorption so rapidly  from the surface  of the diseased parts,
that the  pus shall be taken up as soon as secreted, and conse-
quently its  combination with  oxygen  prevented.   If at the
 same time the medicine   employed to promote absorption
should so powerfully  retard the motion of the heart and cir-
culating fluids,  that the irritating and  morbid actions of the
extremities of the blood vessels, and therefore secretion as itf 
ON HYDROTHORAX.
147
immediate effect, should be considerably diminished,  if not
altogether suspended, another most salutary purpose would be
accomplished."  Letter to Dr. Eeddoes, Medical contribu-
tions, p. 480.
   " A great difficulty," observes Dr. Ferriar, " respecting the
theory  of the action of digitalis, has ofteu occurred to me, on
this subject.   While it lessens the frequency and quickness of
the  arterial contraction, it  often increases, at the same time,
the secretion of the kidneys.   I shall have occasion to mention
some cases, in which these two  operations were combined in a
remarkable  degree.   I feel  it impossible  to explain this phe-
nomenon at  present.   The diuretic  power of digitalis does
not appear to me a constant and essential quality of the plant;
the  power of reducing the pulse  is  its  true characteristic.
According to our  general  notions of therapeutics, these are
contrary effects.  To say that the action of the arterial system
is retarded, and that of the  absorbents stimulated by the same
remedy, is rather stating the fact in different terms, than ex-
plaining it.   The secreting vessels of the kidneys are in gener-
al, aifected  by  stimulants,  which act  upon  the whole of the
blood vessels; but it is inconceivable, that aspasmodic state of
the vessels secreting urine,  or a diseased  action  in them, may
be overcome by a remedy, which lessens the force of the gene-
ral circulation, as, in either of the cases  which I have supposed,
the vis  a tergo (as the physiologists of the last age termed it)
must act as an irritating cause, constantly supporting the dis-
ease.  This reasoning, I am aware, will only apply to certain
states of the kidneys, and leaves many instances of the general
problem unresolved."   Essay on the medical properties of the
digitalis purpurea, p. 13 et seq.
   " My attention was  indeed first directed to the digitalis as
a remedy likely to be useful in phthisic by its almost uniform
effect of rendering the action of the arteries more slow than
oatural at the same time that it appears to excite that of the 
14S
ON HYDROTHORAX.
absorbents."   Dr. Fowler's Letter to Dr. Beddoes, Med. con-
tributions, p. 501. et seq.
   The idea of its proving directly stimulant seems to have
crossed the Atlantic and to have obtained in America, as well
as in this country; a  circumstance  not  to  be wondered at
when it is considered how much the Brunonian philosophy
has influenced medical theory as well as practice in that coun-
try.  In an account of a singular dissection, with very ingenious
remarks, by  George Lee, A. M. of Pennsylvania, published in
the London Medical Review for June 3801, p. 348, are these
words, " Mercury, digitalis, squills, and  even the contents of
the absorbents, are all particular or specific stimuli to them."
   These extracts, (and many more of a  similar tenor might
be adduced) will suffice to  shew the  unsettled and contradic-,
tory state of  medical opinion on this subject  ;—that digitalis
is  considered as a direct and powerful stimulant by  some,
while it is viewed by others, as possessing  both  tonic, seda-
tive and  stimulant effects, at  the  same  time.  Hence, in
dropsy, it is  administered from its  supposed stimulus upon
the lymphatics and kidneys; in haemorrhage from its sedative
effects on the  heart and arterial system, in which, according
to Dr. Ferriar, it is materially  assisted by its diuretic, or in
other words, stimulant,  operation on the kidneys; in consump-
tion by it6 exciting, by which  it is  presumed can only be
meant stimulating the action of the absorbents, and  there-
by promoting absorption,  and at the same time, from its se-
dative power,  retarding the action of the heart and circula-
ting fluids.
  From.these directly opposite effects, the most important ad-
vantages have not only been looked for, but  said  actually to
have been attained.
   That the various effects mentioned are the result of the
use of foxglove cannot be denied,  but that  they should be
the consequence of a directly sedative, and stimulant opera- 
ON liYDKaiHORAX.
149
tion, exerted at the same time,  as the language just quoted
obviously implies, appears extremely inconsistent.  That any
substance should be capable of producing two directly oppo-
site effects on vessels, though different, yet obeying the same
general laws, seems as contradictory to the rules of correct
and sound philosophising, as it is to the known operations of
the animal aeconomy.   In my opinion the synchronous exist-
ence of sleeping and waking, motion and rest, light and dark^
ness, might as well be contended for:  they are two directly
opposite states which  can only exist at distinct and  different
periods: the operation of a stimulus or a sedative is  no les6
so.
   As the only basis on which to build any thing like a solid
chain of reasoning I hold it to be an indispensable principle,
that any substance which  proves sedative, or stimulant, at one
time, in any given dose, or on any one part of the body, must do
the same at all  times,  in all doses, on every part of the bo-
dy under  similar circumstances.  Whatever therefore may be
the  operation of foxglove  on the heart and large arterial
trunks, it must necessarily be the same on their capillary ra-
mifications, those of the kidneys and other glands, as well as
the exhalants; on the absorbents;  on the muscular fibre ; in
short, on  all parts endowed with sensibility and  irritability,
which, however different their functions may be, act in obedi-
ence to the  same general laws.  Had this plain and apparent.
ly obvious truth been first admitted and settled,  many of the
volumes  that had been  written, and the thousands  of frogs
and other inoffensive animals  that have been cruelly mangled
and tortured, in  order  to establish the stimulant or sedative
power  of this or that substance, especially of opium, might
have been saved.   It has been said, and it is still strenuously
maintained by certain medical writers, that opium in its pri
mary operation is invariably stimulant, and that the sedative
effects  attributed to  it by other? are  the  consequence of ex- 
150
ON  HYDROTHORAX.
 hansted irritability from excess of stimulus, therefore seconda-
 ry : and, unfortunately for their cause, the advocates of a pri-
 mary sedative  power, have committed themselves by the
 avowal that in certain doses, and under certain circumstances
 it  is stimulant.  By  this  admission, and by classing it under
 the head of stimulantia, as well as sedantia, the whole force of
 the ingenious reasoning Dr. Cullen  has  called  to his  aid in
 both, in my opinion, is destroyed.   " It  appears  clearly,"
 says he, " that the stimulant and sedative powers of opium
 operate at one and the  same time ; and in no instance  more
 remarkably than that of opium proving powerfully sudorific."
 Mat. Med. vol. 2. p. 198.
   I shall here only observe that, notwithstanding the great
 number of able advocates in favour of the direct stimulant
 power of opium, I see no just grounds for altering  the opinion
 I have long formed, of its proving  uniformly,  directly, and
 powerfully sedative; and  that under this conviction I  have
 always prescribed it.#

  *  The remarks of a learned friend, who has entertained  similar senti-
 ments, appear to me so just and judicious that I shall insert them in this
 place.  " In order to  ascertain fairly," says he, " the specific powers of
 opium it  ought to be applied to healthy subjects.  Its constant effects
 would then be found to be, lessening all action and sensation,  and induc-
 ing sleep."  So it will, in my opinion, in disease, if its effects be fairly and
 impartially observed and recorded.  " I deny," continues he,  " that this
happens ; that opium induces sleep, or allays pain by any secondary, but
 by  a primary operation.  If it  were secondary, the effect  ought  be in
 proportion to the cause ; the indirect  debility should be found in exact
 proportion to the previous excitement which produced it.  Hence a ma-
derate dose causing sleep should be preceded by a lively paroxysm  of in-
toxication and hilarity; a large dose, such as induces stupor, convulsion,
 or death, by outrageous or ungovernable excitement,  however short its
duration : but, in fact,  neither one or other takes place.  Opium allays
cough, pain, and various inordinate actions, without inducing  any raani-
j'est intoxication, or increased vigour.   In violent spasms and pain, opium
may be given in very large doses without inducing sleep.   After much expe.-
 ■iecce in the administration of opium, it has never fallen to my lot to observe 
ON HYDROTHORAX.                  lfc|
   Admitting then that  the digitalis is capable of  produc-
ing only  one of these effects, let us inquire to which class
it strictly belongs.
   The dominion  it possesses  beyond any other known sub-
stance over the heart  in retarding its action ; its power in al-
laying certain painful irritations, in producing drowsiness, ex-
treme  languor, faiutness, and weakness;  in lessening vital
warmth,  nervous and muscular energy, and all this  without
any previous mark of increased action, or stimulant  quality,
would seem sufficient, to establish unequivocally  its specific se-
dative powers.   These are all obvious to the senses:  the most
attentive and accurate observer is unable to discover  any pre-
vious  state of excitement, which, if the opinions of Dr. Dar-
win and those who contend with  him for a direct stimulant
operation, were well founded, must be very considerable, and
consequently so obvious  as not to be overlooked ; for, as hap-
pens from acknowledged stimuli, the cause, or the sum of ex-"
eitement,  must be exactly proportioned  to the effect, or de-
gree of exhaustion ; in other words, the indirect debility, will
be in proportion to the preceding stimulus, and the quickness
of its action.   And, let it be  observed, that according to the
opinion of Darwin- and Brown, indirect debility cannot take

any "intoxicating effect from it.  I have known a degree of serenity and
cheerfulness obtained by the cessation of pain, or grsat irritation,  by means
of opium."  Persons subject to a nervous depression of spirits, who have
accustomed themselves to the frequent use of landanum to remove it,, and
who are unable to go iato company without it, experience this in a re-
markable degree, bordering in some instances upon slight intoxication,
which may be easily accounted for by the sudden transition from painful
to pleasurable sensation.  This will be observed to arise from the sudden
relief procured by cold  applications in violent external inflammation, of
 which, I have no doubt, Dr.  Kinglake could furnish many  instances in
gout, amounting even to intoxication.   On the whole, I conclude with
my friend, that the anodyne effects ef opium is a primary, not a second*
ry operation. 
1B2
ON HYDROlHORAX.
place otherwise than as the effect of a prior stimulant opera
tion.   As happens with  regard to other sedatives too, the
heart becomes in a remarkable degree susceptible of the stimu-
lus of the blood, and the  u hole body of other stimuli, when
the foxglove is suddenly withdrawn, after the habit has been
under its full influence;  for the pulse sometimes rises from 50 to
80 and 100 in a few hours.  But it will be asked how are its ef
fects to be explained, in speedily, and profusely increasing the
flow of urine, and sometimes the alvine  excretion, in dropsy,
so as to empty the dropsical cavities sometimes in twenty-four
hours : the solution of this problem may appear at first sight
difficult; but if we should fail in proving by direct and post
tive evidence that it is by  a similar sedative operation, it sure-
ly follows, agreeably to the principles laid down, that it can
not be by the opposite.
   It has already been observed that the foxglove produced no
sensible increase of urine except  in dropsical effusions; and
it deserves to be particularly remarked in this place that none
of the earliest writers upon it, nor indeed any before Dr. Wi.
thering, have made mention of it as a diuretic ;  and since it is
well known that they made very free with it, and describe its
other prominent effects, is it probable that  this very striking one
would have eluded observation had it really occurred ?  " It is
wonderful," says Dr. Withering," that no author seems to have
been acquainted with its  effects as a diuretic."*  The same
surprise has been expressed by subsequent writers in nearly si
milar words.  To  me it would  appear wonderful if they had
been  acquainted with them.-  The reason they were not, is
obviouq, aRd tends, I think, not only to  confirm the observa-
tions I have made, but the opinion I have  ventured to advance,
that it exerts no specific  diuretic operation on  the kidneys,
namely, because they did not prescribe it in dropsy.  Their
trials were  principally confined  to epilepsy,  consumption,

               * E:sny on  digitalis purpurea, p. 10. 
On hydrothorax.
153
scrophula, and foul ulcers, in which it is said to have worked
wonders; but in which they found it, and it will be found by
others,  to produce no  sensible increase  of the urine, except
when these diseases were conjoined with serous effusion.  Dr.
Withering,  therefore,  was the first regular practitioner who
discovered and made the world acquainted with its effects in
increasing the secretion of urine, because he was the first who
prescribed it as a remedy in dropsy.
   The observations of  the writers of the present day,  even of
those who have had the most  extensive experience  of it, are,
it is to be lamented, so loose in this respect as to furnish no
d ata on which to form a decided opinion.  Some of these in-
deed positively affirm that,  in the diseases unaccompanied
with serous effusion in which they carried it to the  fullest ex-
tent, it produced no increased  flow of urine, and the silence of
others on this head, while its  common effects are mentioned,
leads to the presumption  that this did not happen : others,
however,  mention its having taken place, but in so vague a
manner as to imply a suspicion of the accuracy of their ob-
servations.  " This double  effect," says  Dr. Ferriar, (speak-
ing of its  action on the heart  and on the kidneys) " however
perplexing in  theory,  is extremely  beneficial in  practice :
When it takes place, it  adds in hemorrhages, a mode of natur-
al  evacuation sufficiently efficacious to relieve without directly
d ebilitating  the system ;  and what is of the greatest impor-
tance, continually operating while  we persist in  the  exhibi-
tion*." And in another place he* observes: " I shall have oc-
casion  to  mention some cases  in which these two  Operations
were combined, in a remarkable degree."f
   Had  this excellent practitioner  mentioned these cases, I
should either have considered them as exceptions to a general
rule, doubted  the accuracy of my own observations, or per-

  * Essay on the Medical properties of Digitalis, p. 15.
  f Essay on the Medical properties of Digitalis, p. 13
                            20 
154
ON HYDROTHORAX.
haps  relinquished my opinion entirely ; but as my remark*
were made on a considerable number of cases, and with the
immediate view of establishing either the truth or fallacy of
this question, it will not, I trust, be deemed too presumptuous
to say that they are more  likely to be correct than those of
others which were not directed to the same object.
   On the whole, then, I have no hesitation in concluding that
the foxglove exerts no specific stimulus, either direclly or in-
directly on the kidneys, or any part of the  urinary passages;
consequently,  that the  extraordinary  increase of the urine
which sometimes attends its use in dropsy, must be explained
on  different  principles, and is referable-to  certain circum-
stances immediately connected with serous accumulation, such
as have not hitherto been  ascertained.   The same may be
said of its operation  on the bowels.  I have never observed
those copious watery evacuations, nor indeed any purgative ef-
fect, from the largest doses which were administered, in a sin-
gle instance, except in dropsy; nor does it appear to have been
productive of any such effects under the direction of  others,
except when thestomach was violently disordered by it, as hap-
pens from a variety of other substances, which  are  not in their
nature purgative.   If it possessed any direct  specific  purga-
tive effect on  the bowels, or diuretic action  on the kidneys.
surely these would appear at other times, especially when these
organs were in a sound state and consequently more suscepti-
ble of  its action, than when, under preternatural  torpor, <j.
frequently happens in dropsy.
   It deserves to be remarked,  that when the habit was under
its influence,  the bowels were for the most part preserved in a
natural or somewhat lax state, although before they were on
one or other extreme.  When there  wis colliquative  diarr-
hasa, it checked  it ; when constipation,  it removed  it.  In
one case of encysted dropsy, accompanied with schirro con-
tracted rectum, in  which no natural evacuations  had been 
ON HVDR0XH0RAX.
155
procured  for some years, the bowels \\ ere  perfectly regular
while the habit was charged  with it.  This was repeatedly
mentioned with great satisfaction by the patient as an extra-
ordinary occurrence, and as  in a  great degree compensating
for the distressing sickness produced by it.   These apparently
opposite effects only shew its extensive salutary influence  in
restoring the due harmony and equilibrium between the ex-
halants and absorbents,  as well as the just degree of suscep-
tibility to the  muscular fibres of the bowels, on the loss of
which these different states depended.  In like manner  does
it appear  more than probable that it  acts on the  absorbents
and exhalants opening into other cavities.
  Admitting then that it exerts no  specific stimulant opera-
tion on the kidneys, or any other organ, on the heart and arte-
ries, or on the muscular fibre, does it not necessarily follow,
agreealily to the operation of medical agents on the living, ir-
ritable, and sensible fibre, and the known laws of the animal
oBconomy, that it can exert  no  such operation  or any  other
part of the body ? that consequently it restores the impaired
or lost functions of the absorbents, and places them in a con-
dition of taking up and  conveying to the blood, fluids effu-
sed in cavities, by no other than a direct  sedative operation.
Were it necessary, a variety  of arguments  might be addu-
ced in support of this opinion.
  On attentively  observing the particular cases and constitu-
tions in which the digitalis acts  speedily in evacuating accu-
mulated fluids, it was evident that mere atony, debility, or tor-
por of the absorbents was not the sole cause of the accumula-
tion, as most probably happens when the acrid and stimulant
diuretics  are  successful.   «< It seldom succeeds,"  observes
Withering, alluding to this  herb, " in men of great natural
strength, of tense  fibre, of warm skin, of florid complexion, or
in those of a tight chordy pulse.   On the contrary, if the pulse
be feeble, or intermitting, the countenance be pale, the lips be 
156
ON HYDROTHORAX.
livid, the skin cold, the swollen belly soft and fluctuating, or
the anasarcous  limb readily pitting under the pressure of the
finger, we may expect the diuretic effects to follow in a kindly
manner."*  These observations accord fully with those I have
made: and it may be added, that it seldom succeeds in those
of fat  corpulent habits, with a dull sluggish inirritable fibre,
especially if this state have arisen from the free indulgence in
beer drinking ;  while it speedily relieves those of weak, delicate »
irritable constitutions, with a thin, soft, smooth skin, which in
the anasarcous limb is transparent.    These facts having been
ascertained by experience, it is but reasonable to presume that
the morbid  condition of the absorbents should partake of the
peculiarity of the constitution at large.  A morbid sensibility
and irritability are the characteristics of  such constitutions.
Now, if the absorbent lymphatics opening into cavities labour
under  a  high degree of morbid sensibility and  irritability,
serous  accumulation will be as natural a consequence as from
mere torpor or  debility, and digitalis from its peculiar seda-
tive properties  will be the natural  remedy.   The analogy of
what occurs under similar circumstances in other parts tends
to strengthen this opinion.   Under certain degrees of increased
sensibility and irritability of the stomach, and P. V. substances
which in health produced pleasurable sensation, now often oc-
casion  incessant sickness and vomiting,  and the lymphatics
opening  into these parts either take up the fluids opposed to
them very  sparingly, or not at all.    Ihe peristaltic motion
not only  of the stomach   but of   the greater  part of  the
alimentary  canal  will  be inverted.  In  many diseases  the
whole  muscular system  is  agitated  into  convulsive, irregu-
lar, or inverted actions by the natural stimuli.   Now, since it
is  found that it is under such circumstances, and in such  ha-
bits this herb proves more particularly efficacious in  dropsy,
and that it often fails entirely where the acrid and stimulant
v Withering's Essays, &c. p. 139 
ON HYDROTHORAX.
157
 diuretics prove successful, is it not reasonable to conclude, that
 the lymphatics are thus affected; that the natural stimuli,
 instead of exciting their healthy actions, and propelling their
 contents in the direction of their  valves, all tend to  the con-
 trary, and that  the digitalis, from its peculiar sedative pow-
 ers, removes these morbid states, restores their healthy func-
 tions, or gives to them their due degree of susceptibility. The
 supply by the exhalants may be at the same time diminished,
 in proportion, at  least, to the degree of sedative operation ex-
 erted on  the heart and  arteries, and consequent reduction of
 the impetus of the circulating fluids.   « The operation of di-
 gitalis," says Dr. Mossman, " very certainly lessens the secre-
 tion by the exhalant arteries; but whether it affect the sys-
 tem of absorbents otherwise than by interrupting the farther
 supply of fluid, and leaving them at liberty to take up  what
 is already poured  out, demands I  think a doubt*."   Any
 person who has witnessed the  sudden depletion of enormously
 distended cavities by means of this herb, must be surprised at
 so extraordinary a conclusion, obviously the reverse of what
 really happens.  This circumstance too seems to furnish an
 insuperable objection to those who maintain that the lympha
 tics are mere passive agents, not actively absorbing in any in-
 stance, but "passively admitting the redundant, interstitial,
 or extravasated fluids forced into their permanently open orifi-
 ces by arterial and muscular  impulsef," since they  take up
 and transmit much larger quantities of fluids than they ever
 do in health, when  arterial and muscular impulse are conside-
 rably diminished by the debilitating power of the digitalis,
and when they appear to derive little aid from any source ex-
cept their own inherent  action, which, in my opinion, proves
 them to be endowed with living active muscular powers.

  * Essay oa Scrophula, p. 84.
  f See Med. ami Phys Journal, for December 1301. p. 457. 
ida
ON HYDROTHORAX,
   The healthy functions of these vessels being  thus restored,
their action seems in many instances to be in, proportion to the
quantity of fluid opposed to their mouths, or to the duty they
have to perform; for they now take up probably more water
from  certain cavities in twenty-four hours than they did  in
several weeks before when they had no more than the natural
quantity to dispose of;  and the effused fluid being once ab-
sorbed it will be conveyed to the circulating mass, and from
thence to the kidneys, as the natural outlets;  which process
will be materially accelerated if the exhalants now transmit
less than the quantity they did in health.   In some instances,
however, when there is considerable torpor of the kidneys, and
the bowels are naturally very irritable, the water passes off in
this way, producing copious liquid evacuations ; or it is pour
ed out into the stomach, and probably at the same  time deter.
mined to the salivary glands, causing very profuse  watery dis-
charges from these organs; or if the digitalis be  not assisted
by stimulant diuretics it may be again effused as fast as it has
been absorbed.
  The salivation is of a peculiar kind, being unaccompanied
either with the faetor of the breath, discoloration, pain, or swel.
ling of the gums  or salivary glands, loosening or loss of the
teeth, consequent  on salivation produced by mercury.  The
saliva is either copiously thrown out from the salivary glandSj
or a similar fluid is thrown up in mouthfuls from the stomach,
sometimes  without sickness or efforts to vomit, as I have re-
peatedly observed  while sitting by the patient.   I  have no re-
collection of observing salivation produced in any instance by
digitalis, except where there was every evidence of watery ef-
fusion : when  it happens the determination by the kidneys is
always diminished.
  In order farther to illustrate the apparently opposite and con-
tradictory effects  of certain substances, more especially  of
opium and digitalis on the human body, it may be remarked, 
                     ON HYDROTHORAX.                  159

that different functions of the living system may be in differ-
ent states, at the same time, i.i regard to excitement and action,
and that  the same substances may therefore seem to produce
different  effects on these  states.   In mania, for instance,
the animal function of voluntary motion is often excited  to
four times its natural force, while the action of the heart and
arteries is extremely reduced ; and the sentient function of the
nerves so far obliterated as hardly to receive any impression.
 It has been found that the dose  of  near a scruple of emetic
tartar has been given to a delicate female subject, without ef-
fecting the least operation on the stomach and bowels, and that
active  blisters  have produced no sensible effect on the skin,
while it required the exertion of several persons to hold her in
bed.  Something of a similar  irregularity may  be observed in
hysteria, hypochondriasis, and melancholia.   In acute rheu-
matism, and in synocha, while the heart and arteries act with
an extraordinary morbid  force, the patient is often so  languid
in his animal functions that he can hardly bear to be raised
from his pillow without  fainting.   In the hysteric paroxysm
the animal  functions are  often wholly suspended for sometime,
while the patient  still retains his usual colour, warmth and
fullness of pulse.   The same apparently happens in apoplexy,
and  some instances of palsy.   In inflammation the action of
the heart and larger arteries is'frequently increased very con-
siderably in force, while that  of the  inflamed vessels is always
diminished.*  There issuificient evidence, therefore, that the

  • This being contrary to the generally received opinion, it may he pro-
per to remark, that I  have for several years adopted the idea that the
action of '.he inflamed vessels was invariably more or less diminished.
while that of the  heart, large arteries,  and arterial trunks  immediately
leading into the part affected,  might either be increased, or remain unaf-
fected. Thinking this doctrine original,  I communicated the heads of it l<»
professor Duncan, of Edinburgh, in 1793 ; requesting him to insert them, ii
not too late, in the next vol. of tbe. Med. Commert . nattf I should have: 
160
ON  HYDROTHORAX.
different functions may be in different conditions in respect to
excitement  and vigour, and as this frequently  occurs as the

an opportunity of laying it before the public in detail,  in  a  more finished
form.  In the answer with which he was so obliging as to favour me, af'-
ter informing me that the greater part of the impression was printed off,
he thus proceeds : " Had the article with which you favoured me, arriv-
ed sooner, I must acknowledge I should still have had some doubts about
the insertion of it, lest I should  have been thought  to give you the merit
of an hypothesis really belonging to another.   Several years  ago, the
opinion that inflammation is the consequence of debility, was strenuously
supported in the Medical  Society, by many young men, but particularly
Mr. Allan.  Whether he still retain the same opinion or not  I cannot tell;
but it is now, I am told, almost completely deserted there.   And before
you publish on the subject, let me recommend it to you, to consider atten-
tively the inflnence of topical stimuli, whether chemical or mechanical,
as immediately inducing inflammation, and some of the most remarkable
symptoms with which it is attended, particularly pain,  heat,  and local
pulsation, where there is  no increased impetus of the heart or large ar-
teries."
  It is possible I may have received the  first hint when at  Edinburgh,  in
 1790, yet I have no recollection of any such opinions being  current or
supported in any of the Societies during  my residence there, from 1780
to 1784, or  afterwards in 1790.  I am confident  they were not; yet
though I still  considered this doctrine as my  own, I  thought  it right to
pause before it was ushered into world, lest, as the professor very justly
observes, I should lay claim to an hypothesis really  belonging to another.
But  though the publication has been delayed from causes unnecessary  to
intrude on the reader,  the subject has not been abandoned, a,nd subse-
quent experiments,  facts,  and observations, have tended to remove every
doubt which then existed in my mind relative to certain  parts of it. My
sentiments have  been long known to my medical friends, and the M.  S.
has been submitted  to the inspection of a few ; but the objections urged
by them, as well as by Uie learned Professor, have not only been antici-
pated by myself, but I trust satisfactorily refuted.  It would far  exceed
the limits of a note to state the grounds on which my  opinion is founded,
much less all the arguments that may be adduced in support of it.   I can-
not however  forbear remarking, that the phenomena of the disease, the
exciting causes, aud the means employed wiUi effect in the cure, all seem
fo concur ia  proving the existence  of diminished  tone, energy, or con- 
QN HYDROTHORAX.
161
 effect of disease, medicines which act on the habit at large may
 appear to produce very different effects.   Thus in acute rheu-
 matism and  synocha  the action of the heart  and arteries is


 tractile power of the vessels, both of active as well as of passive inflam-
 mation, though some  of these appear on a superficial view to prove the
 contrary.   If increased action were the eause the veiy reverse of preter-
 natural redness, congestion, distention, or increased capacity, of the in-
 flamed vessels would be  the case, especially in local inflammation, where
 no sensible change takes place in the heart or large arteries.  But if the
 irritability or contractility  of the muscular fibre of the minute inflamed
 arterial ramifications be diminished, these appearances will be the natural,
 and indeed, the necessary  consequences, more particularly if the action
 •f the heart aud large arterial trunks, be at the same time  increased :
 their coats will more readily yield to the distending impetus of the blood,
 or the vis a tergo.
   The exciting  causes are all such as either directly or indirectly dimi-
 nish or exhaust  the contractility  of the  muscular coat of  the  arteries,
 and thereby induce debility.   Those which directly produce inflamma-
 tion are all inordinate stimuli, either mechanical or chemical, which by
 their  excess impair or destroy irritability;  and those which indirectly
 do so  are the ordinary or moderate stimuli suddenly applied  after  they
 have been for a  certain time abstracted, producing precisely the same ef-
 fects, of which alternations of heat aud cold afford the best illustration.
   The means which experience has sanctioned as the best for the cure
 are all  such as  are  calculated to restore lost tone, or remove debility.
 Blood is drawn  from the arm in order to lessen its impetus into the dis-
 tended and debilitated vessels ; from the part immediately affected with
 a view of removing more directly the distending cause, and thus, in both
 cases, iu order to give them an opportunity of contracting more readily ou
 their  contaiued  fluids.  Mechanical and chemical stimuli, astringent lo-
tions, and tonics, are applied externally to the coats of the vessels in or-
der to excite them to a more vigorous contraction ;  and cold in some
instances with the view  of abstracting Uie internal stimulus of heat as
well as of restoring lost tone.
  The increased heat, pain, and local pulsation, appear to me to admit of
the most satisfactory explanation, but  having  already extended this note
beyond due  bounds, the farther consideration of the subject rawrt be de»
fayed till a future occasion. 
102
Utf HYDROTHORAX.
weakened by bleeding and purgatives, while the animal, and
most probably all the other functions are strengthened.   In
inflammation similar effects take place  from the same means,
while the impaired action of the  inflamed vessels is sensibly
increased.   It is not improbable, therefore, that the same may
be produced by remedies which disorder the system ; and
that digitalis,  in reducing  the activity of the vital, animal,
and natural functions by a direct sedative power, may bring
the system  to that state, in which we find, on other occasions,
the functions of the  absorbents to be increased, and this seem-
ingly by an inherent law of the animal oeconomy not yet right-
ly understood.  It appears at the  same time that when the
action of the absorbents is so far restored as to drain any drop-
sical cavity of its morbid accumulation, this happening under
a state of general debility, the water is not thrown off by per-
spiration which requires a state of general vigour to promote
and support it, but by another law is determined to the next
great outlet of watery fluid, namely, the kidneys.   It seems in-
deed consistent with the laws of the human oeconomy, that un-
der an increased activity of the heart and arteries,  the fluids
should be determined to the surface, and under the opposite
state of languor and debility, to the kidneys.   We find accord-
ingly, an increase of natural perspiration, concomitant on in-
creased circulation  and vigour;  an increase  of urinary secre-
tion concomitant often on depressed spirit, and languor of bo-
dy ; at least it w ill seldom happen, that a copious secretion of
urine will take place under a state of activity of the heart and
circulation.  When this  occurs to hard drinkers, it  is* always
during the debility of intoxication.
   It is  therefore a fact, that powers which weaken the animal
and natural functions often have the effect of causing, at  the
same time, an increased flow of urine; and this last effect will
fee in  proportion to the force  and suddenness of the debility
induced,  This effect of the passion of fear is notorious and 
ON HYDROTHORAX.
163
proverbial, as  is strongly manifested in the case of  the  wo-
man labouring under ascites who was terrified on a sudden,
by  meeting oxen  on one of the London bridges j  she  ran
back in consternation, and  was presently  obliged  to squat
down before she could reach any house, and discharged  gal-
lons of water.   If I recollect right, she obtained a cure by this
means.  Care, anxiety of mind, and depression of spirits, how-
ever induced,  will be found frequently to cause a similar ef-
fect.  In like manner, it will be found  thatisome of the most ac-
tive diuretics, as  squills, elaterium, and digitalis, will some-
times not produce their full effect on the kidneys, until after the
stomach has been affected by more or less of nausea  and vo-
miting, with  general languor  and  debility.   Dr.  Darwin
seems to have been acquainted with these truths;  but ac-
counts for them in a whimsical  and contradictory way.   Dr.
Ferriar is impressed with the same  truth in the operation of
digitalis, and is puzzled by  it, as he  candidly  acknowledges.
The fact itself is important,  as it bears on  the  administration
of diuretic medicines.   The explanation is another thing.
  From the foregoing facts  and observations I  am induced to
draw the following conclusions.
  1. That the digitalis exerts no specific stimulant operation
on the kidneys, stomach, bowels, salivary or mucous giands, or
on any part of the body.
  2. That consequently it restores the lost or  impaired func-
tions of the absorbents, and places them  in  a condition of
taking up  the fluids effused in cavities, by a direct  sedative
operation.
  Whatever may be the fate of the opinions advanced in the
foregoing  section on  the mode of operation  of foxglove;—
whether they be confirmed or refuted by future observations, 
164
ON HYDR01HORAX*
it may be right to remark that the practical part of this e^ay
will not be in any degree affected or invalidated : this rests
solely on its  own merits, the solid basis of an ample share of
experience, uninfluenced by any theoretical speculations, ex-
cept such as might arise out of the successful results of a  great
variety of cases.   But if in the first instance we should have
no theory to  direct our steps, and be fortunate in arriving
progressively at successful practice, in diseases deemed for the
most part incurable, by the aid of experience alone, it is 6urely
but natural that we should begin to theorise on the modus ope-
randi of the means by which so desirable an object has  been
attained, 
CHAP. VII
     Of the solidary powers ofDigitqlis in other diseases;

     A.S far back as the year 1799, I hazarded the following
 ppinion of this herb, " On the whole then,  the foxglove will
 be found  a valuable remedy  in consumption.  It will some-
 times succeed when the most approved remedies fail.  When
 of itself it  is insufficient to subdue the disease,  it  wiil prove a
 valuable auxiliary to other means.  It has  always, with me',
 quieted and soothed the sufferings of the patient more or less ;
 and where it  ultimately failed it lengthened the duration of
 life, and smoothed the avenues to death."   And  in another
 place ; " though I  doubt not  it will be found by others the
 most efficacious that has hitherto been resorted to, yet its pow-
 ers are limited, even in the early stages."*
  Subsequent experience having enabled me to  ascertain more
 fully, the extent of its  powers, and to estimate more correctly
 its real merits, it is incumbent on me now to acknowlege that
 these will be found still more  limited, that the expectations
 held forth above, though considered by many at the time  as
 falling short of its real virtues, have not been  fully realized.
 In several instances  it appeared to have no effect either in ar-
 resting the progress of the disease or of palliating the suffer-
ings of the patient.   It will nevertheless be found a valuable
auxiliary in many cases of consumption under the cautions and
restrictions so fully  laid down by different writers, as well  as
 in the paper from which the above is extracted ; but though
 it is in general to be regarded only in the light of an auxiliary
Med, andPhys. Journal, p. U5and 117, 
lb(i
ON HVDROrHORAX.
to other means it should not be omitted in any instance, since,
if it do not succeed to our wishes it will seldom, if ever, inter-
fere with the salutary effects of any other remedy.
  In the influenza or epidemic catarrh of 1802, it was prescri-
bed on an extensive scale both by myself and many medical
friends,  with the  most beneficial results, in those cases and
stages where the cough was extremely urgenl, but in which
opium is found to prove highly injurious.   After the fullness
and tension of the pulse, the  heat and dryness  of  the skin,
were lessened or removed by  appropriate means, and  none
were found more  so than  moderate  doses  of calomel  and
James's powders, the tincture administered in the quantity of
from  sixty to a  hundred  drops in the  day in combination
with saline medicines,  mild expectorants, and free dilution,
its effects in allaying inordinate  cough, pain and irritation of
the lungs,  and the febrile state attendant  upon them, as welj
as in promoting  expectoration, were very  conspicuous.   One
of my medical  friends of extensive practice assured me he
used some pints of the tincture in  this epidemic.  In the se-
condary stages of the complaint when the patient was threat-
ened  with  consumption,  or when the complaint had been
neglected or improperly treated its virtues were still more ev-
ident ; and  I am confident  many patients already labouring
under hectic symptoms were rescued by it; while in others
this state seemed to have been prevented  by the timely but
judicious exhibition of full doses of it.  In this complaint it
should be  prescribed at once in such doses as will speedily
affect the habit,  while in phthisis the exhibition cannot be too
slow or gradual.
  In pleurisy, pneumonia, and other inflammatory disorders,
it has been strongly recommended as a substitute for bleeding
and other evacuations, with a view of reducing the fullness,
hardness, frequency of the pulse, and usual febrile symptoms;
but I will  venture to affirm that  this has not been sanctioned 
ON HTfDROTHORAX.
ier
by the practice of those persons who thus confidently recom-
mend it, but that it has originated in a preconceived theory.
Though 1 differ in opinion  from Dr. Beddoes  as to its mode
of action, yet 1 cannot  express myself  in stronger or more ap-
propriate  terms on this occasion than in quoting  his words.
« In pleurisy," 6ays he, " if any one should be mad or wick-
ed enough to forego the so certain resource of the lancet in
favour of the  sedative virtues of digitalis alone, he would, I
apprehend, increase the disease, if he confined himself to mo*
derate doses. "#  To this it may be added that the same ob
jections  will  apply to all inflammatory, affections, till the
strength of the pulse, the  heat and dryness of the skin, be re-
 duced or removed by  bleeding, or other evacuations.   This
may appear to favour the idea of a direct sedative operation:
the same, however, may be said with equal  propriety of cold.
In violent inflammatory disorders, especially in strong muscu
 lar  habits, which have been suffered to continue till the in-
 flammatory action be fully established, the application of cold,
 as well as of digitalis, will be insufficient to subdue it; and
 by trusting to either  the  patient may be lost.   Nothing but
 the abstraction of the  positive stimulus of  the blood, or the
 reduction of this action by purgatives will  in many instances
 save the patient; and  it may farther be remarked that though
 under these circumstances the digitalis may prove injurious,
 or at least may do no  good, yet in those where its virtues are
 obvious, stimuli in general will do harm,  a strong presump-
 tion in favour of its not  acting by a direct stimulant opera
 tion.
   Cases of pleurisy or  pneumonic inflammation will sometimes
 occur where the most copious evacuations by bleeding,  aid-
 ed by other appropriate  means, will be found insufficient to
 subdue the urgent symptoms, yet in which the pulse and gen
 eral strength are so reduced as to preclude  farther evacus-
* See p. 234, et seq. of this Essay 
 16$                6s  ;iydrotiiora£.

 tions, though the Wood  still continue to exhibit a'dense in".
 flammatory buff.   Such cases are extremely perplexing to
 the practitioner :  they generally arise from the disease being
 neglected or improperly treated in the beginning, or from the
 inflammatory action being suffered  to be  fully established.
 concurring  perhaps with peculiarity of constitution.  The
 digitalis may be resorted to with advantage in such cases, and
 it will be assisted by small doses of calomel, James's powders,
and opium, more  especially if the surface of the body be hot
 and dry, the cough urgent, without expectoration.
  In chronic affections of the lungs it will be found still mort
 efficacious than in the secondary stages of acute ailments.
  In asthma, chronic catarrh, and dyspnoea,  incident, to per-
 sons advanced in life, when the expectoration is viscid but co-
 pious, it will not only be found beneficial in relieving present
 symptoms, but in  preventing remote evil, namely, serous ef-
 fusion, which is always  to be apprehended,  without proper
 precautions in such  circumstances.   In spasmodic  asthma, in
 hooping cough, where I expressed a hope* it  would  prove
 useful before any trials were made, it has not been  productive
 of any material or lasting benefit.
  In the troublesome cough and irritation of the lungs, threat-
ning consumption, often continuing for a  length of time after
measles, as well as in the secondary stages of the Complaint,
digitalis is an excellent remedy.
  In haemorrhage, and ii: acute rheumatism, its powers have
been long established, particularly on the  authority of the-
practitioners of Manchester.   But when a variety of other re-
medies, such as opium, calomel, and James's or  Dover's pow-
ders are administered at the same time, it is not fair to attri-
bute the whole of the  benefit to the foxglove ; which,  how-
ever, seems to have been too generally done.   When a grain
of the powder, with half a grain of opium, is  given at  bed

          •  * Med, and Phys. .Journal, vol. ii. p. 117. 
ON HYDROTHORAX.
169
 sirhe, a few drops of laudanum, with tincture of castor, every
 four  hours during the day in menorrhagia, it is surely unrea-
 sonable to attribute tire cure to this herb alone; or if haemorr-
 hage should chance to stop after the first dose, it is not less so
 to infer that it was in consequence of the medicine.*  Nor is it
 more correct to ascribe to it the relief  obtained in rheumatic
 pains when an equal quantity of opium, and  probably of calo-
 mel, was taken at the same time.   Yet this has been the gen-
 eral practice, as may be seen in the various publications on the
 subject.   In haemorrhage and rheumatism I have had occa-
 sion to use it less frequently  than in the cases just mentioned,
 because they have generally yielded to other means, the for-
 mer to the cautious abstraction of all external and  internal
 stimuli, the latter in the first stage, to the same, though not  to
 an equal extent, assisted by a mild course of mercurial laxa-
 tives, opium, and  calomel at bed time, and by banishing the
 hot and sweating system entirely  from  my practice ; and  in
 the secondary stages, by mild tonics, friction,  exercise, and re-
 gimen.  There is so much of chance and accident in the chan-
 ges incident to disease, both salutary and otherwise,  that the
 practitioner is continually imposing the belief upon  himself
 that these have been effected by his remedies,  when probably
 they had no share  in their production ; lied obtains censure  or
 applause from others when probably he merited neither; and
 his reputation will be advanced or checked according as his
 prescriptions have fallen in with the favourable or unfavour-
 able changes of disease.   Hence the necessity of waiting pa-
tiently the results of numberless trials, under every variety of
 circumstance, and of watching attentively the natural flucta-
 tions of disease, before a general inference be drawn in favour
 of any individual remedy.
  Though few remedies will be found more extensively bene-
 ficial than foxglove, yet few are so limited in their salutary ef-
* See Ferriac's Essay, p. 7. etReq
             3? 
 179                 OH HYDROTHORAX.

Sects uncombined with  others.   Bark will cure intermittent?,
mercury will cure lues and many other diseases, without any
other auxiliary; but digitalis will scarcely cure any disease
without  the  aid  of some  other  medicine.   Though it may
evacuate'the  water in dropsy other remedies will generally be
found necessary to prevent farther accumulation.
   On the mode of preparation and exhibition I have little to
add to the observations published in the Medical and Physical
Journal, for September,  1T99, p. 1-0 to 122.
   Whether the plant of the natural growth, or that cultivated
in the garden, be preferred, it should have attained its full
maturity before it be gathered for use ; the largest and coarsest
leaves  should then be selected  and dried in the shade; and
when sufficiently dry, they should be  packed close in paper
bags, suspended in the kitchen, or in a room where a fire is
constantly kept in the winter, and used for tincture or infusion
without  farther drying.   In this  manner  their virtues will
remain for some years unimpaired ; but when readily procur-
ed, a fresh supply should be laid in at the  proper season every
year.  When wanted for powder noniorethan is required for
present use should be dried at one time, since, if a- larger quan-
tity be kept in a vial,  as is still  the practice with some apoth-
ecaries, it will, by frequent exposure to the air, soon become
inert.  Hence the cause of the great variation of its strength,
and frequent  failures complained of; and  hence the  necessity
not only  of caution in the mode of preparation, but in having
standard formula? which w ill possess  the same powers at all
times, in all situations and circumstances.   Writh this view the
following were recommended at the time, and submitted to
the learned College of Physicians of London, for insertion in
the next edition of their Pharmacopeia,  through their then
worthy and learned president the late sir George Laker : Spe-
cimens of the tincture, accurately prepared, were  at the same
time transmitted to him  aud to Apothecaries' Hall. 
ON HYDROTHORAX.
171
                     Standard Tincture.

   ft.   Folior.  Digital.  Purpur. exsiccat.  §j.  Spiritus  tenu^-
^oris Sviij. Digere per dies scptem,  et  per chartam cola.*—
vel,
   &. Folior.  Digital.  Purpur. recent, incis. et  contus. §iv.
Alcoholis ov. Digere per dies septem, etcola.
   This last makes a beautiful dark green tincture, and if made
in May  -or June is perhaps preferable to the former,  as the
virtues of the leaves will then be unimpaired.   I have ascer-
tained that by drying, the leaves lose from three fourths to four
fifths of their weight, so that iu this formula  I allow the three
ounces of water supposed to be contained in the  fresh leaves, to
the five of pure spirit, which is a larger proportion of the spirit
than  in the first formula,  but nearly the same of the leaves.
The strength will be found nearly equal.

                      Standard  Infusion.

   &.  Folior. Digital. Purpur.  exsiccat. 5;fS  Aquae ferven-
tis  § dij. Zingiberis incis.  56.  Macera per  horas quatuor in
vase operto, et cola.

  * In  the edition  lately published of their Pharmacopeia, the College
have adopted this  formula, directing the maceration  of this, as of all the
tinctures, to be continued for  fourteen days, which, as  a general rule, is
undoubtedly an improvement.
  The Edinburgh College have likewise adopted it.
  Both the London and Edinburgh Colleges have,I perceive, directed the
addition  of a spirituous tincture  to the infusion : this I have purposely
avoided,  preferring some aromatic substance, as I am guided in the kind,
quantity, and quality of the spirituous addition, by the particular circum-
stances of the case for which it is prescribed, for the most part choosing
that which  possesses diuretic powers, and which consequently promotes
♦.he efficacy of the Foxglove 
CHAP.  VIII
 Of Polysarcia, obesity, or corpulency, as a cause of dropsy of
                         the chest.

      W HEN treating  of  the predisponent causes  of the
 disease, p. 61, it was remarked that inordinate corpulency,
 concurring with a thick short make, was one of the most  fre-
 quent and powerful which occurred ; insomuch,  that it  has
 been deemed necessary to allot a separate section for its con-
 sideration, and for  pointing  out. its causes and the means by
 which it may be counteracted.
   In health a certain portion of fat is distributed throughout
 the different parts  of  the body for the most  important and
 salutary purposes  in its oeconomy: hence, when the body is
 corpulent,  it  is found not only under the skin, but between
 the muscles, and even the  fibres of the muscles ; in the cavity
 of the abdomen, about the  kidneys and mesentery; in  the
 loins; and particularly in the omentum or cawl, causing the
 protuberance of the belly in fat people ;  in the  cheeks and
 mammae; and about the heart.
  As long as it is confined within moderate bounds, it  facili-
 tates, and indeed is  necessary to the various  motions of the
 body,  at  the  same  time  that it gives shape, symmetry, and
 beauty to the whole.   But when it increases beyond certain
 limits, so as to impede the free  exercise of the healthy func-
 tions, and  to  occasion  deformity,  it is then considered as a
disease, which has been termed polysarcia, or obesity, by No
sologists. 
ON HYDROTHORAX.
173
   Though the general increase of the body thus induced,  by
pressing in every direction on the lungs, causes imperfect and
difficult respiration,  it is the accumulation of fat in the omen-
tum, and about the  other abdominal viscera, which more im-
mediately  does so, and by  preventing the free descent of the
diaphragm, and full expansion of the lungs, more particularly
predisposes to dropsy of the chest.
   The quantity of fat thus accumulated presses also on the
larger blood vessels and on the viscera, necessarily impeding the
circulation of the  blood and lymph through  them,  while it
occasions an accumulation in the vessels of those parts destitute
of fat,  as the head and lungs; whence respiration is still far-
ther interrupted, and the functions of the brain are imperfect-
ly performed.  Thus the stupor, drowsiness, or  lethargy, im-
paired memory, aversion to exertion, which frequently end in
apoplexy, epilepsy, or other violent disorders, as well as drop-
sy of the chest, incident to corpulent subjects.   The laxity  of
fibre, and  the  great accumulation of fat frequently found
about the heart in such circumstances, contribute greatly  to
the production of these evils.
   The predisposition to obesity is various in different persons;
in some  habits it  is so strong that a deposition of fat takes
place  to  an inordinate degree, in spite of a constant modera-
tion in the gratification of the appetite ; while in others the
unlimited indulgence of it is insutficient to produce any degree
of fatness : this depends on constitution.
   The general exciting cause of polysarcia,  independent  of
peculiarity of habit, is certainly a fme indulgence of the apv
petite in  the use of nutritive food,  and fermented  liquors,
since it is only among those who enjoy the means of obtaining
the comforts of life without hard labour that this state is  at
any time observed.    The money making citizen, the opulent
farmer, (and more  especially their  wives,  who enjoy their
feeding with less rxnrise and anxiety,)  the indolent rector, 
174
UN HYDROTHORAX.
the Serjeants of regiments in  peaceable quarters or of the mi-
litia ; the masters of well  frequented  inns  and their wives,
&c. are those whose rotundity of belly marks the superabund-
ance of their  ingesta, and  mho  percpire and wheeze under
a load with which they have voluntarily incumbered them-
selves.
   Whenever a person of a constitution predisposed to obesity,
is enabled to indulge in good  feeding,  leads a calm  indolent
life, free from mental inquietude, and uses much sleep, corpu-
lency generally ensues.  These facts are  too well known and
admitted to require illustration.
   The causes of corpulency being thus  well  understood, the
means of prevention and removal are not  less obvious: in this
the patient must in a great degree minister to himself: the
prevention and cure will depend upon  the proper regulation
of his diet, exercise and 6leep.  Medicine will only be neces-
sary to obviate particular symptoms, or diseases, arising from
or connected with it.
   The patient must be enjoined moderation in eating, drink-
ing, and sleeping, together with much bodily exercise, so that
the ingesta may be less than the excreta.   By the proper ma-
nagement  of these I have no hesitation in affirming  that the
most corpulent  and unwieldy may be  reduced within mode-
rate bounds in a reasonable time with an acquisition of health,
strength,  vigour  of body and mind;—that  John  Love and
Daniel Lambert  might have got rid of the load of fat with
which  they were incumbered, and by which they were event-
ually suffocated,  and enjoyed comfortable health,  had they
followed the example of the Italian nobleman Cornaro, or of
Thomas Wood, the miller of Billericay, whose  history shall
presently  be mentioned, by changing the  habits of living
which produced their corpulency and conforming to a parti-
cular regimen. 
ON HYDROTHORAX.
17o
   If the stomach possess strong digestive powers, and be capa-
ble of converting into chyle every digestible part of the ali-
ment that is taken in ; and if the proper vessels at the same
time take up this chyle, and deposit much fat, it is obvious
that the most  direct method  of diminishing the  deposition,
will be to diminish the quantity of food, or to take less nutri-
cious substances as food.   The advice of Celsus, of taking but
one meal a day, namely dinner, as far as regards animal food,
is judicious;  for meat should only be allowed once a day, and
suppers should be entirely forbid.  The food should be plain,
and the meat lean, one dish only being  used.  Butter, all fat,
and high seasoned substances, should be avoided, and the vege-
tables should bear a full proportion to the animal food, as being
less nutricious;  and these should be of the amylaceous and
farinaceous, not of the cold, crude,  flatulent kind.   The old
adage of the  temperate,  "  rise  with an appetite," should be
constantly kept in mind ; at least the stomach should never be
surcharged with a quantity which it is incapable of digesting'
perfectly.  " Any one," says Dr. Cheyne, " may lose a pound
of blood, take a purge, or a sweat, by dropping the great meal,
or by abstaining from animal food,  er fermented liquors, for
four or  five days, as effectually as by opening a vein, swallow-
ing a dose of pills, or taking a sudorific bolus :# and it might
be added, with far better effect, and advantage to the consti-
tution;  for bleeding, purging,  and  sweating directly debili-
tate, while they increase the predisposition to corpulency, if
the exciting causes be not  removed.
   The  article of drink requires  still  more attention.   Corpu-
lent persons generally indulge to excess in the use of liquids -
if this be  allowed every endeavour  to  reduce  them  will be
vain, even if they be moderately supplied with solid food :
but abridge them in it, within  certain limitations, and they
may, even at  pleasure, get rid  of the incumbrance.   Wher
* Essay on health 
 176                 ON HYDKOTllORAX.

 the stomach is sound, and the digestive powers are active, the
 unlimited use of liquids, even of water, contributes greatly to
 the more perfect  solution or assimilation, absorption and de-
 position of the nutritive parts of the solid food;  whereas when
 not sufficiently diluted a large portion passes off by the bow-
 els :  hence the common observation that  " water is fatten-
 ing."   If any one wish to prepare, himself for long continued
 laborious exertion, such as has been the fashion of late years
 in this  country, or to reduce his exuberant fat, and increase
 his muscular  strength, he will habituate himself gradually
 to a dry solid nutritive diet, with as little liquid as possible,
 and to regular exercise, by which the superabundant fat will
 be absorbed, the muscular fibre will be strengthened, and all
 the functions of the body will be performed  with greater vi-
 gour.   The groom thus trains his horses for the turf,  or the
 field.   By a law of the animal oeconomy, which has been no-
 ticed above, p. 61, the absorbents will invariably take up and
 convey  to the habit the superabundant deposited fat, and
 thus for a time supply the deficiency of liquids.
  Sleep.  Scarcely less than food and drink  does sleep contri-
 bute to the growth of the body, a certain  portion being ne-
 cessary  to the due performance of its healthy functions, as
 well as those  of the mind,  the quantity depending upon age,
constitution, and habit.   The causes and consequences of sleep
on the body and mind, when indulged in moderation, to ex-
cess,  when disturbed or destroyed, and  the circumstances
which promote or interrupt it, are beautifully described by the
poets: thus Stirling,

    "  O  gentle sleep  ! thou cherisher of health !
      From temp'rance bred, the nurse of sweet repose '
    In whom the peasant finds a mine of wealth,
      To whom his happiness the lover owes;
    Thou balm of life! whose kindly warmth restores
      Light to the eyes,  and vigour to  the heart; 
ON  HYDROTHORAX.
177
    Whose presence luxury in vain implores,
      Kind while thou fly'stto take affliction's part;
        Say, by what magic fetters dost thou bind
        In thy delightful thrall the agitated mind ?

   Persons freest from mental inquietude enjoy the most natu-
ral and sound sleep, and are consequently the most prone to.
corpulence:  thus the immortal Shakspeare,

      " Let me have men about me that are fat
      " Sleek headed men, and such as sleep a-nights •
      " Yond Cassius has a lean and hungry look,
      " He thinks too much---------
      " Such men as he be never at heart's ease."

   While those  who are  continually haunted by an evil coa
science seek for  this balm of life in  vain: hence the  following
lines from the same inimitable bard,

       -----------------" O gentle sleep,
      " Nature's soft nurse, how have I frighted thee,
      " That thou no more wilt weigh my eye-lids down;
      " And steep my senses iu forgetfulness ?—
      u Wilt thou, upon the high and giddy mast
      " Seal up the ship-boy's eyes, and rock his brain's
      " In cradle of the rude imperious surge;
      " And in the visitation of the winds,—
       M And, in the calmest and the stillest night,
       " With all appliances and means to boot,
       " Deny it to a King?"-------

   The effects  of  sleep, however,  have  been  over-rated.
Though it be universally admitted that much sleep  favours
the deposition of fat in animals as well as man, yet that its in-
fluence is so powerful, independent of food, as to increase the
fat of animals  who sleep  during  the winter- months, as has
been   asserted by some respectable writers, is not fownded In
                              3» 
irs
ON HfDROiHORAX.
  fact,  since more accurate Observations have clearly  demon-
  strated the contrary.  The mistake seems to have originated
   with Aristotle,' and other naturalists copied it from him: he
  asserted that the loir passes the whole winter without eating,
  and that during this period of abstinence,  it becomes extreme-
  ly fat, being more nourished by sleep alone, than any other
  animal is by food : whence these lines by Martial,

        '* Tota mihi dormitur hyems et penguior illo
.       " Tempore sum, quo me nil nisi soiunus alit."

     The celebrated  Haller appears to have  given  credit to the
  same assertion.  " Nam et  animalia," says he, " quae  hye-
  mem inter somnos transigunt, nihil de alvo egerunt, vix per-
  spirant quidquam, denique circulatione sanguinis ita sunt mo-
  dica, ut penitus frigeant.-----Si vero nihil consumunt, non vi-
  detur necesse, ut reparent.-----Et in somno adeps adeo non vi-
  detur consumi ut augeatur :"* and again, " Neque satis cer-
  tum est animalia macra ex hibernaculis prodire, in quibus la-
  tuerunt."  The functions of animals who sleep, or are in a
  state of torpor, during the winter, being nearly  suspended,
  the consumption of fat, which serves them for food, is necessa-
  rily proportionably small;  but that there is a sensible  dimi-
  nution on their re-appearance hi the spring has been clearly es-
  tablished.
     From the obvious effects of much sleep, in favouring obesi-
  ty, it has been affirmed, that the functions of digestion, assimi-
  lation, absorption,  and deposition, were more perfectly and ac-
* tively performed at night, during sleep, than in the day ;  but
  this opinion is contradicted by experience. They doubtless go
  on uniforndy and regularly without interruption ; hence, as
  sleep is intended to restore the powers of the body and mine!,
  as well as the juices, impaired or exhausted during the exer-
* Elem. Phys. T. 1. p. 48 
0* HYDROTHORAX.
179
 tions of the day, it will be obvious that, in constitutions natu-
rally prone to corpulence, so powerful a cause must to a cer-
tain degree be removed, by abridging the quantity of sleep,
before the effect can be expected to cease.

                        —»^J>—

   Instances of enormous corpulence giving rise to the most se-
rious inconvenience, and  eventually leading  to fatal diseases*
are very frequent in this country, from these  causes, and more
especially from the general consumption of animal food and
fermented liquors, as ale  and  porter.  A few examples of the
most  extraordinary in illustration  of  the  principles  which
have been laid down, shall next be selected.
   Mr. Johii Love was, in the early part of his life, so thin and
meagre, that a tabes, or consumption, was apprehended ; and
having, by the advice of physicians, been provided with ev-
 ery kind of nutritious food, he was led into such habits of in-
dulgence, that he resigned himself entirely to the pleasures of
the table.  Having  commenced  business as a bookseller at
Weymouth, which required little corporeal exercise, he gave
full scope to his propensity for good living, and soon grew as
remarkably corpulent and  heavy as he was  before light and
slender ;  his weight amounting to 26 stone,  or 364 lbs.   At
length, suffocated by fat, he died in the 41st year of his age,
in October, 1793.
   The following interesting case published in vol. 2d. of Me-
dical Transactions of the College of Physicians, by sir George
Baker, is strongly illustrative of what may be accomplished in
circumstances  of the greatest  corpulence, and diseases conse-
quent upon it, by a rigid adherence to the  plan of diet and
regimen we have been recommending.
   " Mr.  Thomas Wood,  a miller, at Billericay, in Essex, was
born on th c:. Hh of November, 1719, of parents who were apt 
lxt
UN HTDROIilORAA.
 to be intemperate in their  manner of living, and was subject
 to various disorders, particularly rheumatism till he attained
 uae age of 13 years.   He then had the small pox in a favoura-
 ble way ;  and from that time became health>and continued
 to have no complaints,  to the age of about forty-three years.
 From his  attaining the  state of manhood to this period,  but
 especially  during the latter  part of the time, he indulged hin>
 self, even  to excess, in fat meat, of which he used to eat vora-
 ciously three times a  day,  together with  large quantities of
 butter  and cheese.   Nor was he more cautious with respect
 to strong ale, which was his common drink.  About his  for-
 tieth year he began  to grow very fat; but finding that he
Jhad a good appetite, and digested his food without difficulty,
 and that his sleep was undisturbed he made no alteration ia
 his diet.  It was in his 44th year  when he first  began lo be
 disturbed  in  his sleep, and to complain of the heartburn, of
 frequent sickness at stomach, pain in his bowels, headach, and
 vertigo.   He was now sometimes costive, at other times in the
 opposite extreme ; had an almost constant thirst, a  great low-
 ness of spirits, violent rheumatism and frequent  attacks of
 gout.  He had likewise two epileptic fits.  But the symptom
 which  appeared to him to  be  most formidable, was a sense of
 suffocation, which often came on him, particularly after meals.
 Under such a complication of diseases, every  day increasing,
 he continued  till August, 1764, when the Rev. Mr.  Powley,
 a worthy  clergyman in  the neighborhood, observing his very
 ill state of health, and the  extreme  corpulence of his person,
 recommended to him an exact  regimen ; and pointed out  the
 " Life of Cornaro," as a book  likely  to suggest to him a salu-
 tary course of living.   This book convinced him that intem-
 perance was  the cause  of all his complaints ;  and he deter-
 mined to try the effects of a change of life.   At first he con-
 fined himself to one pint only of his ale every day • and used
 animal food sparingly.  Finding this method to answer to his 
                    ON HYDROXIIORAX,                 1§1

satisfaction, (for he felt easier and lighter, and his spirits be-
came  less oppressed,) he was encouraged to proceed ;  and af-
ter having pursued this regimen for two months, he deducted
half the quantity from his allowance of ale, and was still more
sparing of gross animal food.  In  January,  J 765, he left off
all malt liquor ; and  in  the  following month he began  to
drink water,  and to  eat only the lighter meats.   Under this
degree of abstinence, although some of his complaints  were
relieved, yet others remained in full force; the rheumatism
tormented him, and he now and then had slight fits of the
gout.   In June, 1765, he began the exercise of the dumb bell,
which he constantly persevered in.  He continued to drink
water only  till the 25th of October in the  same year; but
from  that time he abstained altogether from drink, (except
on the 9th of May the following year, 1766, when he drank
two glasses and a half of water,) and took no liquor whatever.
except what  he swallowed  in the form of medicine.  From
June, 1767, he abstained from  butter and cheese;  and the
31st of July, in the same year, was the last time of his eating
animal flesh; his diet,  from that date, being principally con-
fined to pudding made of sea biscuit.  He  allowed himself
very  little sleep, generally going to bed at eight  in the eve-
ning, sometimes  earlier, and  rising about one o'clock in the
morning, very rarely being in bed after two.
   Under this strict  course of abstinence he still continued to
live till the year  1783, expressing, in the highest terms, the
great  pleasure and tranquillity of mind which he enjoyed in
consequence of it.  The poor diet, to which he had accustom-
ed himself, became  as  agreeable to his  palate, as his former
food  used to be; and he had the additional satisfaction, to
 tind his health established, his spirits lively, his sleep no longer
 disturbed by frightful dreams, and his strength, so far improv-
 ed,  that he could carry  a  quarter of a ton weight; which
 weight he in vain attempted to  carry when he was about th^ 
 182                03 KYDRO-fliOKAS:.

 age of thirty years.  IJis voice,  which  Mas entirely lost for
 several years, became clear and strong.   In short, to use his
 own expression, he was metamorphosed  from a monster, to a
 person of a moderate size, from the condition of an unhealthy,
 decrepit old man, to perfect health, and  to the vigour and
 activity of youth.  He used much exercise, his business lead-
 ing hiinto ride a great deal on horseback; continued the exer-
 cise of the  dumb bell, and took every occasion of leisure to dig
 in his garden.   Mr. Wood was a great enemy to all fermented
 liquors, to butter, and to salt; and he found that a  pudding
 of common fermented bread was less agreeable to  his stomach
 than one of sea biscuit.  The pudding which was  his sole sup-
 port during two years,  was made as follows : three pints of
 skimmed milk, boiling, were poured on one pound of the best
 sea bispuit, broken into pieces: this was  done over night, and
 the  ingredients  were left to stand together till the following
 morning, when two  eggs were added: this compound, being
 boiled in a  cloth about the space of an hour, became a pudding
 of sufficient consistence to be cut with a knife.  Of this,  his
 quantity used to be a pound anfl  a half,  at four or five in the
 morning, at his breakfast, and the same at noon, as his dinner;
 after which he  abstained from food till  the next  day.  But
 having grown fatter under this diet, he judged it necessary to
 quit it, as  being too nutritious ; and during three months he
 lived on the following composition, viz.:  one pound of coarse
 flour, and one pint of water, boiled together.   This he was at
 first much  pleased with ; but afterwards found it disagreeable
to his  stomach, and not  easily digestible.    The pudding
 which   he  afterwards used, was composed of one pound of
flour, of which the coarse or ordinary kind of sea biscuit is
made, boiled with a pint and a half of skimmed milk, without
any other addition.
  Mr. Wood continued in this course of abstemiousness, lively,
active, and  full ©f strength, until the 21st of May, 1783, when 
                    Oil HTDROrHORAX.                18S

 he died, in the 64th year of his age, of an inflammation of hi*
 bowels, by which disease his  mother and brother had been
 carried off.  A  few days previous to his death,  he had tra-
 velled more than sixty miles on horseback, without any sense
 of fatigue.
   The principal reason which  led Wood to refrain from drink-
 ing, was, that it  excited a desire for a larger quantity of food.
 .Much drink, he  said, operates as a provocative to eating, as
 salted meats  and high sauces excite a desire for drinking.
 But in  order to be able to abstain  from drinking, the food
 should be of a moist nature, and all dry and salted meats, and
 indeed every thing commonly called relishing, should he chun*
 ned.   He did not mean to assert, that any animal can live
 without moisture; but considered eating his pudding the
 same  as eating  the  dry flour, and afterwards drinking the
 quantity of water of which it was made."  The sequel of the
 case is given in the 3d vol. of Med. Trans, by the same.  This
 ease supplies the place of volumes on the subject, by compre-
 hending every thing that can  be  said upon it: It exhibits in
 a striking manner the regular operation of the causes in pro-
 ducing, in the first place, the different stages of corpulence, in
 the next, the morbid states consequent upon it, and finally the
 salutary effects of a particular regimen, in removing both, ap-
 parently under  the most  hopeless circumstances.  It shews
likewise that the  most sudden transitions in diet may be resort-
 ed to, in  certain circumstances, not only with impunity, but
 with the most beneficial results.  Let those who are wheezing
and groaning under the load with which they have voluntari-
ly incumbered themselves, follow the example of Wood, and
they may with equal certainty get rid of their incumbrance
and enjoy, health of body  and mind, as  he did, for many
 years.
   The good effects of a diet, thus reduced and regulated, both
ih quantity and  quality, were long before illustrated  by the 
15 i                  bu hydrothorax.
texamplc and precept of a noble Italian, Cornaro : He was at
an ;arly age incumbered with a corpulent habit, but relieved
himself, and lived in health and comfort to an extreme old age,
by a rigid adherence to temperance and sobriety.  He restrict-
ed himself to twelve ounces of solid  food a day, which com-
prised one egg, and bread ;  ahd his drink to fourteen ounces,
never including more than  one glass  of wine.  See his trea-
tise sulia Vita sobria.
  What a contrast does these two instances exhibit to that of
Love, and Edward Bright, a grocer of Maldon in Essex, which
I am about to relate !  The disposition to corpulence was, in
this case hereditary ; many of his ancestors being remarkably
fat, and so early  as the age of twelve  years and a half, he
weighed  10 stone and 4 pounds, or 144 pounds.  Before he
attained the age of twenty he weighed 24 stone ; and increas-
ed about 2 stone in each year, so  that  at the time of his death
his weight amounted to 44 stone, or  616 pounds.   He was 5
feet 9 inches and a half high ;  his body round the chest, jnst    ,
under his arms, measured 5 feet 6 inches ; ahd round the bel-
ly 6 feet 11 inches; his arm in the middle, was 2 feet 2 inches
in Circumference; and his leg 2 feet 8  inches.   He died at the
early age of 30 years, in November,  1750.  The great consti-   i
tutional predisposition to fatness was here evinced by the cir-
cumstance, that from his childhood, to within three years of his
death, when lie became unwieldy, he took much exercise, and
was a nimble and quick walker.   Buc this predisposition was
not  counteracted  by his mode of living ; for he had always
a good  appetite,  and in his youth  was rather remarkable in
that respect; and he drank also a considerable quantity of
ale and strong beer : latterly his principal drink was small
beer, of which he usually drank a gallon a day.  He enjoyed
good health  during the greater part of his life; but within
the last three years he suffered several  inflammatory attack?,    (
one of which terminated fatally.  After his death, seven men 
                    ON HYDROTHORAX.                 185

of 21 years  of age were inclosed in his waistcoat, in conse-
quence of a wager, " without breaking a stitch or  straining a
button."-
  Senertus  mentions  an instance of a woman of 36 years of
age, who weighed 480 pounds, and another of a man whose
weight was 600 pounds.
  But Mr. Daniel Lambert, who exhibited himself in Lon-
                        F
don, in the spring of 1806, furnishes an instance of the great-
est bulk, perhaps, to which the  human  body has ever been
known to arrive: " He was  born at Leicester, in  177©, and
was  very strong  and active in  his youth, being  an  expert
swimmer, and much addicted  to the sports of the  field.  Be-
fore the age  of 20, he found  that he was disposed to obesity,
and in his 23d year he weighed 30 stone: when  he arrived in
London, he attained the enormous weight of 50 stone and four
pounds, or 704 pounds.  His height is five feet eleven inches.
He succeeded his father in the  office of keeper of the prison of
Leicester; and it was within a year after this,  that his  bulk
received the greatest and most rapid increase.   This he just-
ly attributed to the confinement  and sedentary life to which
he was then obliged to submit; especially as he had former-
ly been accustomed to active exercise: He is  said to have
been  temperate ; but we have no particular account of his
mode of living, except that, in his younger days, he was nev-
er accustomed to drinking, though he spent all his  evenings in
convivial parties, and at present that he drinks no  other beve-
rage than water, and  eats of one dish only at a time.  It  is
said that he scarcely  knows what indisposition is, is cheerful
and intelligent, without any difficulty in respiration, and not
disposed to  drowsiness.    Notwithstanding  his enormous
bulk, he is  able to go up stairs with great ease, and  con-
ceives himself," says his biographer, " that he  could walk a
quarter of a mile.   He measures  9 feet 4 inches, round the bo-
dy, and  3 feet 1 inch,  round the leg.   The feet and handle
                             24 
l-fc#
ON HYDROTHORAX
are not much enlarged, but the skin, distended with fat, banc*
in folds over the ankles."  See Eccentric Mirror for 1806.
   Very different from the above was his state when he exhi-
bited himself at Sudbury, in May, 1809.  He had been recent-
ly weighed at Ipswich, and his weight was 52 stone 11 pounds.
or 739 pounds.  His breathing was very laborious and diffi-
cult, even when sitting still in his  chair; his countenance was
of a leaden hue, and expressive of great anxiety ; he seemed
to have  constant drowsiness, amounting nearly to lethargy ;
though I saw him about eleven o'clock in the morning he ap-
peared as if he  had had no rest the preceding night: he an-
swered the questions which were put to him in a hurried and
abrupt manner, and  frequently made a kind  of quick con-
vulsive inspiration, clearly evincing the difficulty  with which
respiration and pulmonary circulation were performed : when
his attention was not roused he could scarcely keep  his eyes
open ;  yet his pulse was regular, and somewhat full.   He had
for some  months suffered severe rheumatic pains, which, he
said, prevented him from using exercise ; but it was obvious
that this was only a pretence to conceal his real inability; for
he  seemed  scarcely able to change his posture on the chair,
when it  became  irksome to him,  which  was  frequently the
ease from the immense  weight of his body and consequent
pressure  on the  hips.   From this cause and from the  dis-
tention of the skin, owing the accumulation of fat, the cuticle
was separated, and there were painful excoriations about the
hips and  on his feet.   The weight of his feet too seemed very
troublesome,  his attendant being  frequently called  upon to
move them from, and to re-place them on,  a stool which serv-
ed them as a resting  place.   Though Mr. D.  Lambert had
not lived intemperately for some years, yet he was not remark-
ed for those habits of strict self-denial and  abstinence, eithev
in eating  or drinking, which were necessary to render his situ-
ation tolerable; and  lie  could  enjoy a bottle of port with any 
OH HYDROTHORAX.
137
person who chose to treat him with one; his gaiety was evi
dently assumed, and forced, as his life seemed obviously a bur-
then to him.   I retired with disgust from the sight of such a
monster, observing to the clergyman who accompanied me,
that his life was  not  worth  a day's purchase, and that he
would most probably die suddenly.—-He died early the fol-
lowing month suddenly, I understand, as he was preparing to
exhibit himself at Thetford, in Norfolk.
  The above examples serve to demonstrate clearly that, un-
der the most healthy condition of the body, there is a certain
point or stage beyond which  the accumulation of fat cannot
increase, without serious derangement of the functions of some
important viscus; and the instances are indeed rare where it
advances so far without much greater inconvenience than oc-
curred in these: the most frequent seems to be that connected
with the function of respiration, appearing in the form of asth-
ma, all the varieties of dyspnoea, generally attended with
cough, and a copious yellowish expectoration, very frequently
ending in dropsy of the chest, of which  many of the  cases in
the appendix No. 1. furnish striking examples. 
 
APPENDIX
                        JVo./.

               CASES OF HYDROTHORAX, &C

     JL HE following case was published in the Medical and
Physical Journal, for March, 1802. Though not immediately
connected with hydrothorax,  it is so  interesting in many re-
spects as to appear worthy of being recorded in  this place.
Beside furnishing a subject for speculation to the Physiologist,
it  may  serve as a guide to the inexperienced practitioner
should similar instances fall under his care, by shewing him
that the operation of tapping may be performed with perfect
safety in any period of pregnancy, and by pointing out at the
same time the manner of performing it.

                        CASE I.

  On the 13th of June, 1791,1 was desired to visit Mrs. C—
qf----Hall, in Essex, a  married woman, in the 34th year of
£er age.   I found her labouring under confirmed genuine as-
cites, unaccompanied with the slightest traces of anasarca in 
2
APPENDIX.
any part of the body.   She had in a certain degree the ch*
racteristic emaciation of this disease, but not  its general con-
comitant debility.   The appetite, bodily strength, and indeed
all the bodily functions, with an exception  or two, which
shall be  presently noticed, were  unimpaired.  The eye and
countenance too had lost none of their wonted animation, for
she was remarkable for the vivacity and gaiety of her dispo-
sition.   The urine, she imagined, was somewhat diminished
in quantity, but natural in appearance.   The  origin of the
dropsical affection was dated about two  years  back ; and it
was  attributed to an injury  she  fancied she received in  her
last and  only lying-in, five years before.   This  opinion seem-
ed countenanced by the catamenia having been more or less
irregular, both as to time and quantity, ever since.   She was
supposed to have inherited  a scrophulous diathesis,  several of
her family having died of what was pronounced phthisis scro-
pkulosa.
   "Various remedies had  been used without any advantage ;
she had  been tapped three times; and the water was rapidly
accumulating, though evacuated only four days before.
   After attentively considering all the circumstances of the
case, I had no hesitation in ascribing the dropsy to disease  of
the  right ovarium: this I found to have been  the opinion  of
Dr.  Orme, of London, who was consulted in  the early period
of the disorder, and  it gained additional confirmation from
the  facts communicated by Mr. Gretton, a respectable practi-
tioner of Colchester, who had always attended her.   He assur-
 ed  me,  that on evacuating the water, an evident fullness  or
 tumefaction could  be felt  in the  right side, apparently in the
 region of the ovarium.
   The common remedies  were administered in various  com-
 binations for some weeks, but without effect.  They could
 not, however, be said to have had a fair trial, having been
taken only in small quantity, and very irregularly, owing to a 
APPENDIX.
3
 petuliar irritability of the stomach to almost all diurectic me-
 dicines.   Though every precaution was taken by the addition
 of the most grateful aromatics, and smaH doses of opium, yet
 they were seldom retained long enough to act upon the habit
 As I could not possibly be aware, of what was ascertained
 some weeks afterwards, that my patient was pregnant, this pe
 Guliar state of the stomach was at the time a source  of sui -
 prise  and  embarrassment to me, the appetite and digestion be-
 ing good.
   On my visit,  the 9th of August, when the  operation was
judged  necessary, for the first time since my attendance,  I
 found Mrs. C----'s mind strongly impressed with the belief
 that she was pregnant.—This she grounded on  the absence
 of the catamenia the two last periods, and on her having  the
 usual symptoms especially  sickness,  and  sometimes  vomiting
 in the morning.   After a lapse of five years since her lying-in^
 with  every reason to  believe the  existence  of  disease  of  one
 ovarium so extensive, as to be the sole cause  of the dropsy,
 apparently extending its morbid influence to the uterus itself,
 (if a constant irregularity  in its functions ever since, were to
 be regarded as a criteria to judge by,) besides this organ hav-
 ing been surrounded  by,  or  floating in a body of water for
 more  than two years, I could not be supposed to assent readily
to her opinion.   No inconvenience occurred either during or
after the operation.   When the water was evacuated, the  hv
pogastric  region was  fuller than usual;  so much so, as to in
 duce  me  now to think her opinion  well founded.  The en-
larged ovarium was distinctly felt on examination, but no tu-
mour perceived externally.
  In order to  avoid repetition, the different times at which
the operation was performed, and the quantity of water drawn
off each time, are specified in the annexed table,  and onh
such  circumstances  mentioned as seemed worthy of being- re-
corded 
4
ATPENDIX.
   Toward the middle of August, every doubt as to her preg-
nancy was removed, for she quickened, the motion of the foe-
tus having been distinctly and repeatedly felt by her.
   On the 25th of September, tapping being again deemed
expedient,  additional precaution  was  necessary,  with  the
view of avoiding the hazard of abortion, or of wounding the
distended uterus,  now emerged above the brim of the pelvis.
1 directed a cordial draught  with twenty-five drops of laud-
anum to be administered  half an hour before the operation;
and the patient being placed in the usual posture, I endeav-
oured to press the body of the uterus as far back as possible
with both my hands, at the place where the puncture was to
be made, while, with my fingers, the integuments were at the
same time protruded forwards.  By these precautions, the dis«
tance betvveen the parieties of the abdomen and the uterus at
this place was increased, and  the integuments rendered more
tense.  In the mean time, Mr. Gretton measured on the trochar
the lengththat was judged merely sufficient to enter the cavity
of the abdomen;  and by firmly placing the  forefinger of the
right hand as aguardupon it, prevented any more entering than
was absolutely necessary.  The puncture being then dexter-
ously made, and the stilette withdrawn, the water was evacu-
ated more gradually, the mouth of the canula being now and
then plugged up by a piece of wood prepared  for the purpose;
and a more regular uniform pressure was preserved by means
of a proper bandage.  No untoward circumstance  occurred
either during, or after the operation.
  Before the whole of the water was removed, the motion of
the foetus was not  only felt with great force against the haw'
but distinctly seen through the integuments and flannel band-
age.
   November 9th, she had incessant sickness and vomiting,
with severe uterine pains which threatened abortion the whole
of this morning.   The breathing was much interrupted, and 
APPENDIX.
&
    she suffered great inconvenience, from distention of the integu-
    ments of the abdomen. As these evidently proceeded from in-
    ordinate pressure on the diaphragm, uterus, and other abdo-
    minal viscera, the operation having been too long delayed, so
    they all speedily vanished on the evacuation of the water.
    Some part of the fluid was tinged with blood, and considerable
    delay and inconvenience were experienced from the pressure
    of the uterus against the canula; yet she made no complaint
    either during or after the operation.
      December 30th, she bore the operation better than usual,
    being in high spirits  the whole time; though the motion of
    (the foetus occasioned her much uneasiness, and though greater
    delay was experienced than before.   During the latter months
j    of pregnancy, she became, as might naturally be imagined, ex-
\    tremely  heavy and unwieldy, especially for some days before
    the two last tappings: yet  her strength, appetite, and natural
    vivacity continued unimpaired to the last;  and on the 24th
    of January, 1792, she was delivered of a strong, full-grown
    boy, after a very easy and  quick labor, before Mr. G. her ac-
    coucheur, or myself arrived.  The boy is now living, and is
    remarkably strong and healthy.
      Her recovery was unusually  rapid, though there were sev-
    eral pints of fluid in the cavity of the abdomen at the time of
    her delivery,  and though  it accumulated so quickly  after-
    wards as to require being drawn off in eleven days.
      It may be worthy of remark, that after this period till the
    sudden change which preceded  and occasioned her death, she
    affirmed, her general health appeared rather to improve than
    otherwise ; a circumstance to be wondered at, considering the
    immense quantity of matter that had been for a great length
    of time collected within the  body, as will  be seen in  the  dis-
    section.   It serves however, I think, to illustrate and confirm
    a  fact in pathology, which  is now generally admitted, that
    what is called well digested or concocted pug, whether it be
                              25 
                        -PFrENDlX,

shut up in a cavity, exposed to the air, or carried to the habiH
through the medium of the absorbents, is productive of no-
inconvenience, either to the surfaces on which it rests, or the
constitution at large:  so aware is every judicious 6urgeon of
this, that he cautiously avoids exposing the tender and irrita-
ble granulations of healing wounds and ulcers by wiping their
surfaces too clean.  It seems at the same time to prove, what
is I think likewise allowed,  and what  I have more than once
observed, that the ovaria are endowed with comparatively less
acute feeling than perhaps  any other part of the body; for in
the present instance,  the mechanical stimulus of distention oc-
casioned no  uneasiness.  What other part or organ would
have suffered so serious an injury and so great a degree of dis-
tention  without proportionable  inconvenience both local  and
constitutional ?
  It is interesting too, to observe the influence pressure had
on the accumulated fluids during the last month, as  might na-
turally be expected,  when the uterus  was attaining its utmost
extent of size,  and when,  consequently, the pressure on the
numberless  exhalant and absorbent mouths  opening into the
cavity of the abdomen was the greatest, the effusion was pro-
portionally  retarded.  This  did not  occur so uniformly and
regularly in the preceding months, for the obvious reason  that
it must  have been influenced by various causes and circum
stances which did not now  exist.   But while the mechanical
influence of pressure,  muscular, and arterial aetion inproniot
ing lymphatic absorption and circulation, is to be admitted t
a certain extent, yet I am far from assenting to the notion o
some modern physiologists, that they are the sole agents concern*
ed in producing these effects.  The operation was in this  c
performed  in the usual place on the left side.   Wou Id a pu
ture with a lancet at the umbilicus, as recommended by the
learned president of the London Medical Society, Dr. Sims,
be a more  simple, easy, or  safe mode of drawing off the w*- 
APPENDIX.                      £
 £er in similar cases ?  I am induced to  think  it would not.
 It might,  probably, succeed equally well in  the  early stages
 of pregnancy ;  but the pressure of the uterus, after the fourth
 month, against the  opening thus made,  would very  soon be
 such as to require the introduction of a  female  catheter, or
 similar instrument, to push it backwards; and it is well known
 that a round instrument passed into an opening made with a
 lancet would occasion much pain and inconvenience ;  more so,
 I am persuaded,  than our patient experieHced.   For these
 these  reasons,  the  method adopted with so  much success
 in the case of which the history has been given, claims, I think,
 a decided preference.    A large female catheter was occasi-
onally introduced through the canula,

    DATES OF THE DIFFERENT TAPPINGS, &e.
When tapped.	1 No. of Pints.	Days intervening	. Pounds weight,
1790. August 23. 1791. March 23. June 9. August 9. September 25. November 9. December 30. [ 1792. [January 24, [ delivered. I	11 25 33 33 37 38 18V*	212 78 61 33 45 5*	12a# 28* 38 37 42 41 U 213
    1 his was not weighed, only guessed at; but all the other times the
water was accurately weighed and measured, either by, or in the presence
of the husband of the lady ;  and from  the period of ray attendance, m
my presence also, 
3
APPENDIX.
When tapped.	No. of Pints.	Days intervening i	. Pounds weight.
	189*		213
1792.			
February 4.#	27	36	30*
March 2.	18£	26	20
April 11.	44	40	51
May 9.	44	28	49* '•
June 6.f	36	28	40
June 11, died.			,
	359$		404
                     DISSECTION.

   Permission having fortunately been obtained to inspect the
body, Mr. Gretton very.obligingly attended to conduct the
dissection.   On opening the abdomen,  a sac of considerable
size was observed  in the right side of the hypogastrium, and
nearly filling the right iliac region.  This was found to be the
right ovarium attached to the uterus  by a thick neck, and ad-
hering anteriorly to  some extent to the peritoneum.   It was
partially collapsed, owing to about two pints of its contents, a
thick, brown, well  digested  pus, having escaped through an

  * About an ounce of thkk good pus issued  from the opening, at the
close of the operation.
  f The evening after the operation of this date, a train of symptoms
came on, which left no room to doubt the gradual approaches of the fatal
event which soon followed.
  X The case of Lady Page  Turner, related by Dr. Mead,*  though more
remarkable that this for the number of tappings and the aggregate quanti-
ty of water evacuated, is less so in other respects, in so far as none of
them were performed during pregnancy, and  as there appeared no mate-
rial disease of any organ, though the dropsy was supposed to have originat-
ed in. the ovaria.
* Afomt. et Frxcepta Med.p. 148, 
APPENDIX.
U
 opening on one side, sufficiently large to admit three fingers,
 into the cavity of the abdomen.  Neither  the  uterus nor
 left ovarium shewed  any marks of disease.  The os tinene
 seemed to be closed by a gelatinous-like substance, which h>
 duced me to think a second  impregnation had taken  place.
 But my esteemed friend and  preceptor, the celebrated profess-.
 or Munro, to whom the  parts were transmitted, after having
 been carefully removed and preserved in spirits, assured  me
 that this was not the case.
  On  dividing the sac,  it was very thick but of a soft and
 spongy texture, extremely irregular on its internal surface, and
 containing upwards  of three pints of matter similar to that
 found in the  cavity of the abdomen.   The external surface of
 the intestines, both great and small, was very considerably in-
 flamed, verging in some places on gangrene; and it was smear-
 ed all over with the matter which escaped from  the  abscess,
 of which the greater part was contained in the pelvis.  The
 liver was softer in its texture; and its connecting ligaments
 more relaxed and elongated than natural.  The other viscera,
 as well as those of the  thorax, were sound.   The head was
 not opened.
  The inflammation of the intestines, not the mere rupture of
 the abscess, was, without doubt, the immediate cause of death;
 and that this  was occasioned by the morbid stimulus of the
 purulent discharge from the sac seems equally probable ;
which shews, that though good pus be productive of no incon-
venience to the surfaces by which it is  secreted, it is highly
noxious to others.
  Had this case  occurred to  me  at an earlier period, before
suppuration,  and impregnation  had taken place, and before
the  stomach had, by sympathy with the uterus, in consequence
pf the latter, acquired such inordinate susceptibility to  medi-
cine, I think it probable the event might have been more fa-
vourable.  I  am  inclined to draw this inference from thefor-i 
10
APPIiKDIX.
tunate results of two similar cases  which fell under my care
not long afterwards.
  The case of Dame Gregory  Page, referred to in p. 8, of the
appendix, is in many respects highly interesting.—-It appears
that the first year fifty-four pints were drawn  off by tapping
every month.  The following year so  great a quantity was
evacuated that twelve pints  must have accumulated every
week.  The third year the water began to diminish so that
only twenty pounds were taken away every month.  But the
fourth and fifth years she was tapped only three times in six
and seven months, and no more than sixteen pounds removed
every time.
  During the intervals of tapping she was lively and cheerful,
$njoying the society of her friends, and even dancing at balls,
as before the attack.
  After the last tapping her general health, strength, and spi-
rits began to decline, and a dropsy of the chest being added
to her former sufferings, she gradually sunk under them.
  u It is truly wonderful," says the learned author,  ?«that in,
such a period of time, so large a quantity of water as 1920
pounds should be supplied from the human body, which ap-
pears to have been first collected in the ovaria."
  She directed  in her  will that a monument should be erect-
ed to commemorate so extraordinary a circumstance, with the
following inscription :-r-

              Uere lies Dame Mary Page,
          Relict of Sir  Gregory Page Baronet.
     She departed  this life March  iv, MDCCXXVIIl
              In the  LVI Year  of her age*
     In LXVII Months  the  was  tapped LXVI  times,
        Had  taken  away CCXL Gallons of  Water,
            Without ever repining at her case,
             Or ever fearing  the  operation. 
                       APPENDIX.                     U

   The monument was erected in the fields, called BunhihV
fields, near London.
   The following case is inserted merely with the view of shew-
 ing, among many  other instances, peculiarity of habit, ae
 strongly predisposing to the disease, not having at this period
 begun to presei '?e minute reports of any case.

                        CASE II.

   January 24,1791.—Mr. Ellis, a farmer, of Fordham, MU
 60; a man of thick short make, and very corpulent.   Strong-
 ly marked symptoms of  hydrops pectoris, with hard anasar-
 cous swellings  of legs.   Blind from a cataract of both eyes.
 Was  prescribed squills,  calomel, and extract of gentian in
 pills, with crystals of tartar largely diluted.  Returned some-
 time afterwards much relieved;  but hearing no more of him*
 presumed the disease soon triumphed over medicine.

                        CASE III.

   April 29, 1792.—Mr.  Hammond, of Cavendish, a  farrier
 and blacksmith, .flit. 50.  Addicted for years to  excesses in
 drinking intoxicating liquors.  Has strongly marked symp
 toms of hydrothorax, attended  with oedematous swellings of
the ankles.   This man applied to me more than once for dys-
 peptic and other symptoms, consequent on intemperance, be-
fore the dropsy commenced.  He was  repeatedly relieved by
medicine, but  persisting in his habits of drinking he fell a sa-
crifice to  the disorder, about two years  afterwards.  This case
is introduced with a view of shewing the influence of peculiar-
 ity of  habit in predisposing to certain diseases more than <© 
12"
APPENDIX;
 others.  Two of his brothers, the one  a butcher, the other a
 carpenter, but equally addicted to the bottle, died of the
 same disease, after having experienced much and frequent re-
 lief from medicine.   They were all men of low stature, of a
 thick make, and corpulent.  Two of their wives died also of
 dropsy.

                        CASE IV.

   Mr. Joseph Bell, JEt. 53.  Every symptom  of  hydrotho-
 rax, together with cough and copious yellowish expectoration.
 Derived great benefit  from blisters,  squills, the resinous bal-
 sams, and other diuretics, but how long he  survived after-
 wards I had no opportunity of learning.

                        CASE V.

   August 18.—Mrs. Riddleston, of Lawford, Essex, JEt. 46,
 the mother of several children.   Confirmed genuine ascites of
 more than three years standing, apparently arising from dis.
 eased ovarium.  Has taken many and various medicines with-
 out any relief.  The enlargement of the abdomen being very
 considerable I advised  tapping, before any medicine was tried,
 to which,  however, she  would not submit.   I held out no
 prospect of success.  She was, however, permanently cured by
persevering in the following medicine, and is  now  in perfect
health. #
  Hr. Nitri pur. 9ij.  Scillse Pulv. gr. viij.  Calomelan. gr. ij.
 Zingiber, pulv. Bi. teresimulet Syr. Zingib. q. s. ft. Boli viij.
 Sumat. i. mane, merid. et h. s. cum mist, infra praes. cyatho.
  fti Bacc. Juniper, contus. 3 ij- Infunde in Aq. ferv. lib. ij.
per horas aliquot; dein cola, Colatur. Adde Kali Acetat. 3 ft.
 Sp. Juniper. C. 3 ij- M.
• October, 1808. 
APPENDIX.
13
  Though this is hot a case of hydrothorax, yet it deserves to
be recorded as an inducement to a perseverance  in a similar
Course of medicine, even under the most unpromising circum-
stances,

                        CASE VI.

  August 31.—Mrs. B. the wife of the Rev. Mr. B. late of Bu-
Ires, Et. 30.  Confirmed ascites, of several weeks standing, evi-
dently arising from a considerable enlargement of one ovarium,
for which various means were prescribed under the direction of
Mr. Cline, prior to the appearance of dropsy.  Mrs. B. is a wo-
man of low 6tature, of delicate frame, and lax fibre, disposed to
corpulency, and the mother of several children.   The leg and
thigh of the same side with the diseased ovarium were ana-
sarcous to a  very great  degree, but those of the other side
were not affected.   Was  perfectly and permanently cured by
a plan  similar to that prescribed for the subject of the last
case; but with larger doses of calomel, and the occasional ex-
hibition of mild laxatives of crystals of tartar and jalap. Had
two children since her recovery, before she left this country,
about three years after she first consulted me.  I have not
heard of her lately.

                      CASE VII.

  October 7.—-Mrs. F. ELt. 60.  Extreme  difficulty in respira-
tion, especially on  motion; paucity of urine, anasarcous swell-
ings of ankles, and other symptoms which left no room to doubt
the presence of water in  the  cavities of the chest.  She was
extremely weak  and emaciated.   I prescribed an electuary,
consisting of crystals of tartar,  the cynchona, and pulv. aro-
mat. made with syr. zingiber: but it disordered the bowels,
and weakened her so much that it was discontinued; and tihe
                            26 
14
APPLNDfT
 digitalis, by which she had been repeatedly relieved, under
 the direction of the family apothecary, was resumed.  Her
 life was protracted for several years afterwards by this herb.

                       CASE VIII.

   August 28, 1794.—Mrs. B. the wife of my worthy friend
 Admiral B. Mt. 42.  Of low stature, slender make, and deli-
 cate constitution.  Great difficulty in breathing, especially on
 the least motion, or on going up stairs.  Extreme languor and
 weakness;  and is subject to fainting fits at times.   Pulse about
 100, feeble, and intermitting every three or four strokes.  An-
 asarca of  feet and ankles;  urine defective;  no thirst; T.
 clean ; appetite tolerable.  Alvus astricta  cumflatu ac borbo-
 rigmi.   Has been extremely delicate  for some years, and sub-
ject to nervous complaints.  Only one child, four years since.
 I suspect effusion in  the pericardium,  as well as the sacs of
the pleura.  Was restored to  perfect health by the following
 plan and has since enjoyed better health than before.
   ft.  Mass. Pilul. Scillas 3i. Camphors Pulv. Bi. Canella? alb.
Pulv. gr. v.  M. ft. Mass. in Pilul. xx. divide; Sumt. ij. ter
ind. cum mist, infra pries, coch. No. iij.
   ft.  Colomb. Rad. P. 3i. Cort. Aur. P. 3ij. Semin. Coriandr.
eontus. Dij. Infunde in Aq. ferv. 3 viij. per hor. vi. dein cola;
Colat. 3vij. Adde. Sp. Juniper. C. 3i- Kali pp.  9ij. ft. mist.
   ft. Cryst. tart. P. 3iij. Conservas Cort. Aur. 3i. R.ad. Rhab,
P. 9ij. Syr. Zing. q. s. ft. Elect, molle, cujus Sum. coch.  min.
sing  mat. vel p. r. n.
  The dosfs  were varied occasionally, and the medicines, aid-
ed by mild tonics and appropriate regimen, persevered in, till
the water was evacuated and every unpleasant symptom re-
moved.*
  * This amiable lady passed some days  at my  house, in September
<E0C, after an absente of more than 10 years from tbia country, and I 
APPENDIX.
15
                         CASE IX.

    January 27, 1795.—Mr. Mumford, a  farmer of Grotton,
 Mt. 60.   A bachelor, brother to the subject of case 74. Tall
 but corpulent, and naturally of a florid complexion.  Strong-
 ly marked symptoms of hydrothorax ; with cough, palpitation
 at times, and irregular pulse.   By means similar to those used
 in the foregoing cases, occasional blisters to the sternum, and
 the digitalis,  the disorder was kept in check for upwards of
 two years afier my first visit.

                         CASE X.

   March 20—Mr. Ling, of Stoke  by Clare,  a butcher, JEt
 .ibout 60, extremely fat and corpulent.  Addicted to the free
 use of strong  beer and other intoxicating liquors.  Extreme
 dyspnoea ; palpitation; cough, with copious viscid yellow ex-
 pectoration ;  intermitting pulse, inability of  lying down  in
 bed, or of walking quick, without being threatened with imme-
 diate suffocation.  I suspect water in the pericardium as well
 as in the other cavities of the chest. Was immediately relieved
 by squills, the lac amnion, blisters, and the common diuretics;
 but neglecting medicine and the other injunctions, and persist-
 ing  in his favourite  gratification, he died  suddenly  a few
 months afterwards.

                        CASE XI.

   May 31.—Mrs. Bigg, of Glemsford, very fat and short, JEt.
 70.  Distinctly characterised hydrothorax ;   with anasarca

had the gratification in finding she had no return of the dropsy, and that
she> enjoyed  better health than before the illness which has been detailed
above, 
16
APPENDIX.
 of lower extremities.   All the symptoms almost immediately
 relieved by the means prescribed ; but refusing to persevere
 in medicine, for more than a fortnight, the disorder returned,
 and she died a few weeks afterwards, as I prognosticated to
 her friends, suddenly.
   I had hitherto prescribed the digitalis only in an irregular
 and casual way,  and my success was not such as to encourage
 farther trials.   But  often observing no  sensible effect either
 good or bad from what I had reason to believe were full doses
 of it, I began  to  suspect the quality of the preparations that
 were used.   Accordingly about this time I took some pains to
 procure  the herb genuine, and began to cultivate it in my
 own garden.   The result I have every reason .to be satisfied
 With ; indeed it has exceeded my most sanguine expectations.
 The fortunate  issue of the following case, the first that occur-
 red afterwards, induced me to pay still further attention to it«i
 preparation and exhibition.

                       CASE XII.

   March 12, 1796.—Mrs. E. JEt. 40, the mother of several
 children;  of  a  constitution naturally delicate, and  much
 weakened by the cares and fatigue of a large family.   Has oc-
 casionally consulted me for three  years back, for complaints
 which indicated great weakness and irritability of the heart
 and lungs, having been subject to quick, hurried, and difficult
respiration, attended frequently with palpitation, orfluttering,
as she termed if, of the heart, increased on bodily exertion or.
emotion of mind.   Of this date I find the following memoran-
 dum in my case book : " Symptoms  of hydrops pectoris."
 A blister was directed to be applied to the chest, and some
 expectorant and  diuretic  medicines were prescribed which
soon removedL her complaints. 
APPENDIX.
i;
  June 23, 1798.—I find her again on  my report book, with
the same symptoms, for which similar remedies were prescrib-
ed.
  July 13.-r-No relief from the last medicines.  In  every re-
spect worse.  Respiration  very much interrupted, especially
on motion, or on lying down  in bed.  Pulse quick, feeble, and
extremely irregular; urine very small in quantity, and high-
coloured, with sediment ;  ankles and legs oedematous.  Sup-
poses herself in the fifth month of pregnancy ; and there is ev-
ery reason to suspect the foetus has been dead for a fortnight,
in which  period her complaints have made very  rapid pro-
gress.  Has for  some months suffered great  mental anxiety
and  uneasiness,  from  causes unnecessary to  state here ; to
which her present illness is to be attributed.
   ft. Dig  Purp. fol. nostr. pulv. gr. j. Confect. arcm. q. s.
ft. pilul. nocte maneq. cum mistur. infra  prses. coch. No. ij. s-
   ft. Fol. Dig. Purp. incis. 3j.  Infunde in Aq. ferv. ^viij. per
nor. iv. dcin cola,
   ft. Infus. Colat. 3v. Spt. Juniper C.  3ft. Spt. JEth. Nitr
Spt. vEth. Vitr.  C sing. 31J.  M.
   Particular injunctions  were  given to discontinue the Fox-
glove as soon as it produced any of its unpleasant effects.
   July 17.—I heard no  more  of her till the  evening of this
date, when my  immediate attendance was desired.   I found
her retching violently, and bringing up at times a dark colour*
ed matter, like coffee grounds;  the extremities cold; the
pulse extremely  small, fluttering, and irregular ; had frequent
faintings,  or to  use the language  of those about  her, " they
could not keep life in her ;" and the body was covered with
cold sweats.  She had been in this state for several hours :
the cause  of these alarming symptoms was sufficiently obvious.
On inquiry, I found she had experienced immediate relief from
the medicines ; that the quantity of urine was  very much in-
creased ; the swellings nearly gone, and that she was considered 
 I&                     APPENDIX.

 as mending very rapidly till this morning* when the stomach
 began to be disordered.  I found also that she had been un-
 der the influence of the Foxglove nearly two days;  yet, in di-
 rect  contradiction to  the  directions  rigidly  enjoined,  she
 was  desired to continue it this morning!  it was in vain that
 relief was  attempted through  the medium of the stomach ;
 for every thing  liquid, even in the smallest quantity, was im-
 mediately rejected.  By an Anodyne Glyster, warm Anodyne
 Embrocations rubbed  into the  Epigastrium,  Abdomen, and
 Feet, small pills of solid Opium with  Confect. Aromat.; all
 the urgent  symptoms subsided in a few hours, and I had the
 pleasure of leaving my  patient in the morning quiet and com-
 posed.
  She continued gradually to mend from this  time till about
 a fortnight  after, when she miscarried  of a foetus which bore
 evident marks of having been dead at the time she apprehend-
 ed.  The water now began to  accumulate in the chest and
legs with unusual rapidity, and with it all her former distress-
 ing symptoms  returned.—^But  although  her strength was
 nearly exhausted the water was speedily evacuated by the
same  means ; and by a combination of tonics with diuretics,
 lie was restored to health in a few weeks.—She has had no  re-
turn of the dropsical symptoms, but has had occasional attacks
of her former complaints, and always received advantage from
medicine.   On  the whole, her health  has been of late years
improved.
  In every point of view this case will  appear interesting:  an
amiable woman has been rescued from a very alarming state,
by a remedy which, by the most flagrant inattention, had near-
ly proved her destructions
  The result of this case impressed on my mind so favourable
j.n opinion of the  Foxglove, that I determined to direct my
attention more than ever to  it: from this period it has always

     * Mrs. E. was living and in good health in November, 1803. 
APPENDIX.
19
 formed  a part of my  remedy  in  dropsy ;  and my failures
 hitherto having been as much owing to the quality of the herb
 used, as to my ignorance of the proper dose and mode of exhi-
 bition, I furnished the practitioner with whom it was prescrib-
 ed with a portion of the leaves out of my own garden.  Hav-
 ing been absent from Britain when Withering's excellent work
 was published, and for  some years afterwards, I  had not the
 good fortune of seeing it at this time, and of borrowing light
 from so safe a guide.

                       CASE XIII.

   April  19.—Mr. Williams, Et. 54.   A draper  and master
 taylor, very  corpulent, with lax fibre ;  addicted for years t6
 the free indulgence in intoxicating liquors, at all hours; but
 not often to the degree of absolute intoxication.
   Breathes with extreme difficulty, especially when he walks
 quick, or attempts to lie down  in bed.    Is  often  suddenly
 roused from sleep by a sense of suffocation,  pulse very irregu-
 lar, and  intermitting ; legs  anasarcous;  urine small  in quan-
 tity  ; high coloured, with copious  sediment.   These com-
 plaints have  been  coming on for several months.   Has been
 taking the digitalis in small quantities, and other medicines un-
 der the direction of his apothecary, for some time, with advan
 tage at first;  but the disease has gained ground rapidly of late.
   A blister was applied to the breast; the digitalis in pow-
 der, oxymei scilhe> warm  antispasmodics, and saline diure-
 tics were prescribed,  which in about three weeks seemed to
 remove the serous effusion from every part.
 May 21.—With the view, if possible, of eradicating the com-
plaint, the following was ordered.
   ft. Scilhe Pulv.  gr. iv. Cabin, gr, ij. G. Ammon : Sapon.
5a. 9j. M. ft.  Massa in pilul. xij. divid. Sumt. duas  mane et
vesp. cum haust. infra pries. 
so
APPENDIX.
   ft. Oxym. JJcilla; 3ij. Sp. nucis mosch. muc; G. Arab.i
3ij. Aq. Hyssop. 3iij. Sp. Mlh.  Vitr. C. 3I M. ft. haust.
   By the use of these means, with appropriate regimen, which
last however was not rigidly observed, the dropsical symp-
toms  were subdued, and  his general health was very much
improved  for two years;  But continuing his former mode of
living, the water began again to accumulate, and all the  for-
mer symptoms returned with additional violence.
,   May, 1798.—I was desired to see him.   He  had been unj
der the  care of the  family  practitioner for some  time; by
whomjhe dropsical symptoms were more than once removed
by the same remedies.   His constitution,  however, seemed
now nearly exhausted.  Instead of being full and corpulent
as I left him before,  he was much emaciated, especially  the
lower extremities, which were likewise extremely cold and of
a livid hue, with very little sensibilty.   He had been confined
to bed for  some  time, and  could breathe  with  perfect
freedom ;  the blood was propelled with so little force by the
feeble fluttering contractions of the heart as scarcely to  be
said to circulate in the more distant parts, so that the pulse at
the. wrist could seldom be felt; and it  was extremely irregu-
lar.   For many days before his death, which happened on the
5th of June, his feet and legs as high up as the knees, were of
a dark purple hue, perfectly cold, and without any circulation
or feeling,  the cuticle separating in  different  parts in gangre-
nous vesicles containing a dark coloured ichor.
   The digitalis in combination with the other means perform-
ed every  thing that could be expected fr..m medicine; for
the dropsy, aud even the disposition to  it,  had been removed
for some months prior to his dissolution ; but it could not be
expected to restore a constitution  exhausted by a  long  and
uniform career of intemperance. 
APPENDIX.
21
                      CASE XIV.

  March  7,  1797.—Mr. Driver, M. JEt. 60.  A farmer of
the parish of Edwardstone;  naturally of a florid complexion,
and still corpulent.  Has committed occasional excesses, but
can scarcely be said to have been addicted to the bottle.
  Complains of a sense of distention, oppression, and what he
terms a " fluttering," about the epigastrium, with flatus, in-
creased after eating.—Appetite good.
  At this time I had no suspicions of dropsy, but considered
the symptoms as arising from dyspepsia, and prescribed ac-
cordingly.
  March 14.— In every  respect worse, the symptoms already
mentioned  having increased, with the addition  of frequent
palpitation, especially on quick walking.  I did not as yet sus*
pect any dropsical tendency.  Prescribed under the  first im-
pression.
  March 19.—He had hitherto come to me; but being now
worse in every respect, I was desired to visit him at  his own
house.  He had extreme difficulty in breathing, increased on
the  smallest motion ; and was threatened with suffocation on
attempting to  lie down.   His pulse was very irregular and
intermitting.   For a few days the urine began to assume the
characters of dropsical urine, and was much diminished in
quantity.   The ankles were somewhat oedematous.   The na-
ture of the disorder seemed now  too clearly marked  ; and I
apprehended his life in immediate danger.
  Quamp. Admov. Empl. Canth. Sterno.
  ft. Mist. Camph. 3j. Muc. G. Arab. 3j. Sp. JEth. Nitr. Sp.
Eth. Vitr. C. 5. 3 ft. M. ft. haust. sextis horiss.
  ft. Mass. Pilul.  Scilhe 3j. Calom. gr.  iv. M. ft. PHute xv
Sumt. ij. sing. noct. et mat.
                           97 
22
APPENDIX
   March 22.—Immediate relief from the  blister; and iu  h-
 every respect amended.   Urine increased in quantity.
   ft. Dig. Purp. fol. pulv. gr. ft. Scillae Pulv. gr.  j. Zing. P.
 gr. ij. Confect. Arom. q. s. ft. bolus sing. noct. et mat. s. Per-
 gat in usu haust. u. a.
   I directed the digitalis to be increased until  it  produced
 some sensible  effect on the habit.#
   April 8.—Urine considerably augmented in quantity and
 natural in appearance ; and all his unpleasant symptoms near-
 ly vanished.  No sensible effect on the head or stomach from
 the  digitalis, though it has been increased to gr. jft. iu ice a
 day.
   ft. Scilla.%  Digital. P. Zingib. Pulv. a gr.  ij. Calomelan.
 gr. ft. Confect. Aromat. q.s. ft. bolus sing. noct. et mat. cum
 haust. infra prses. s.
   ft. Lact. Myrrh* 3j- Oxym. Scillae 3ij. Sp. .Eth. Nitr. 3j.
 Kali Acet. gr. xv. M. ft. haust.
   April 17.—Continues to improve and recover strength pro-
 gressively.—Was desired  to persevere for some time  in the
 following medicines; to live well, use much exercise  in the
 open air; to  refrain from beer, but now and then  to  drink
 gin punch.
   ft. Crystal, tart. P. 3vi. Cinch. Angust. P. 3 ft". Cons. Cort.
 Aur. 3fS- Zing. P. 3J. Syr. Cort.  Aur. q. s. ft.  Elect,  molle,
 cujus Sum. coch. min. ter  ind.
   ft. Scillae'Pulv. gr. ij. Opii, Colom. aa. gr. ft. Itlyrrhsegr.
 vi. Confect. Aromat.  q. s. ft. Bolus sing. noct. s.
   In a few weeks he wa« restored to perfect health, and  con-
tinued well till March 10th, 1798, when he again  applied to
 me, as w ill be seen in course.

  * I cannot now account for the digitalis not having been ptescribed cg
the 19th, only by supposing  the apothecary had ncue of it, and waited
 till I should aippl}' him at wy next visit. 
AtTJSNDIX,
23
                        CASE XV.

   April 13.—Miss I. JEt. 50.  Has lived a sedentary life for
several  years.  All I find recorded  in  my  note-book of this
date is  as follows:  "Symptoms, of Hydrops Pericardii."
Pulse very irregular ; urine tcanty and high  coloured, with
sediment on cooling.
   ft. Dig.  Purp. Scillae P. a.  gr. jft, Zingib. Pulv. gr. j. Con-
fect. Aromat. q. s, ft. Pilula  mane et vesp. cum haust u infra
prass. s.
   ft. Mist. Camph. 3vi.  Solut. Myrrhae Muc. G. A v. aa. 31J.
M. ft. haustus.
   As far as I could recollect  the particulars of the case some
months after this  period, she had  little or no interruption in
breathing,  except on walking or going up stairs.  A peculiar
fluttering about the heart, amounting at times to palpitation,
with great weakness, a disposition to fainting, and inability of
lying down in bed, were  the principal symptoms.
   By pursuing the above plan for some time,  and increasing
the digitalis, until  the habit  was  sensibly under its influence,
and afterwards by the use of tonics, all these symptoms gra-
dually disappeared, and  she  has continued free from any re-
turn.*
   She  consulted me a year or two before this attack, for what
appeared to be dyspepsia, and was  soon cured.

                      CASE XVI.

   April 16.—Mrs. Newman, JEt. 43.   The  mother  of se-
veral children.   I  ouly find  " Symptoms of  Hydrops Peri-
cardii,  with general anasarca," in my  report-book.   After

  * I heard she died in 1807, whether of dropsy or not I had no oppor-
tunity of knowing. 
24
APPENDIX.
 having experienced relief repeatedly from the  digitalis and,
 Other means,  the disorder at length resisted every effort  that
 was made to remove it, and proved fatal some months after-
 wards.

                       CASE XVII.

   •May 26.—Mr. Partridge,  a farmer, .Et. 74.   The uncle of
 the subject of case  34.   A man of short stature, and corpu-
 lent.   Not addicted to intemperance, but partial to his own
 old home brewed ale, which I found to be of an excellent qua-
 lity, but extremely strong.  Breathing exceedingly quick and
 difficult, especially on the least exertion, or on talking;  and
 performed with a peculiar wheezing noise.   P.  frequent, fee-
 ble, and  intermitting.   Countenance in health  very florid;
 but now,  especially the  nose, very livid.   For several  days
 and nights has been obliged to sit up in an elbow chair, being
 threatened with immediate suffocation when he  attempted to
 lie down.  This has occasioned considerable swelling  of his
 legs.   Urine very small in quantity, high coloured, with thick
 sediment.  Has been subject to asthmatic cough, with  diffi-
 cult breathing, for some years.
   ft. Fol. Dig Purp. gr. j. Zing. P. gr. ij. Confect. Arom. q. s.
 ft. bolus mane et vesp. cum haust. seq. s.
   ft. Fol.  Dig. Purp. incis. 3j. Aq. ferv.  3vj.  Infunde per
 hor. iv. dein cola;
   ft.  Infus. Colat.  3j. Oxym. Scillae 3J. Sp. Eth. Nitr. 315.
 Sp. M. Pip. 3ij- M. ft. haust.
   May 30.—Breathing and every other symptom much re-
lieved.  Urine increased in  quantity.   Three loose  motions
yesterday and  two to-day.  Pulse still irregular.   The digi-.
talis appearing to have produced the desired effect, it was dw:
 continued. 
APPENDIX.                      25
  ft.  Myrrhas gr. x. Aq. Pulegii 3j- Kali Acet. gr. xv. Sp.
jEth.  Nitr. 3j. Sp. Menthae Pip. 3ij- M. ft. haust. mane et
vesperi cum Pil. infra praes. No. ij. s.
  ft. Scilla? Pulv. gr. iv. Kali Acet. gr. xv. Zing. Pulv. gr. v.
Confect. Aromat. q. s. ft. Pilulae viij.
  In  about a fortnight more he was restored to his  usual
health, and continued free from any dropsical symptom du-
ring the remainder of his  life, which was terminated the lat-
ter  end of January,  1800, by pneumonic inflammation, in
which I attended him.

                      CASE  XVIII.

  June 5, 1797.—Mr. Carr, of Boxford,  Mt 66, called  for
my advice.   He was of the middle stature, neither robust nor
muscular; not addicted to any excess in drinking; within a
few years he had retired from an active business, and lived a
sedentary, studious life ;  but he enjoyed good health before
the illness to which he dates his present complaints.
   Breathing quick, hurried,  and anxious, especially on  any
sudden bodily exertion or emotion of mind, attended frequent-
ly with palpitation, and what he called a  " fluttering" about
the heart;  pulse feeble, irregular, and intermitting;  feet  and
ankles oedematous towards evening, and  readily  pitting on
pressure ; urine natural in every respect; can lie down in  bed
on  either  side without any  inconvenience; has  never been
roused from sleep by a sense  of  suffocation; appetite  good;
bowels regular ; bodily strength much impaired.
  About three years since had an attack of Hemiplegia, in which
 I attended him, and from which he  soon recovered ; a slight
degree of weakness of one side, and distortion of the mouth, on-
ly remaining.—In this attack the  pulse intermitted, since
 which it never recovered its former regularity;  and  he re-
 marked that his breathing had not been so free as before. 
26
APPENDIX.
   Being about to remove  to Colchester, his native place, I
was  glad of the opportunity of committing my sentiments of
his case to paper, to his nephew Mr. NeweJI, a Medical Prac-
titioner of experience and reputation, who resided there; as
well  as of the  plan I  thought best suited to obviate present
and remote evil.
   Having been fortunate in meeting  with five well marked
eases of watery effusions into the cavities of the chest, some of
which I was now attending, and which  were doing  well;
since the subject of the former case fell under my care;  1 had
no hesitation  in  predicting the approaches of a serious and
formidable disease, namely, serous effusion, most probably, in-
to the pericardium; and that  although it might not as yet
have commenced, such a morbid state  of the heart existed as
would eventually, and, without proper precautions,  speedily
lead  to it.
   In addition to the medicines prescribed, I directed a nu-
tritive, chiefly meat diet, with  a glass or two of old generous
'vine at dinner; exercise on horseback daily;  diligent fric-
tions to the whole body; in short such a plan of diet and regi-
men  as was  likely to give strength and tone to the habit, and
to excite an  active and vigorous absorption.—He was desired
to refrain from malt liquors.
   ft. Decoct. Cinchonae 3 vij. Tinct. Card. C. 3 ft. Sp. ^Etherii
Vitriolic C. 3ij- M. Sumat Cochlear iij. ampla maneet  meri-
die cum pilul. infra Praes. No. ij.
   ft.Massae Pilul. Scillae Myrrhas sing. 3j. Syr. Tolutan. q. *
ft. Pil. xxx.
   The above  plan  of regimen and medicine was rigidly ad-
hered to, and  in his occasional visits to me the amendment in
his health was very obvious.   In the course of a few  weeks he
was so far recovered as to  obtain my sanction to discontinue
medicine; but was directed not to relax in the regimen, and 
APPENDIX.
27
 if he should perceive any symptoms of a relapse, to apply for
 immediate advice.
   Not many months had elapsed before his symptoms return-
 ed, with the addition of diminished secretion of high colour-
 ed urine ;  increased difficulty in respiration, and inability of
 lying down in bed.  The digitalis was now prescribed with
 the happiest'effects.
   In March, 1800,1 had a letter from Mr. Newell, in which
 he observed,—" 0»r friend Carr is finely ; I have lately  ex-
 perienced equally good effects in two cases similar to his."—
 After this period I saw him occasionally;  he continued to
 have returns now and then, and the disorder seemed to have
 assumed more and more the character of Hydrops Pericardii;
 —but the  intervals were longer, and the digitalis never failed
 to remove them ; so that for several years prior  to his death
 he continued to enjoy tolerable health ; to use regular exer-
 cise ; and to make excursions on horseback, to visit his friends
 in the country.—The latter end of 1806 I last saw him, after
 an attack of the Hemiplegia; and on the 21st of December he
 died of exhausted constitution, the consequence, it might fair
 ly be said, of a different disease, in the  75th  year of his age.

                       CASE XIX.

   June 9,1797.—Mr. Baker, .Et. 28, M. Extremely fat wii.
 a lax fibre. Has been in the habit of drinking beer freely at
 all times, as is the custom  of the country ; but not to excess.
 —"  Severe cough, with great dyspnoea,"  are the only symp-
toms I find of this date, the first time he applied for  my
advice.   He expectorated  with  difficulty a viscid yellowish
matter; but I had  no suspicion at this time of any serous ef-
 fusion in the chest.
  ft. Lact. Myrrhae 3ij. Aq. Puleg. Jvft.Sp. Mtb. Nitr. 3iij
Sacch. jjij.TVI, Sumt. coch. tria ter ind. 
2$
APPENDIX.
   ft. Mass. Fil. Scillae, Myrrhae, a- 3j. M. ft. Pil. xxiv. Sumt
trcs sing. noct. h  s.
   June 17.—The only memorandum I find of this date when
he came to me  again is the  following prescription,  from
Which  I presume there were evident symptoms of serous effu-
sion in the cavities of the chest.
   ft. Dig. P. fol. Pulv. gr. ivft. Zing. Pulv. gr. vi. Confect.
Aromat. q. s. ft. Pil. vi. sumt. duas sing. noct. per tres vices.
   ft. Aquae Puleg. 3vi. Sp. Menth, Pip. Tinct. Cinnam.  Sp.
M.th. Nitros. aa. 3 ij- M. Sumt, coch. triater ind.
   June 29.—" Symptoms of Hydrops Pericardii together with
general anasarca," are the only remarks I find noted down.
   ft. Infus.  Dig. Purp. (3Jft. ad 3 viij.) 3 v.  Mist.  Camph.
3jft. Sp. -Eth. Nitr. Sp. JEth. Vitr. C. aa. 31J. Muc. G. Arab.
3j. M.  Sumt. coch. tria ter ind.
   ft. Fol. Dig. Purp. P. gr. jft. Scillae P. gr. ft. Opii pur. gr.i.
Zingib. Pulv. gr. j. Confect. Aromat. q. s. ft. Bolus cum Mist.
supra praes. nocte maneque s.
   ft. Cryst. tart. Pulv. 3.j- Conservae Rosae 3 ft. Syr. Zingib.
q. s. ft. Elect, Molle cujus Sumt. coch. duo min. ter ind.
   Though the habit was placed under the full influence of the
digitalis, and the other  remedies were persevered in, yet  the
rapid career of the disease seemed not in any degree to bear-
rested, for the patient died on the 7th July, universally ana-
sarcous.
   From  the  progress and termination  of this case,  and the
extreme difficulty in respiration at  an early period, it is pro-
bable that serous effusion had commenced much  earlier than
was at first apprehended.  I suspected considerable accumu-
lation of fat about the heart.
   Had the digitalis been prescribed at first, blended with ca-
lomel,  squills, saline diuretics, in full doses, and blisters repeat-
edly applied to the chest, it is probable the issue would have
been very different.   Subsequent experience enabled me to 
APPENDIX.
29
 ascertain that no advantage was  to be expected from the di-
 gitalis alone, in such cases, where there was universal languor
 and torpor.

                       CASE XX.

   July 8.—Master Mays, of Halstead, in Essex, Et 3.—Uni-
 versal anasarca, with symptoms of effusion in the chest.—Has
 been recently much weakened by previous illness.
   ft. Decoct. Cort. Angust.  3v. Sp. .Eth. Nitr. 3jft. Syr.
 Pap. Alv. 3 ft. M. Sumt. coch. Iarg. ter quaterve de die.
   ft. Fol.  Dig. P. gr. iv.  Sacchari pur. gr. vi. Simul tere et
 divid. in chart, vi. Sumt. 1. mane et vesp.
   The child was quickly unloaded of the accumulated water,
 by a copious flow of urine : has had no return since, and is now
 grown to a strong healthy youth.

                       CASE XXL

   August 31.—Mrs.  Simpson, of Melford, Et  70.—Very
 strongly marked symptoms of Hydrops Pectoris et Pericardii;
 such as quick, hurried, respiration; inability to lie down in a
recumbent posture; frequent, feeble, and extremely irregular
pulse; defective secretion of urine, &c.
   ft. Dig. Purp. gr. vi. Zing. gr.  iv. Conf. Ar. q. s. ft. Pil. vi.
Sumt. 1. mane et vesperi, cum Mist, infra praes.
   ft. Aq. M. Pip.  3v. Kali Acet. 3J. Sp. Eth.  Nitr.  3 iij,
Syr. Zing.  3 ft. M. Sumt. coch. tria ter quotidie.
   These remedies were soon followed by a copious flow of
urine, with speedy relief of every unpleasant symptom, and
she was soon restored to her ordinary state of health.
   Had occasional returns after this period, even in a more vio-
lent  degree, and was as often restored to health by the same
means.  For more  than three years before her death, the dis-
                            28 
30
APPENDIX
position to serous effusion was entirely subdued, though  she
had a very formidable attack of Pneumonic  Inflammation, in
which her life seemed in the most imminent danger.  She di-
ed of the influenza in 1802.

                      CASE XXII.

   October.—Mr. King, of the parish of  Belchanjp St. Paul's,
B. Et 30.—Corpulent, yet  strong; and naturally of a florid
complexion.   Has been subject for some years to very violent
inflammatory  affections, in which copious bleedings and other
evacuations were deemed absolutely  necessary.   In two very
formidable  attacks  of this  kind  1 attended him.  The first
was in September, 1796, and might be said to be a Bilious In-
flammatory fever, resembling in  many of its features the Yel-
low fever, as described by Dr. Rush.  It was treated in a si-
milar way;  and in no instance of fever, that has ever occurred
to me, were evacuations so strongly indicated, or attended
with more  sensible advantage.  Aware of the habit of free
blood letting  which  had been previously established, I was
desirous, if possible, of overcoming it; and trusted the cure to
calomel sometimes  blended with James's  powder, given at
night, and quickened by saline purgatives in the morning, as-
sisted by the antiphlogistic regimen to the fullest extent.
   The relief procured by the evacuations was so great, and
the necessity for their use so urgent, that at every visit he beg-
ged  for still more active purgatives.  In ten days the fever
shewed a disposition to a  favourable change ;  in  a few days
more he was pronounced out of danger, and continued gradu-
ally to recover.
   December 19.—My attendance was again desired.  I found
he had been ill a week.  He had now not only a most violent
inflammatory fever,  but considerable local inflammation of the
lungs, especially about the left side of the chest, deep seated, 
APPENDIX.
31
apparently extending to the substance or the lungs, and even
to the heart itself; the left shoulder was likewise much affect*
ed, together with severe pains all over the body.  Respiration
was extremely difficult and laborious ; with a peculiar  sense
of stricture, great anxiety and oppression about the region of
the heart.  The P. was quick but not full, somewhat unequal
and oppressed ; T. very brown, foul and dry in the middle,
but moist at the edges.  Skin very hot and dry, with a yel-
low suffusion all over the body ;  eyes were likewise  somewhat
yellow.   Urine small in quantity, dark coloured, with a sedi-
ment  like coffee grounds.  Was let blood this morning, and
had a laxative with effect.
  The inflammatory symptoms seemed too formidable to be
trusted  to laxatives and saline  medicines aloRe.   I directed
him to be let  blood to 3 viij.; to have saline laxatives with ca-
lomel ; and to be put under a strict antiphlogistic regimen.
  December 20.—Though  the  medicines operated freely on
the bowels, no relief in any respect; and the pulse was much
stronger and more regular.   The blood had the thickest and
most dense buff I had ever observed, assumed the cup like
form,  and floated in  the eentre of a full proportion  of very
yellow serum.
  Mitt. Sang, ad 3xiv. et  Pergat U. A.
  December 21.—Relief for some hours after the bleeding;
but the  symptoms returned in  the evening with  additional
violence, especially the affection of  the left  side.    Blood
equally buffy with the former.
  Iterum sit  V. S. et  Mitt. Sang, ad Sxijet Pergat U.  A.
  December 22.—While the  blood was flowing yesterday all
his symptoms were considerably relieved ; and I directed the
surgeon to take at least 3*vj.;  but without any diminution
ef the fullness of the pulse: the relief however was of short
duration, the symptoms returning as  before in the afternoon.
Apparently much worse to day, pulse 120 and full, but irre- 
S3
APPENDIX.
gular at intervals.  After this he was let blood five tunes the
three following days on the 23d to 3 xij. at noon, and to 3 xvj.
in the afternoon ;  had several evacuations procured from the
bowels daily, without any diminution of the hardness and full-
ness of the pulse, or before there was any tendency to a fa-
vourable change.  There was  no disposition to fainting at
any time, though gruel,  gratefully acidulated with orange
and lemon juice, was  the only nutriment allowed him.  At
every visit he expressed an earnest desire to be blooded, and
to a larger extent.   The blood was bufiy and dense, with
yellow serum to the last.
  I was  aware of the consequences eventually  to.  be appre-
hended from such inordinate evacuations; yet I was aware
also that  life  must inevitably be speedily sacrificed without
them.   I am  now fully convinced, if the lancet had  been at
first used with the same freedom that has been done in many
instances of the yellow fever recorded by Dr. Rush, the disor-
der would have had a more speedy, and ultimately a more fa*
vourable termination.  But such cases rarely occur  in  this
country ; and until I had seen this, I could hardly suffer my-
self to believe such profuse evacuations could be required in
any instance.
  When an internal organ labours under violent and acute in-
flammation, one or two bleedings in the beginning, often save
the necessity of the loss of many pounds afterwards, when the
vessels have once acquired the confirmed inflammatory action;
and they likewise obviate the serious ultimate consequences of
effusion of coagulable lymph, or of serum, and adhesion of
contiguous surfaces, which generally follow, as most probably
happened in this instance, when too long delayed, or when not
proportioned in quantity to the urgency of the symptoms.
  In the incipient stage of inflammation the blood drawn very
often has little or none of the inflammatory character;  whereas
on the  second or third bleeding, it assumes it in a high degree j 
APPENDIX,
33.
and if delayed to the very advanced period', it comes too late,
and every drop of blood in the body if drawn, will exhibit the
same appearances.
  In country practice, serious inconvenience often arises from
the physician and apothecary reading at a distance from the
patient, and not having it in their power to visit him when their
aid is most wanted.  Had Mr. Kii'g been bled freely on the
first and second  day of the attack, it is probable that the co-
pious  bleedings which were afterwards  used w ould have been
unnecessary, that relief might have been obtained earlier and
that the dropsical state which followed, might have been ob-
viated, or at least protracted to a more  distant period.
  In about a week  after  the date of the last report he  was
pronounced out of danger, and continued gradually to recover
The progress however was very slow,  nor did  the  following
spring and summer re-establish his health completely.   He
complained of unusual languor, and inability of taking mode-
rate exercise without being fatigued  and out of breath.   His
appetite returned, but he had generally a fullness and oppres-
sion, with flatulency after eating.  He  became corpulent, bnt
his  countenance did not recover its florid aspect, nor the mus-
cular  fibre its tone.
  On  the  9th of October he came to consult me.  Being un-
willing to suspect as yet any serous effusion,  I prescribed  bit-
ters with  mild diuretics, regular exercise on horseback, a nu-
tritive chiefly meat diet, with wine, and  a total abstinence from
malt liquors which, I was concerned to  find,  he had indulged
in contrary to my former injunctions.
  October 13.—-Returned to me in  no degree amended.   I
was still willing to hope his complaints arose from debility and
prescribed accordingly.
  October 17.—In every respect worse  ; breathing more hur-
ried and ditncult, together with a peculiar fluttering about the
seat of the heart, and epigastrium, and other symptoms \\ hich
left no room to doubt the commencement of effusion in the ca. 
S4
APPENDIX.
vities of the chest,  and seemingly in the pericardium,  the di-
gitalis  was prescribed in combination with  tonics and other
diuretics; and a blister applied to the chest.
  Receiving speedy relief from these medicines he was put on
a course  of  calomel,  squills, digitalis, and bitters, combined
with alcaline diuretics.  Soon after this period he removed to
a brother's house  a considerable  distance from me, and his
apothecary dying in the mean time, he never returned home.
It having been proposed to consult Dr.  Goodwin, in whose
immediate neighborhood he now resided, I was glad of the
opportunity  of stating my ideas of the case, the remedies which
were used, and the subsequent  plan which was intended to be
pursued, to so respectable a Physician.  Our opinions coincid-   '
td in every respect, except as  to the presence of water in the
pericardium, which I thought highly probable, from the ori-
ginal seat of the  inflammation, from the constant fluttering
about the heart, and  from the pulse becoming extremely fee-
ble, irregular, and fluttering,  from being full, hard and re-
gular.
  He was repeatedly relieved  by a plan of treatment similar
to that which I recommended,  but he survived only a few
months afterwards.

                      CASE XXIII.

  February 12,1798—Mr.  William Smith, Et  60.  A far-
mer of thick short make, and fat.  Orthopnoea,  inability of
lying down  ;  P. irregular,  feeble, and  intermitting  ; urine
scanty and  high  coloured ; legs anasarcous; severe  cough.
Having rode the distance of eight miles to consult me, and the
symptoms being so extremely urgent as to threaten imme-
diate suffocation,  I directed a blister to be applied,  and an
antispasmodic draught similar to the following mixture to be
administered immediately, more especially as he said he could 
APPENDIX.
35
not have the medicines from his apothecary till the following
morning.
  ft. Myrrhas  3j.  Mist. Camph. Lact. Amygd.  S5.  giijft.
Tinct. Opii C.  Sp. Eth. Vitr. C. aa. 3iij. Syr. Tolut. 3»j. ML
Sum. coch. iij. 8s. hor.
  ft. Fol. Dig. Purp. P. gr. jft, Confect. Arom. q. s. ft. bolus
sing. noct. et mat. s.
  The  usual  directions were given to  Mr. Eastcot, his apo-
thecary.   In about  a fortnight the dropsical symptoms were
entirely removed, the cough was much relieved, in  a short pe-
riod he was restored to his usual health,  and remained free
from any return for more than two years.   Had two attacks,
but was relieved by the same means, and lived for  some years
afterwards.

                      CASE XXIV.

  February 18-—Mr.  Brown, a shopkeeper, JEt.  60.  Similar
in shape and  stature  to, with symptoms resembling those oi
the subject of the last case, but refusing  to take any medicinrs,
he died soon after suddenly, as I foretold-

                      CASE XXV.

  May 18.—Mr. Williams, a master tayloc, Et. 55, of a full
habit, and corpulent; but with a lax fibre.  Addicted to ex^
cesses in drinking for  several years,  and using little exercise.
Had the disease very distinctly marked, and was  repeatedly
unloaded of the water by  the foxglove and other remedies,
under the direction of the family practitioner and myself.
  The most remarkable circumstance connected with this case
was, that for  some months prior to his death the dropsical
habit was not  only  corrected, but the lower extremities from
being considerably swelled became extremely emaciated, or 
36
APPLNiyJA'i
 rather shrivelitd;  intensely cold, of a dark livid hue, and ap
 parently without any circulation ; and  for about a fortnight
 before his death they were perfectly black, void of sensibility
 and covered with gangrenous vesicles.  The hands were cold
 also;  and the action of the heart was feeble and irregular.

                     CASE XXVI.

   July 23.—Mr. Wood, a farmer, of Foxearth, Et. about 55.
 Similar in make and constitution, but stouter,  to the subjects
 of cases 23 and 24.  The leading symptoms were orthopncea;
 palpitation ;  intermitting, and irregular feeble pulse, togeth-
 er with defective  secretion of urine, and some tension, but no
 fluctuation of the abdomen.   Refusing to have the family
 practitioner to attend him regularly, and apparently not dis-
 posed to conform to any restrictions, I prescribed only simple
 remedies, and I heard that he died soon afterwards, suddenly.

                     CASE XXVII.
                                           *

   October 22—Mrs. Wright, of Tilbury, Et 35.  Apparent-
 ly in the last stage of phthisis, with  general dropsy,  and her
 strength so much exhausted as to be unable to get out of bed.
 The dropsical symptoms were  entirely  removed ; the cough
and other phthisical symptoms so far  subdued,  and her
strength restored,  as not  only  to get  out of bed but walk
about.  She however never recovered her strength perfectly,
and she died in  December following  suddenly, when she was
thought by those about her mending.

                    CASE XXVIII.

  November 5.—Miss Scarfing Et 60.   Naturally of  a thin
slender make ; now much emaciated and reduced in strength 
APPENDIX.
3?
Having had the superintendance of a seminary for female edu-
cation for  several years, has lived  a very  sedentary  life, and
scarcely allowed herself sufficient sustenance, to which her disor-
der is to be attributed.—First consulted me in May,  1797, for
anasarcous swellings of legs, especially the left,  attended with
dyspnoea, and a large elastic irregular swelling in the left side of
the abdomen, apparently an encysted dropsical swelling.  These
complaints were nearly removed  by bitters, in combination
with saline diuretics and small doses of calomel.  Is now  af-
fected with similar complaints, but in a much greater degree.
There is a large elastic tumour in the epigastrium, extending
to the umbilicus, and some way into the right hypochondrium,
and connected by a thick neck with another smaller tumour in
the left iliac region.   No relief from the bowels for several
years without the most active purgatives, which appears to be
in  some degree owing to a* schirro contracted rectum under
which she has laboured.  Urine of late only diminished.  P.
slow, 56 to 58.
   In a few days the dropsical symptoms were much relieved,
and by the 24th they were not only  removed, but  the abdo-
minal tumours much reduced in size, by means of the foxglove,
saline diuretics, squills, and calomel.  The foxglove, however,
produced distressing nausea, and more than once vomiting, be-
fore its full salutary effects were experienced.
   After this period, the disorder returning, she was repeated-
 ly relieved,  but her strength by degrees declining she died of
 exhausted constitution the following winter, which the unusu-
 al severity of the weather seemed to have accelerated.
    A remarkable circumstance connected  with this case was,
 that while Using the foxglove, more especially while under its
 full  influence,  the  bowels performed their functions without
 the aid  of  any medicine which they had not done for some
 years.  This she mentioned with great satisfaction, and a:s
 fully compensating for its unpleasant effect*
                            29 
dCf
APPJESD1X.
   This case lias betn iuserted in order to shew the efficacy of
 the plan recommended in encysted dropsy,  and the salutary
 effects of digitalis in relieving permanently a most distressing
 state of habitual constipation  eonneeted  with  schirro con-
 tracted rectum.

                      CASE  XXIX.

   November 26.—Mr.  Walford, a  publican, Et 28.   Ex-
 treme difficulty in respiration,? as usual increased on bodily ex-
 ertion.  P. very irregular.   Palpitation of the heart at times.
 Countenance of a  livid hue.  Legs anasarcous.  Abdomen
 somewhat swelled and hard, with fluctuation.   Urine smalt
 in quantity,  high coloured with sediment.  Present  symp-
 toms commenced ten days  ago, and have rapidly increased
 since.   Has had attacks of a similar nature for  three years,
 but much  less in degree;  and was relieved by medicine.
 Has drank very hard.
   Admov. Empl. Canth. pectori.
   ft. Dig. Purp. P. gr. j.  Conf.  Arom. q. s. ft. bolus noctc
 maneq. cum  Mist. seq. coch. ij. s.
   ft. Infus. Dig. Purp. (3J. ad 3vi.) 3v. Kali Acet. Bij^Sp.
 Eth. Nitros. 3 iij.  Sp. Cinn. 3 v. M.
   December 1.—Called  upon me to say he  found relief the
 first night  from the medicines; that the following day the  t
 urine was sensibly increased in quantity ; that the swellings,.
 and with them every unpleasant symptom, gradually subsid-
ed, and that  his Health  is in every respect  considerably  im-
proved.  P. quick and still irregular at times; appetite good ;
countenance much improved, and he gains strength.
   ft. Bals. tolut. 3j. Calom. Scillae P.  a. gr. vi. Opii gr. iij.
Mix. G. Ar. q. s. ft. Pil.  xx. Sumt. tres sing. noct. h. s.
  He was directed  some tonic medicines at the same time. 
                        APPENDIX.                     39

  He called on me several times after this to say he continu.
ed in tolerable health.   But continuing his  former career of
intemperance, I was informed, by his surgeon Mr. Tweed, of
Socking, he relapsed and died some months afterwards,

                      CASE XXX.

  DecembcrdQ.—Mrs. Stow, a mantua maker, EX. 40.  Has for
several years  lived a very sedentary life, and of late,  has fre-
quently sat up whole nights.    Every symptom of confirmed
hydrothorax, with anasarca.   P. quick and irregular.   Urine
scanty, high coloured, with sediment.  Has had two  or three
slight attacks of dropsy before, and was relieved by medicine;
but the swelling of the legs never subsided ; it is now consi-
derable.
  Was directed the digitalis and other diuretics ; but though
she  was repeatedly relieved,  and the disorder kept in check
for  some months, yet the dropsical symptoms were never en-
tirely removed.   The digitalis excited profuse salivation, and
considerable quantities of a watery fluid were  brought up in
mouthfuls  from the stomach without sickness or exertions to
vomit.   It was  found extremely difficult in this case to act
upon the kidneys; and the medicines ceased at length to af-
ford any relief, consequently the swellings of the legs, with ev-
ery  other symptom increased, and she died not many weeks
afterwards, considerable quantities of water having been pre-
viously  discharged by  scarifications.   The swellings were
hard and tense,  a circumstance which is always unfavourable
to the operation of the foxglove  ; but the constitution was ex-
hausted. 
40
APPENDIX.
                      CASE XXXI.

  March  10,  1799.—Mr. Driver, (vide case 14), Et  62,
JJreathing quick, hurried, and difficult; together with a pecui
liar fluttering about the scrobiculis cordis and region of the
heart. P. extremely irregular and feeble.  Urine very small in
quantity with reddish sediment.   No swelling of legs.  Ap-
petite and strength much impaired of late.  No thirst; B.
natural.
  Has remained free from any dropsical or other complaint
since I attended him in 1797, till a  fortnight ago, when, on
walking quick, he perceived his breathing short and difficult;
but it became free and easy on re6t.   Of late, however, it is
more or less affected at all times, and he is unable to lie down
in a horizontal posture.
  This attack appears to have proceeded from a violent cough
he had five weeks ago, from cold, added to  disappointment
and anxiety of mind which he has suffered in consequence of
being turned out of his farm.
  ft. Dig. Purp. P. gr. viij. Scillae P. gr. vi. Calomel, gr. jft.
Simul tere et Conf. Arom. q. s. ft. Pil. viij. Sumt. 1. sing. noct.
et mat. cum haustu seq.
  ft. Myrrhae gr. x. Aq. Menth. Pip.  3x. Sp. Jgih. Nitr.
Mell. Scillae aa. 3j. Kali Acet. gr. vi. M. ft. haust.
  As he purposed removing the following day a considerable
distance from me,  I furnished  him with full directions in re-
gard to regimen and medicine; to continue the use of the fox-
glove and to increase it if necessary till the desired effect
should be produced.
  I heard from his friends that he soon recovered; and  that
he continued free from  return more  than twelve months af-
terwards when I last had any tidings of him: 
APPENDIX.
41
                     CASE XXXII.

  March 13.—Mr. Clark, of Melford, .Et. 83.   Great Dysp-
noea, not uniformly violent, but at times, even on rest, return-
ing in paroxyms. P. extremely irregular.   Urine very scanty,
high coloured, with sediment.  Legs anasarcous, great stupor
and drowsiness, and talks incoherently at times.
  Had  a blister applied to the  sternum this morning and
has been taking the digitalis in combination with other medi-
cines, under the direction of his surgeon.
  Ha6 been subject for years to dropsical affections; especial-
ly of the chest.
  Was directed to take the digitalis in  infusion, by means  of
which he was in three days completely unloaded of the accu-
mulated water by a copious flow of urine;  but he died  soon
after of completely exhausted constitution,

                     CASE XXXIII.

  March 22.—The Rev. Mr. Larwell, a dissenting minister of
Redgewell  in Essex, Et. 70. Extremely fat and corpulent, of
short stature, with a lax fibre.   Has been temperate in the
use  of strong liquors through  life; but  used little exercise of
late.  Incessant cough, with very copious  but viscid yellow-
ish expectoration; extreme dyspnoea, aggravated on the slight-
est  motion,  Unable to  lie  down in  hed for some days.
Countenance approaching to a livid hue.  P. regular but op-
pressed.   Urine scanty, very high coloured with reddish se-
diment.  His complaints seem to have originated in a  violent
cold he caught  five weeks ago ; since which time he has
coughed with more or less violence.
  ft: Bals.  Tolut. 31'j. Muc. G. Arab. 3ij- Mannae 3j. tere si-
mul. Aq. Cinnam. 3*j. Mel. Scillae 3j-  Sp. Eth. Vitr. C. Sp. 
iZ
APPENDIX.
 Eth. Nitros. 5a. 3ft. Kali Acetat.  9ij. M. Sumt. coch. duo
 3tiis. vel 4tis. horis.
    ft. Dig. Purp. fol. P. gr. viij. Conf. Arom. q. s. ft. Pil. viij.
 8umt.  1. nocte maneq. Appl. Empl. e Pice Burg. Pectori.
    A particular friend of the patient being desirous of knowing
 my opinion of his case, the letter which I wrote to him, ex-
 pressive of the imminent danger I thought him in, and of my
 doubts and fears as to his recovery, was by mistake  delivered
 into the worthy pastor's  own hand: he read it without emo<-
 tion, and with a firmness and composure of mind, which con-
 vinced me that he was not unprepared for the change which I
 feared was not far distant.
   He experienced  speedy relief from the medicines, and by
 persevering in their use for some time his health was perfectly
 re-established, a slight cough in the winter season excepted.
   Being at Sudbury in May  1800, he  called on me, and con-
 firmed  the above  intelligence.  He was then remarkably cor-
 pulent, though he used cider for common  drink, having in-
 terdicted the use of all malt  liquors.  I found him, how-
 ever, with the remains  of his winter cough, expectorating
 freely a yellowish matter.  Though  he did not come  for m>
 advice, yet apprehending a return of his  former  formidable
 complaint without due care, I thought it incumbent on me to
 bestow  such salutary admonitions  as appeared necessary.  I
 advised  a stimulating plaster to the breast,  and a mixture
 similar  to that formerly prescribed with so much advantage.
   That there was  water effused in the  cavities of the chest
 in this case,  it is presumed, admits not of doubt; and that this
 happened without  disease  of  any thoracic viscus, is equally
 certain.  It serves to shew in a striking manner the power of
 medicine in a constitution previously sound, and not exhausted
by intemperance, even at the age of 70, and under  the most
unpromising circumstances.*
* Mr. L. was living and in good health in December 1808. 
APPENDIX.
43
   The violent cold or catarrhal affection was here evidently
 the occasional cause, operating on a habit powerfully predis-
 posed by extreme corpulency and laxity of fibre, as has been
 mentioned in the history.

                      CASE XXXIV.

   March 30.—Mr. Partridge, of Bures, Et 49. M. Nephew of
 the subject of case 17.  Extreme difficulty in respiration, in-
 creased on the least motion,  or on  talking,  attended for the
 most part with a  peculiar wheezing noise.   Has great tight-
 ness or sense of stricture and oppression across the chest.   P.
 irregular, feeble, and frequent; it may be called a quick suc-
 cession of weak irregular vibrations.  Urine very scanty, high
 coloured, with a  copious pink coloured sediment.   Has been
 obliged  to sleep  in a chair  for a fortnight, in consequence of
 which his legs especially the  left are much swelled, and pit-
 ting on pressure.   A small degree of tumefaction of the abdo-
 men also.  Whole face, especially the lips and nose, of a livid
 hue.   Eyes dull,  heavy, and expressive of great suffering ; the
 conjunctiva  somewhat yellow.  Very little thirst.  Appetite
 much impaired, as is his general strength.  Was taken ill three
 weeks since with nearly all these symptoms, which  have  gra-
 dually increased since; of late very rapidly.
   Has taken  no medicine except a powder  the 28th, which
 purged him violently, and a spermaceti mixture, his disorder
 having been considered as gout, to which he has been subject
 both in a regular and  irregular way from eight years of age,
 and  which  appears  to  be hereditary.   The gouty parox
ysms have at  times been very severe,  and the leg now prin-
cipally swelled has suffered the most.  His lived temperately.
 No cough.
   Appl,  Empl. Canth. uectcri 
44
APPENDIX
    ft. Dig. Purp. Fol.  P. nostr. gr. viij. Zing. P. gr. vi. Corif
  Arom. q. s. ft. Boli viij. Sumt. 1. sing. noct. et mat.
    ft. Bals. Tolut. 9ij. Muc. G. Arab. 3ij. Mannae 3ft.tere
  simul. Aq. Menth. Pip. 3vjft. Sp. EXh. Vitr. C. Sp...£th.
  Nitrosi aa. 3iij. M. Sumt. coch. tria6ts. horis.
    April 4.—Immediate relief from the blister ;  and  in the
  course of the following day, the 31st ult. the urine began to
  flow in increased quantity, but still high coloured  with sedi-
  ment, and he was able to lie down in bed.   On the morning
  of the 1st,  had five loose watery stools  ; but nevertheless Ihe
  urine continued to increase considerably, and became perfectly
  natural  irt appearance :  in the course of the day the  swel-
  ling of  the legs  was nearly subsided :   when  it began to
  lessen, in the morning, he complained of very acute pains in
  them.   Breathing now perfectly free ; yet he still  complains
  of some  tightness across the chest.   P. much more regular.
  Water since last night less in quantity, and deposits a sediment,
  but he has drank less.  Countenance greatly improved ; ap-
  petite perfectly restored ; and lie sleeps as usual in bed.   No
  sensible effect from the digitalis except in increasing the flow
  of urine, and once  on the bowels.   The weather so intensely
  cold that he  is prevented from going out and deriving advan-
  tage from air and exercise.
    Appl. Empl. e Cymino inter Scapulas, et Empl. Canth. Alt.
- pect. si urgeat dyspnoea, nee non,                  "
    ft. Dig. P. P. gr. xij. Zing. P. gr. viij. Conf. Arom. q. s. ft.
  Boli viij. Sumt j. mane et h. s. U. A.
    Pergat in usu misturae ter ind.
    April 8.—Being alarmed by the appearance  of  unusual
  symptoms  he desired  my  immediate attendance.  He com-
  plained of being extremely faint, and low, with giddiness and
  imperfect vision  since yesterday.   These  were evidently the
  effects of the digitalis, having taken the  last bolus this  morn-
  ing.  In other respects were sensibfy amended. 
Appendix^
45
   Omitt. Dig. sed,
   ft. Decoct. Cinch. Ang. 3vij. Myrrhas 3j. Tinct. Gent. C.
 3iij.Sp. jEth. Nitr. 3y- Kali pp. 3f5- M. Sumt. coch. tria ter
 ind.
   April 22.—Called on  me to say that he continued in  ev-
 ery respect free from dropsical symptoms ; the legs being re-
 stored to their former state ;  the urine in full quantity ;  ap-
 petite good; and strength much improved, though the weather
 has been extremely unfavourable for his riding on horseback,
 as particularly enjoined.   Both the plasters were applied, and
 the mixture persevered in since last report.
   Was caught in  a hail' storm four days since, got wet, and
 has had some cough, with dyspnoea.  P. irregular.
   ft. Caloim gr. vi. Scillae gr. iv.  Digit, gr.  x. Myrrhae  9j.
 simul tere et Adde G. Assaefaet. 3 ft. Extr. Gent. q. s. ft. Pi-
 lulae xviij. Sumt. duas sing. noct. h. s.
 t.  June 8.—Again came  to me.  Says that  till  a few days
 back he continued tolerably  free from  complaint; that his
 urine has diminished in  quantity, with the usual sediment;
 that he has a slight cough, some difficulty in breathing, and
 a pain of the right side and breast.  Looks well in the coun*
 tenance, has  no thirst; nor do the legs swell.  Appetite and
 strength, however,  somewhat impaired.
   ft.  Scillae  Pulv. gr. x. Dig. Purp. 9j. Myrrhae  3j. simul
 tere et ConfecL Aromat.  q. s. ft. Pil. xxiv. Sumt. duas meri-
 die et hor. viij. P. M. cum Mist. seq. coch. iij.
   ft.  Infus.  Gent. C. 3vij. Kali pp. 3J. Sp. Eth. Vitr. C. Sp.
 .Eth. Nitr. a  3 iij. M. ft.  Mist.
  Si Urgeat Dyspnoea Iterum  Appl. Empl. e Pice Burg.
 Sterno.
   The above symptoms were quickly removed, and he enjoy-
ed his usual state of health till the autumn of 1800, when fee
again consulted me, as  will be seen in course.
                           30 
4j
ArPEKDIXo
                     CASE XXXV.

   April 8.—Mr. Loudon,  a  carpenter, Et 65.   Confinv.dd
genuine Hydrops Pectoris,  w ith  severe cough; an irregular
intermitting pulse ;  legs beginning to be oedematous, and
last night  for the f.rst time  unable to lie down in bed.  He
was  naturally of a strong  robust  constitution, but  having.
passed many years in the army, worked hard at his business
for the last twenty years, and drank freely at  times of malt li-
quors, his constitution may naturally be supposed to have suf-
fered.
   Appl. Empl. Canth; Sterno.
   ft. Dig. Purp. P. gr. vj. Zing.  P. gr. xij. Confect. Arom,
q. s. ft. Pil. vj. Sumt. 1. mane et h. s.
   April 11.—Came to  me  in every respect  much amended;
the cough and breathing being relieved, the expectoration less
in quantity, but more free  and easy ; he was able to lie down
in bed the whole of last night without inconvenience.  Urine
very copious.   P. still intermitting, but not so much so.  An-
kles only swelled towards evening.   Pergat.
   April  13.—So far recovered as to think himself able to re-
turn to his work.   Slightly under the influence of the fox-
glove.  Omitt. Med.
   This poor man having no means  to support himself and fa-
mily but by his labour, as soon as he  found the symptoms
removed returned to his work, but after some time relapsed.
He was thus repeatedly  relieved by medicine, and as often re-
lapsed.  At length, however, his constitution being overcome
by such repeated attacks, he was confined to the house from
the beginning of August, and died in September.   As an op-
portunity was given me  of inspecting the body after death,  I
shall mention the leading symptoms of the disorder for a f<r*
weeks prior to his dissolution 
APPENDIX,
1-7
  Jn May he had a most formidable attack, attended with vi-
olent fever, incessant cough, and copious yellowish expectora-
tion, with an aggravation of every other symptom.   He was
confined to his bed for several days, but contrary to my ex-
pectations recovered so far as to be able to return to his usual
occupation in June free from every dropsical symptom.
  July 21.—1 prescribed the following pi.Is for him.
   ft. Dig. Purp. fol. P. 3 ft. Calom. Scillae Pulv. at. gr. xij.
simul tere et Confect.  Arom. q. s. ft. Pilulae xxiv.  Sumt. 1.
ting. noct. h. s.
  The  first few doses affected him with the most distressing
nausea,  faintness, intense  burning  heat,  followed by profuse
sweating over the chest, which,  he said,  " he thought would
have killed him."   I was  much  surprised at  this effect, as he
had taken the digitalis aione in larger doses, without any in-
convenience,  and  when his strength was  equally reduced.
The medicines continued to produce similar effects afterwards
though in a less degree.
   From the beginning of August his "bodily strength gradually
declined, and all his painful symptoms increased in proportion ;
yet these did not appear to proceed from increased accumula-
tion of water, but apparently from extensive confirmed disease
of some of the thoracic viscera.  He had complained through-
 out of pain and distressing sense  of weight, across  the chest.
 These were now more  constant and  violent, especially about
 the middle of the sternum.  The  cough which had never left
 him entirely, was extremely harrassing, sometimes with copi-
 ous expectoration, at others without any.  The breathing was
 extremely difficult and laborious;  the  pulse  small and fre-
 quent,  without any regular strokes.  The whole chest, neck,
 sometimes the head, (but seldom any other part of the body,)
 were generally covered with profuse sweats preceded by intense
 heat; yet the  extremities were generally  cold.   The  urine
 was scanty, high coloured,  with  thick sediment.   The appe-
  * :te was various, even a few days before he expired, he said he 
4S
APPENDIX.
 relished food.  He was unable to lie down on either side: the
 posture I always found him in,  was with his chest elevated,
 half sitting, inclining to the right side.   In short he exhibited
 a picture of extreme distress and suffering for some time be-
 fore  his dissolution,  which happened the 5th of September.
 Two days prior to his death he  brought up a large quantity
 of pure florid blood,

                   DISSECTION,

  Mr. Anderson who attended with me during his illness, and
 with his usual humanity afforded him every  assistance, very
 obligingly at my request opened the body.   On opening the
 cavity of the thorax the  right  lung did not collapse in the
 slightest degree :  it was observed to adhere universally to the
 pleura costalis, except in two places of no great extent, which
 were filled with yellow serum; neither did it recede from the
 ribson separating the adhesions,  but continued to fill the ca-
 vity.  Or* cutting into its substance, it  was  hard  and solid,
 resembling a schirrus liver in colour and consistence; the pul-
 monary artery  was ossified  in many places, but not until it
 had performed several ramifications, . On the surface of the
 lung between its external covering and parenchymatous sub-
 stance were  two distinct sacs, the one  containing about an
ounce, the other  an ounce  and a half, of a yellow serum ;  in
its interior  substance was  a small  cyst about half  an inch in
diameter which contained a gelatinous like viscid substance ;
and in the upper part was found a considerable quantity  of
frothy muscus,
  The left lobe had no adhesions, but contracted only to about
half the natural size, on the admission of the external air.   It
was firm and solid in the general texture, and in one place as
much so as the right Jung.  There were no vomicae or abscesses
in either.  The left cavity contained by measure rather more
than a pint  and a quarter, of a yellowish fluid,  which on ex> 
APPENDIX.
49
posure to the air for some time became of a gelatinous consist-
ence.   In the pericardium were more  than two ouncos of a
similar fluid, but which did not, as far as I recollect  coagu-
late.  Firmly attached to the left side of the mediastinum
were  several soft  fleshy appendicular, indented like a cock s
comb.  The^ heart was very soft and flaccid, seemingly pre.
ternaturally large; and at the basis of  each of the semilunar
valves were small ossifications, but  apparently not of suffi-
cient extent to interrupt their functions. . The right sinus ve-
nosus and cavity of the auricle, were unusually large, and the
latter as well as the right ventricle formed one continued ca-
vity, the auricular opening being nearly as large as either ca-
vity,  the functions of the  tricuspid valves having been there-
by apparently destroyed.   The opening into  the pulmonary
artery likewise, as well as the trunk of the artery itself seemed
preternaturally large, and the coat of the vessel was thin.
The semilunar valves however were perfect.
  Nothing unusual was found  in the cavity of the abdomen.
The gall bladder, as frequently happens, was very much dis-
tended with thick yellow bile.

                     CASE XXXVI.

  March 4.—William Jones, .Et. 18, a hair-dresser's appren-
tice.  Breathing very short and difficult especially on motion.
Pulse quick but regular.   Urine very scanty and high colour-
ed.   Abdomen somewhat  swelled with obscure fluctuation;
legs anasarcous ; his body very  much  emaciated, great pros-
tration of strength.   Appetite good.  B. regular.
  Had a violent rheumatic fever six weeks ago.  The present
complaints  gradually supervened  on his beginning to sit up.
Pains  in the hypogastric region.
  ft.  Dig. Purp. gr. j. Zing. gr. ij. Confect. Ar. q. s. ft. bolus
-;;ng. noct. etmat. s. 
50
APPENDIX.
   Was directed to drink a pint of gin punch, acidulated with
3ij. of crystals of tartar, daily.
   March 9.—Increased flow of urine the first evening after
beginning his medicines, which has continued since, with near-
ly complete reduction of the swelling of the abdomen and legs,
and entire freedom in breathing.   Was desired to  omit the
digitalis but to continue the punch and  to return to  me in a
few days.
   March 15. Dropsioal symptoms entirely removed.
   ft. Cinch. Angust. P. 3j-  Cryst. Tart. Pulv. 3 ft-  Zing. P.
3j. Cons. Cort.  Aur. 3 ft* Syr.  Zing. q.  s.  ft. Elect, cujus
Sumt. nucis raosch. mag- ter ind.
   From this time he continued to mend progressively, and he
was in good health some years  afterwards.#
   This may  be said to be one of the most favourable cases of
dropsy which occurs, the subject being young,  and the disease
arising from general debility after acute fever.

                     CASE XXXVII.

   The subject of the following case was a hard working indus-
trious labouring man ; and it is proper to observe that he had
to encounter every privation  likely to defeat the  succ ess of
the means which were used for his relief.   He was very scan*
tily supplied with food  and  every necessary; and being un-
willing to apply to the parish,  to which he belonged, for either
medical  or other aid, he had  no medicines except those with
which I furnished him.   It is probable that the case would
have terminated otherwise than it did had he  been fortunate
in  having every assistance  his situation required.   He la-
boured hard too at  his work  for some time under his disor-
der.
* I saw him in January 1809. 
APPENDIX.
H
           ANASARCA  PULMOJTUM

  May 16—John Ruggles, JEt. 54.  Naturally of a strong
constitution.  Breathing  extremely  laborious but  unusually
slow ; can lie down, at first without  much inconvenience, but
after being some time in bed,  it becomes more  difficult, and
he is obliged to get up frequently, but not suddenly, in'order
to obtain relief.  His face and neck are.so much swelled, and
his features consequently  so much distorted, that though he
had sometimes worked for me I did  not recognise him. The
swelling is increased towards morning,  when  his breathing is
somewhat relieved j but after being up some time the  former
lessens while the latter  becomes more difficult.  The whole
body is likewise anasarcous.   The legs are tense and hard,
of a livid hue, and not readily receiving or retaining the  im-
pression  of the finger; the swelling being evidently of that
kind which Dr. Withering has very justly said to be unfavora-
ble for the exhibition of the foxglove.   Urine high coloured,
but without sediment, he  thinks in the usual quantity.  P. full,
66 and regular.   B. in a  natural state.  Appetite good,  but
says  " he has not room for his victuals."  Has been  ill five
months, but derived occasional benefit from  some  simple re-
medies  prescribed by his neighbours.  Of  late these have
failed, and he has been getting worse rapidly.
  In this case the Anasarca Pulmonum, seems  very strongly-
marked ; and there is reason  to suspect disease  of the  adipose
membrane, perhaps throughout the body : in instances simi-
lar to the present,  where  the  cure is, I  believe, always diffi-
cult, I have had strong grounds for  believing that the above
cause constitutes this difficulty.
  I was desirous of putting the truth of Dr. Withering's re-
mark still farther to the test  by giving the digitalis alone in
this case,  Accordingly he was supplied with eight powders 
52
APPENDIX.
of gr. jft. in each, and directed to take one evening and raof*
ning.
   May 20.—Urine, he says, was increased the two first days;
but now thinks it is diminished in quantity.  Has  been  sub-
ject to giddiness which he says is now increased.   P. 54 and
full.  Pergit.
   May 22.— So farther effect from medicine^
   ft. Calom.  gr. iv- Scillae gr. j. Cryst. Tart. Pulv.  9j. M. ft.
Pulv. e Mell. tant. ter in Sept. s. Pergat in usu Digit.
   A few days after this he came to me to say that the day af-
ter taking the first calomel powder  a  salivation  came  on,
which soon increased  to a most profuse degree.  It differed
in many respects from that arising from  mercury ; there be-
ing no fastor of the breath ; no swelling,  tenderness, or in-
flammation of the" gums; and considerable quantities of a wa-
tery fluid came from the stomach without any exertion to vo-
mit, which continued for several days.
  Did this arise from the application of the calomel to the
extremities of the salivary ducts ? or from the digitalis ?  or
from both ? It seems to have been produced solely by the di-
gitalis.
   The mercurial powder  was not repeated, but  after a lapse
of some days, the digitalis was resumed with  the addition of
other diuretics, which relieved him so much that he  did not
come to me again till,
  August 6.—Complains of severe dry cough and hoarseness,
with great dyspnoea.  Ana arcous swellings of late increasing.
P. full and regular.  Sumt. Tinct. Digital. (Nostr.) gt. xx.
ter ind.
  August 14.—A  good  deal relieved.   P. 60, and more op-
pressed.   Vision impaired; frequent nausea  and retching,
without  bringing up any thing.   Great faintness at times.
Urine not increased.  Pergat, 
APPENDIX.                        53
  August 19.—-Has continued  the  drops without interrup-
tion, and been more or less sick with efforts to vomit ever since
last report.  B. more open, which he says relieves the sickness
much.  Profuse salivation for three  days;  but he thinks the
clear liquid which is copiously thrown out comes chiefly from
the stomach but not during the retchings.  P. 46, soft and
perfectly  regular.   Violent  throbbing  of the whole  head.
Appetite good.  Breathing somewhat relieved but still diffi-
cult.  More urine for the last 24 hours.
  Finding that the digitalis alone produced no good effect,
after this period, he was prescribed a combination of this with
other active diuretics, which  at one time unloaded him so
completely, and relieved all his symptoms, that he engaged
himself with a neighbouring farmer for the harvest; but he
soon found himself unequal to any laborious exertion, and re-
turned to me several times afterwards: he however derived
only temporary relief from medicine, and his strength as  well
as his spirits gradually declining, he at length swelled to an
enormous size, and died the latter  end of October or begin-
ning of November.
  I am persuaded from subsequent experience that a combi*
nation of calomel, squills, crystals of tartar largely diluted, in
full quantity, would have been  the only remedy likely to en-
sure success in the above case, and with proper diet and atten-
tion it is probable his life might have been  protracted for
some years.

                    CASE XXXVIII.

  July.—Mrs.  Moss, of Assington,  about 35 years of age-
Has had for some years a very  foul ulcer on one leg.  Symp-
toms of anasarca pulmonum, together with general anasarcous
swellings, especially of the lower extremities.  Was ordered
the digitalis in  the form of boluses,  with ginger and. Confect.
                           31 
£4
APPENDIX.
Aromat. and was completely unloaded of the water in a kvt
days, and permanently cured;  for when I  saw her lately she
told me, and her countenance confirmed the assertion, that she
was in good health, and had no return of the dropsical com-
plaint since.  She was very much under the influence of the
foxglove,  complaining of distressing nausea, iaintness, giddi-
ness and imperfect vision for some days.*

                     CASE XXXIX.

   July  22.—Mary  Gotdirig, the subject of the following ex-
traordinary  case and dissection, was first brought for my ad-
vice about six years ago.   She was then 11 years old.  Her
breathing was  short  and difficult, attended with occasional
palpitation of the heart; the pulse Was small and irregular ;
the whole body always chilly ; the face pale and  sallow, re-
sembling  that of a person  under confirmed chlorosis.  The
chest, especially the left  side, was very much distorted^ the
lower part  of  the sternum being protruded outwards, the
spine curved, the left side much larger, and the ribs more cir-
cular than the right.  The bodily strength and flesh  were
much  reduced, yet  the  appetite  remained  unimpaired.
While examining the chest my attention was engaged by an
incessant throbbing of the  right side, in a parallel line with
the natural seat of the heart.  The  emaciated  state of the
body enabled me to ascertain with certainty that this really
arose from the heart, the alternate systole and diastole of the
auricles and  ventricles being very perceptible.  On inquiring
into the cause of this singular phenomenon, I  was informeot
that a year and a half before, in consequence of a  fall from a
waggon, she received a violent blow oh the pit of her stomach,
&9n succeeded by great  difficulty  of breathing  and feven
• July 1808, ia health, 
APPENDIX.
Of
which confined her to bed for ten days; that about twelve
months  afterwards a painful  swelling appeared  on the left
fide of the cartilago ensiformis, from which period she dated
all her present symptoms.  It being obvious  that the  heart
was not only displaced, but highly  probable also that  there
was a morbid change of structure of the other thoracic  visce-
ra, to which the interrupted  respiration and circulation, the
distortion of the chest, and other symptoms were to be  attri-
buted, I thought the case beyond the reach of medicine, and
that her end was not far distant.   This opinion  I communi-
cated to the mother, requesting at the same time to be ap#-
prised of the  fatal event, whenever it happened, which I
thought would be suddenly.   I directed her to be kept quiet
and  still, to avoid ali violent exertions, to be  supplied with
mild  simple nutriment;  and prescribed  a tonic chalybeate
medicine.
  She was brought to me some mojaths afterwards, and I was
surprised to find she had received considerable  benefit from
the means  recommended.  This, however, was not of long
duration, and  the complaints already enumerated were now
sensibly increased.  She was repeatedly brought to me after
this  period, and every  time there  was a  sensible increase of
her sufferings, as well as of the distortion of the chest.
  For several months prior to her dissolution, during which
time I frequently visited her, although she suffered no acute
pains, yet her situation was truly distressing.   From an early
period  of her  illness she could neither lie  on her back  or the
right side.  When, forgetting her former sufferings, she  at-
tempted either, she was threatened with  immediate suffoca-
tion ; and latterly the smallest inclination  of the body either
backwards or  towards the right side was  productive of simi-
lar effects.
   In the  last month of her existence she was obliged to sit up
constantly in a chair, and sought repose by resting her  left ej- 
oij
APPENDIX.
bow and head on a pillow placed on a table before her, near
the fire; and though all the  movements of her body were
performed with great caution and deliberation, yet such was
the difficulty in respiration, so often was she threatened with
suffocation, and so constant was the palpitation, though  now
much more  obscurely felt, that every  day, nay every hour,
was expected to be her last.   The whole body was always
chilly, and  the extremities, especially the  lower, up  to the
knees, were intensely cold, of a dark livid hue, and to use the
mother's expression " were dead a fortnight before the rest of
the body."  The feet and legs were likewise considerably
swelled, and a quantity of serous fluid was discharged from a
sore on one of the great toes.  The pulse which  was always
feeble  and extremely irregular could not be felt for the last
fortnight;  the  livid aspect of  the face, and indeed of the
whole  body, sufficiently  demonstrated that the blood circu-
lated with force scarcely  sufficient  to support life.  The ap-
petite  continued unimpaired to the last; yet such was the
pressure on the oesophagus that repeated efforts were generally
made before any  food could pass  into the stomach ; and the
same pressure being applied to this organ, it was often thrown
up without any sickness or action of vomiting.   In the efforts
and struggles to swallow she had often been nearly suffocated,
owing to the food remaining for some time in the oesopha-
gus ; and it passed suddenly into the stomach with a pecu-
liar wheezing noise, which could be distinctly heard by those
standing by,  From these causes the habit received but very
little nutriment,  for a great length of time; and for the last
week she was supported only  by  the smallest  quantities of
liquids.  The urine was latterly much diminished in quan-
tity.
   She had never  menstruated, nor had she attained to much
more than half the size of a full grown healthy subject of mo- 
APPENDIX.
5?
derate bulk at the age of seventeen years.   She died  on the
21st.
  Permission having been obtained to open the  body, Mr.
Anderson, who frequently Visited her during her illness, being
equally desirous with me to ascertain the cause of her singu-
lar complaints, was so obliging as to conduct the dissection.
  On viewing the body before we proceeded to examine the
internal organs, the distortion of the chest was more distinct-
ly observed than before death.   There was a considerable tu-
mour in the epigastrium which  protruded the lower end of
the sternum and scrobiculis cordis a considerable May out-
wards, and  descending  as  low as the umbilicus.   The ster-
num, as well as the spine, was curved towards the  right side.
The left  side of the chest  was nearly double  the size of the
right, the ribs being proportionably elongated,  and anteriorly
much more convex than natural.
   On laying open the abdomen, the swelling already mention-
ed-was observed to be the left side  of the diaphragm, nearly
as thin and transparent as a bladder, thrust down not only as
far as the umbilicus, but filling the whole of the left  hypo-
chondrium, and  extending half way into the  right,  the sto-
mach  and liver  being pushed down below  the umbilicus.
The liver was extremely small, firm  in its texture, and paler
than natural,  AH the other viscera were sound also, but unu-
sually small and pale.   On removing the integuments of the
thorax, the cartilaginous extremities of the left ribs were sof-
ter than  natural.  When divided,  and the left  cavity laid
open, it was filled with a cyst of considerable  size, adhering
in several places to the pleura,  but not to any considerable
extent to the diaphragm.   No traces of the heart  or left lung
could  be discovered in any part of this cavity : on passing
the hand under the sternum along the sac these and the medi-
astinum were found, thrust about two thirds of the way into
the right cavity.  We attempted to detach the cyst from its 
58
APPENDIX.
adhesions, and to remove it whole; but being very thin an^
transparent, this was found impossible.   Two or three open-
ings were unavoidably made in it, through which some of the
fluid  escaped, which prevented accurate measurement; but
we obtained near two gallons of a fluid that  was nearly trans-
parent ; and within its cavity was a very thick, but soft, spon-
gy substance of a whitish colour, which appeared to have
been  in some places loosely attached to its internal surface,
and to be an encrustation formed by the coagulable lymph,
probably at an early period.
   On opening the right side the lung collapsed to  its natural
size, seemed free from disease, withoutadhesions to any part;
and there was but just room for the hand  to pass between the
mediastinum and the ribs.  The heart  and lungs were, as
might naturally be expected, extremely small.
   The whole contents of the thorax were carefully separated
and transmitted to Mr. Cline, (with a short sketch of the his-
tory of the case,)  who favored me with the following report.
   " I am very much obliged to you and Mr. Anderson for
the extraordinary morbid lungs which I  received some time
since."
   " From a careful examination of the parts, it appears that
the origin of the disease was the formation of hydatids in the
inferior lobe of the left lungs, which by gradually increasing
had produced that large membranous bag.  The heart and
lungs appeared to have undergone no other change than such
as might be expected from great pressure, and thereby inter-
rupting their functions.   I have sometimes met with hyta-
dids in the lungs but in no case like the present, therefore the
parts are carefully preserved."
   " This case serves to illustrate how the most important or-:
gans may be altered in their situation by gradual pressure,
without producing speedy death." 
A'PPENDIX.
Wo1
  A case fe related by Hoffman vol.7. Obs. vii. p. 471, in which!
dear 71bs. of water were found in the left cavity of the chest,
after death : it was originally contained in a sac, which burst
in a fit of laughing three days before death.  The left foot,
leg,  and thigh only,  together with the scrotum, were swell-
ed.*
  That  the origin of the immense cyst which occasioned the
train of symptoms described in the above case, and ultimately
the death of the patient, is to be referred  to the violent blow
which preceded her illness, can scarcely be  doubted.
  The precise manner in  which this happened, or the part
where it first commenced I had no opportunity  of ascertain.
ing, being unwilling to injure the parts by a minute examina-
tion, choosing  to reserve this for  far more able  hands.  It is
probable, however, that the foundation  was laid in the lower
part of the left cavity of the chest, where the cyst was attach-
ed to the diaphragm, this being near the part where the blow
was inflicted, though the  strongest adhesion was in the upper
part.
  This case exhibits in a striking degree the wonderful pow-
ers  and resources of nature in protacting life untler the great-
est  possible interruption of the functions of the most import-
ant organs, when very gradually induced and when unaccom-
panied with positive  disease of these organs.  The peculiar
circumstances  under which this happened and continued for
so great a length of tinie are extremely interesting,  and high-
ly deserving the attention  of the Physiologist.  The pressure
on the heart and lungs, especially the left  lobe, were such as
to admit only of a  very imperfect and feeble circulation
through  the body; of which the paleness at first, afterwards
the livid colour and coldness of the face and whole body, the ex*
tremely irregular and weak pulse, were sufficient proofs. Hence
if the pressure on the oesophagus and stomach had not prevented
* Vide appendix N«. ii case 2. 
60
APPENDIX,
a quantity of nutriment adequate to the ordinary purposes of
health from being taken, her life would most probably have
terminated much sooner; it being obvious that had the di-
gestive organs supplied materials  for a full portion of chyle*
the lungs could not have transmitted the quantity of blood
which would thus be formed, even under a more free and vi-
gorous action of  the  heart.   Death  therefore from  sudden
plethora, apoplexy or suffocation, must have speedily followed.
But in proportion to the  diminished capacities of the pulmo-
nary vessels,  and action  of the heart,  in consequence of pres-
sure, the supply of food to the stomach and chyle to the blood
were lessened also by the same cause; and thus a due equili-
brium between the quantity of blood generated, the power of
the heart in propelling it, and capacity of the lungs for receiv-
ing it, was preserved throughout.  The blood too being thin,
poor, and pale from imperfect oxygenation, the heart would
consequently be less stimulated, the growth of the body would
necessarily  be interrupted ; every  organ  be preternaturally
small; the body would be at first pale,  afterwards cold and
livid; and life  was naturally prolonged  from these causes,
though in a state of feeble existence,  for so great a length of
time.
  Had the real nature of this case been  suspected at an early
period, I cannot help thinking that relief might have been  pro-
cured by art. The habit was in every respect such as promised
a happy result from the use of digitalis, which, together with
& combination of steel,  myrrh, and the Kali pp. would most
probably have acted on  the lymphatics, provided this artifi-
cial cavity was supplied with a sufficient number of these  ves-
sels, like the natural cavities of the body.  If medicine failed
it was a favourable case for the paracentesis. 
APPENDIX.
61
                      CASE XL.

  March 8.—Mrs. O. of Sudbury, Et about 60.  A very fat
Bhort corpulent woman; has for some years lived a sedentary
life, seldom going out in the summer, and never in the winter.
Has been ill some weeks, and taking for some days small doses
of digitalis from the family practitioner, but without any sen-
sible effect.  Breathing very difficult and laborious, increased
on any bodily exertion ; preventing  her lying down.  Abdo-
men increased in size, but without fluctuation.   Urine scanty,
of a dark colour,  with corresponding thick sediment.   Legs
somewhat swelled,  but hard.  Appetite unimpaired.   No
thirst.   Pulse full and regular.
  ft.  Infus. Dig. P. (3j- ad  3vij.)  3vj. Tinct. Card. C. 3ij.
Sp. Eth. Nitr. Sp. Eth. Vitr. C. sa. 3ft.  M. ft. haust. bis ind.
mane nempe,  et h. s. cum.  bolo. seq.  s.
  ft.  Dig. P. P. gr. j. Nitr. pur. gr. iij.  Conf. Arom. q. s. ft.
bolus.
  The digitalis, after being for some time under its influence
did not  act readily on the  lymphatics.  Squills and small
doses of calomel, With other diuretics, were afterwards blend-
ed with it, by means of which the dropsical symptoms were
removed in a few  weeks;—have not returned since.#

                      CASE XLI.

  September 5.—B. Myall, esq. of Castle Hedingham,  in Es-
sex, Et. 58.   Very corpulent.  Till within a few months has
enjoyed good health; lived well; indulged freely in the use
of strong beer, to  which he has been in  the habit of adding
large quantities of sugar ; and committed occasional excesses.

           • Mr*. O. was in good health in January 1R09.
                         32 
Lit
APPENDIX.
Apparently in  the last stages of hydrothorax,  of which the
following are the leading symptoms.
  Respiration performed with extreme labour and difficulty^
so as to be unable to walk a few yards or up stairs without the
greatest caution, and without stopping several times, support-
ed  by two  persons.  He is frequently obliged from a  most
distressing sense of weight and stricture across  the chest, to
make several laborious inspirations,  in  which  he raises his
neck and  head erect,  with his mouth open, and throws his
arms above the head,  apparently with  the view of assisting
the  intercostal  muscles to elevate the ribs, and thus enlarge
the  capacity of the chest.  Though he has been unable for
some time to lie down, and compelled to seek repose at night
as well as in the day with his shoulders very much elevated,
yet he is often  suddenly roused from sleep by a sense of suffo-
cation, for some minutes after which* his recollection of events
recently  passing before him, as well as of persons about him,
is lost, and he  talks incoherently.   These  paroxysms have of
late occurred so often, and been  so  alarming,  that the fami-
ly practitioner has been repeatedly sent for and sat up with
him whole nights, apprehending every hour would be his last.
Even when sleeping in his chair in the day time, these happen
though in a less violent degree.   Legs anasarcous in a conside-
rable degree, the swelling in the evening extending above the
knees; the skin is transparent, readily receiving, and for some
time retaining the  impression of the finger  The feet are not
cold at any time, as very generally happens; the pulse  is full,
hard, regular,  and' 90.#  Intense thirst at first, but now less.
T.  dry, brown  and furred.   B. open.   Countenance swollen

  * In the history of the disease, it has been  observed, than when the
pnke was full and regular, and when consequently the blood was pro-
pelled with due  force to  the extreme parts, the feet and legs retained*
their natural warmth, though the cellular substance was  loaded with wa*
ter. 
APPEXDtX.
6$
 5,nd bloated ; not of a livid hue, nor cold, but expressive of
extreme suffering.  Constant drowsiness, but no natural sleep,
 being hurried and interrupted.  Urine natural both in quan-
 tity and  quality  since the  commencement of his illness, nor
 has it been influenced in either respect by any medicines he
 has taken.
   The above  complaints commenced some months ago, first
 with general languor and weakness,  soon succeeded by oeda-
 matous ankles and  interrupted respiration.   Had  a severe
 cough in January last, during which he vomited some blood;
and his strength was thereby much reduced, to which, and to
his having for some years suffered great anxiety and uneasiness
01 mind from the loss of a female relative who lived with him,
added to some bodily  fatigue in conducting his extensive
concerns,  the  present illness may be in a principal degree at-
tributed.
   I had never prescribed for any part of this gentleman's fam-
ily before, having been for many years attended by a physician
of extensive  practice, and justly acquired reputation.   In the
present illness  he had repeacedly seen him.  Two other phy-
sicians of respectability, had Ukewise prescribed for him ; but
no impression having been made on Ills disorder, and not even
temporary relief having  been  procured by the various means
that were recommended, his case was now regarded  by all
as hopeless, and he had for sometime no other attendance than
that of the family surgeon and apothecary.   In this deplorable
state he was earnestly  entreated by a neighboring friend to re-
pair without delay to Bath, in order to place himself under the
care of Mr. Tikel, who as an inducement it was said, had recent-
ly cured admiral B. of a similar disorder.   The Cth, or the day
subsequent to my visit was  actually fixed for  his departure,
when  a  friend of mine accidentally called on him on the 4th.
He requested I might first be  permitted to visit him ;  and so
bent was  he on his journey that my immediate attendance 
64
APPENDIX,
was in consequence desired.  I could not however see him ti.i«
the following day.
  From  the situation in which I have described him I pre-
sume I shall be acquitted of having discharged my duty in
dissuading him from yielding to the solicitation  of his kind
friends until some more favourable change took place in his
disorder.  1 hesitated not to say, what indeed seemed obvious
to all those constantly about him, that so far from being able
to reach  Bath, he would in all probability never get to Lon-
don, having  been for several days threatened every hour with
suffocation.   My confidence in the  plan which 1 had in so
many instances practised with success, was now such that I
promised speedy relief of all the  urgent symptoms;  yet I
think it right to say, that I gave no encouraging hopes of per-
manent recovery.
  Besides the urgency  of the symptoms described there were
other circumstances  unnecessary to detail here, on which my
prognostic was in some degree founded.
  He had been for some time desired to drink large quantities
of strong beer, brandy and water, and various cordials, to-
gether with asther and laudanum,  in order to remove the vi-
olent spasms with which he was supposed to be affected.
  I  directed him to refrain from all malt and other strong
liquors; to  have a generous nutritive chiefly animal diet; ta
drink a few  glasses  of sound old wine at dinner •,  to have gin
punch acidulated with cream of tartar, and besides to indulge
freely in   other diluting liquors;  to lie  with his shoulders
more elevated than usual ;  to ride out as soon as he was able,
to use frictions with camphorated oil to his legs ; and pre-
scribed as follows,
  A)pl. Empl Canth. satis Amplum  pectori.
  ft. Infus.  Dig. Purp. (3j. ad 3vj.) gj. Sp.  JEth. Vitr. C.
Sp. jEtheris Nitrosi a 3j. Kali Acet. gr. xv. M.  ft. haust. cuifl
Pilul. seq. sing. noct. et matutinis sum. 
                        APPENDIX.                      65

  ft.  Fol.  Dig. Purp.  gr. j-  Kali Acetat. gr. iij.  Confect.
Aromat. q. s. ft. Pilula.
  August 8.—At 6 P.  M. saw him.—Did  not begin  his
medicines till  the  6th  at noon.  The following evening the
urine was sensibly augmented;  and he has since voided four
times the usual  quantity, about 8 pints by measure the last.
twenty-four hours,   The quantity as well as frequent propen-
sity to void it has alarmed him, fearing he may have a disor-
der no less dangerous entailed upon him.  In  every respect.
very considerably relieved ; his breathing being now perfect
Jy free, and having no  drowsiness, or  starting up from sleep
eince I saw him.  Countenance much improved in its aspect.
Contrary to my injunctions however he  had been too liberally
supplied with strong brandy and water, and has had no  gin
punch.  P.  72  and full.   T.  dry and brown with  more
thirst.  Legs less swelled  and  softer.   Two  motions daily.
Slight nausea ;  but this appears to proceed  from  his hav-
ing ate a full meal of goose for dinner.  Pergat. U, A.
  August 10.—5 P. M.  Urine has continued to flow profusely
with  proportional relief of his breathing  and every  other
symptom.   Can now lie down in bed, and enjoys sound unin
terrupted sleep, without ever being roused as before.  Swell,
ings nearly gone this morning, but now  returned about  the
feet and ankles in a slight degree.  {Imperfect vision at times,
with frequent nausea, sense of faintness and sinking of the sto-
mach ; but his appetite continues to improve.   T. moist and
clean and  no thirst.  B. regular.   Pulse from 56 to 60  and
much softer.*   On the  whole  has mended rapidly since  las I
report,

  * As the pressure on the  lungs, flora the absorption of water, is levell-
ed, and the transmission of the blood through thein is consequently facili
tated, it is seen that the contractions of the heart become less forcible. 
66
APPENDIX.
   ft. Dig. P. P. gr. j. Scillae Pulv. Calom. ii. gr.fl. Kali Acet.
 gr. iij. Conf.  Ar.  q.  s. ft. bolus mane et hor vij. P. M.  cum
 haust u seq. s.
   ft. Infus. Gent. C.  3x. Tinct. ejusd. 3jf$. Kali Acet. 9i.Sp.
 £th. Nitr. 3J. M. ft. haust.
   August 13.—Has  continued to improve in every  respect
 since last report.   Was a good deal under the influence of the
 digitalis yesterday and day before, having sickness, languor,
 faintness  with imperfect vision, which to day have been less,
 the digitalis  having  been  discontinued.   No swelling of the
 legs in the morning, and but little  in the evening.  Urine
 continues in  full quantity, though, as the swellings have sub-
 sided and the breathing has been relieved, it is much less than
 before, there  being evidently no superfluous moisture tcwab-
 sorb.  In every other respect improving, P. bO and  soft.  The
 additional frequency of the pulse may be attributed  to his
 having rode some miles in a post chaise, and partly to  the di-
 gitalis having been withdrawn.  I directed his feet and legs
 to be bathed evening and morning, in a solution of salt water
 at first tepid but by degrees cooler, and at length quite cold.-r*.
 To adhere strictly to regimen.
   Pergat in usu haust. et hac nocte encipiet sumere bol. e Dig.
 Purpur. U. A.
   August 16—Continues to  improve  in every respect.  No
 sensible effect on the habit  from the digitalis.   Urine in full
 quantity. B. always open.
   ft. Dig. Purp. P. gr. viij. Calom. Scillae, a. gr. iv. Myrrhae
 3j. Confect. Arom.  q. s. ft. Pil. xxiv. Sumt. duas ter ind cum
 haustu seq.
   ft. Decoct. Cinch, flav. fort. 3x. Tine. Gent. C. Sp. Mh.
 Nitr. aa. 3J. Kali Acet. 9j- M. ft. haust.
  Appl. Empl. Canth. Sterno.
  August 19.—Progress very rapid since last report. Scarce-
ly any swelling of legs even at night, and says  he is  much 
                        APPENDIX.                      67

stronger.  Finding his breathing perfectly free, the blister
was not applied.  I directed it, however, to be applied  this
night by way of precaution.  Discovers a great reluctance in
persevering in medicine, and  does not take it  punctually.
Augeatur Decoct. Cinch, ad 3*iv. sing,  haust,  et  pergat.
U.  A.
  August 22.—Rode  to Sudbury; and he continues to  im-
prove.  Some days since had slight swelling of hands, which
is now gone.   Blister rose well.  Directed  flannel rollers to
his  feet and legs, after they are  bathed.  I now discontinued
my regular visits, earnestly requesting he would persevere
wilh  unremitting attention in  the regimen and medicine re-
commended.
  October 11.—I was desired to see him.  Has for some days
been getting worse, having at times had sickness and bilious
vomiting, but evidently not from the digitalis, as he has taken
very little of this or any other medicine since last report.  His
nights are extremely restless, yet though he frequently gets up
in bed  his  breathing  is free.  Urine natural.  Little or no
swelling of  the legs.   Appetite and strength somewhat im-
paired.  P. 84 and full.  Thinks he caught cold.   Objects to,
and indeed refuses to take medicine in a liquid form.
  ft. Vini Ipecac. 3fS- Aq. M.  P. 313- Pulv.  Ipecac, gr. vj.
Vini Ant. 3J. M. ft. haust. Emet. quamp. sum.
  ft. Dig. P. P. gr. jfj. Canella? Alb. P. gr. iij. Kali Acet. gr.
vji.  Tinct. Benz. C. q. s. ft. bolus sing. noct. et mat. s.
  October 13.—Rather worse.  Breathing begins to be affect-
ed in a recumbent posture, or on  quick motion, and  he com-
plains of a  most distressing  febrile restlessness Mith thirst
Emetic operated well.   B. costive. P. 96 and full.  The ne-
cessity of medicine strongly urged.
  ft. Calom. gr. iv. Aloes, gr. v.  Kali Tart. gr. iij. probe S>
raul tere et Confect. Arom. q. s. ft. bolus quamp. sum. 
63
APPENDIX.
  ft. Infus. Dig. P. 3j. Sp. juniperi C. Sp. Mh.  Nitr. Aceti
Scillse, a 3j. M. ft. haust. mane et h. s. cum bolo seq. s.
  ft. Dig. P. gr. j. Calom. gr. ft. Confect. Ar. q. s. ft. bolus.
  October  16.—Laxative bolus  operated  kindly.   Almost
immediate relief from the draughts and boluses: aud he has
siuce been able to lie down in bed, and to sleep sound.  Thirst
and  febrile restlessness  gone.   Urine increased  in quantity
the last 24 hours.   Acknowledges he  has been considerably
better, especially since yesterday.   Being evidently under the
influence of the foxglove yesterday it was omitted.  Sickness
Jess to day, P. 76 and softer.
  ft. Mist. Camph. 3j.  Kali Acet. 9j. Sp.  Eth. Nitr.  Acet.
Scillae  Tinct.  Gent. C. a.  3J. M. ft. haust. hac nocte  et eras
mane s. et vespere incip. Sumere med. die 13 praes.
  November 7.—His complaints having fluctuated as before,
having taken  his medicines and conformed to every restriction
very irregularly since last report; and finding the journey to
Bath had been again mentioned to him, in my late visits I
strongly encouraged it.  The swelling of the legs had been
for some time subdued, and there being every reason to believe
the serous effusion in the chest had been removed, the exercise,
variation of scene, and the amusement of the journey,  there-
fore, promised to be productive of more advantage to him.  I
had another object  in view likewise.  Persuaded in my own
mind that neither the Bath waters, nor any medical assistance
he might have in that city, celebrated for men of eminent ta-
lents, were likely to prove of any essential service to him, I
was desirous  of convincing those officious friends  who had ta-
ken the lead in directing his movements of the same.  Of this
I apprized his brother, a very sensible and  intelligent man
who was to accompany him.   Accordingly,  after furnishing
them with the necessary directions they set out this day.
   November 23—Returned home yesterday, after a residence
of about a week at  Bath, without deriving any  benefit either 
APPENDIX.
69
ifrom the journey or the medicines that were prescribed for
him.  His  nights are extremely restless  and  hurried,  his
mind being greatly agitated at all times, but especially in the
course of the night.  Appetite not much impaired. P. quick;
and he has  frequent thirst.   Dr. Parry prescribed saline diu-
retic medicines, which however produced no diuretic  effect,
but  he  thought relieved the febrile restlessness  for the first
two  days.  Dr. P. and Mr. Tikel discouraged his staying at
Bath.
   I directed a blister to be applied to his breast, and to return
to the digitalis and squills, with the addition of crystals of
tartar, which for a time relieved him very materially.
   Having  a natural aversion  to medicine, and finding, after
repeated trials, that  relief was only transitory, he at length
refused every thing in the shape  of medicine; became ex-
tremely peevish, fretful, and impatient of every restraint; his
strength gradually declined, and after having several convul-
sive paroxysms for the last  few weeks of his life  in  which he
remained for  some time totally insensible, he died on the 2d  of
February, 1800, of completely exhausted constitution.  Lat-
 terly he could lie down in bed without any difficulty in respi-
 ration, from which I had reason to believe that not only all
 the water  in the cavities of the chest was removed, but that
 the disposition to its  farther effusion was corrected.

                       CASE XLII.

   September 11.—Mr. Steam, Et. 57, of the parish of Wald-
 ingfield.  Of a  very full and corpulent habit.   For some
 years has been subject to plethora for which he has  been  re-
 peatedly  let  blood  with  relief.   Of late  has suffered great
 mental uneasiness and anxiety, in  consequence of his having
 had unexpected  notice from his landlord to quit his farm,
                              33 
ro
APPENDIX
u hich appears to have contributed iu a very great degree to
his present illness.
   Breathing extremely quick, hurried, and anxious, especial.
Jy on walking, &c.  For six months has been unable to lie
down  on  the right side, though  formerly he always lay on
this;  and for a fortnight has been obliged to have his shoul-
ders raked very high hi bed, owing to a most distressing sense
of suffocation  and palpitation which he experiences if he at-
tempt to lie down.   Has a sense of weight and oppression at
times, under the sternun*, with a peculiar  fluttering or a sense
of sinking as if his  life were going, at the pit of the stomach.
P. by accurate measurement 152,  extremely small, fluttering,
and irregular.   Urine very scanty, high coloured, with copi-
ous thick reddish sediment, not more than half a pint in 24
hours.  B. in  general very loose; but now regular.   Appe-
tite and strength much  impaired, and he frequently vomits
up his food.  T, slightly furred, with thirst.   Has been sub-
ject to coughs in the winter season for some  years, and  last
winter and spring had a severe  attack attended with short
difficult breathing.  Countenance swollen or bloated, of a li-
vid hue,  and expressive of extreme suffering.  Ankles only
slightly oedematous, but his lower extremities have been re-
markably cold for some months.
   The present symptoms commenced about a month ago, but
for the last fortnight, have increased rapidly, although he has
had regular medical attendance.
   Has in general lived well and used much exercise,  but not
addicted to  excesses.  Had a blister applied to the sternum
on the 8th, which procured only temporary relief.
   ft. Dig. P. P. gr. j. Kali Acet.  gr. iij. Conf. Arom. q. s. ft
bolus mane et vesperi cum haust. seq. sum.
  ft. Infus. Dig. Purp. (3J. ad 3 vj.) 3j. Sp. iEth. Vitr. C. Sp.
Xth. Nitr. a 3J- Kali Acet. gr. xv. M. ft. haust. 
APPENDIX.
n
   I •directed him to live on light animal food ; to have wine
 in moderate quantity ; gin punch for drink, and no beer.
   I had no doubt but that in this case there was water in the
 pericardium as well as in the left  cavity of the chest; and as
 the situation of the patient appeared imminently hazardous,
 I requested his surgeon and  apothecary, who  came to my
 house with him, to conduct him home as soon as possible, and
 that I should visit him again on the,
   14.—On the night of the 12th, after taking three draughts
 and as many boluses, the urine began to flow more freely, and
 in the course of the following twenty-four  hours,  he voided
 about six pints of nearly transparent water, without any sedi-
 ment ; and  it has continued in the same proportion since,
 with remarkable  relief Qf every distressing symptom.  To-
 wards the morning of yesterday, he could lie down in bed,
 and on either  side ; and he lay in  a recumbent posture the
 whole of last night without any inconvenience, which he had
 not done for six months.  Breathes with perfect freedom, and
 goes up or down stairs as when in health-  Countenance much
 improved in every respect.  P. from 80 to 81, more firm but
 still irregular and  intermitting, though  much less so than
 when I first saw him.  T. clean and moist.   Appetite perfect-
 ly restored, and he feels himself already stronger.  Two mo-
 tions daily.   Legs as to swelling the same, but have recov-
ered their natural warmth since the urine  began to How free-
 ly.  Has at  intervals a troublesome dry cough.   Besides his
regular  meals, I directed him to take a glass of sherry, and a
crust of bread with a slice of cold meat, at noon; to bathe his
feet and legs in a saturated  solution of salt  in water, to use
frictions to them afterwards; to have the blister kept  open, or
rather a weak one applied, and to continue  the medicines a
day or two longer, or until the habit should be in a slight de-
gree under the influence of the digitalis, when, as I invariably 
72
APPENDIX.
do, I desired it might be withdrawn ; and I fixed the 17th
for my next visit.
   The morning after my visit, however, the aspect of things
suddenly changed for the worse : he was seized with general
languor, weakness, faintness, and coldness, which increased ra"
pidly till his death,  which happened either in  the evening or
the following morning. As I had not an opportunity of seeing
the medical practitioner who attended with me, and who saw
him some hours prior to his death, for  several months after
this unexpected event, I regret  not  being in possession of the
particular circumstances which preceded it.  Candour, hoAv-
ever, obliges me to declare, that I think  the digitalis was con
tinued too long, that its powerfully sedative effects co-operating
with the sudden depletion of the cavities that were  before
considerably distended,  and the proportional removal  of pres-
sure from off the heart, lungs, and large arterial trunks, may
have contributed to the fatal  event of this  case.  It is proba-
ble however there may have been a polypus concretion in some
of the cavities  of the  heart, as the symptoms bear a striking re-
semblance  to  those  mentioned by  authors in  which polypi
were found after death.  Though the digitalis had produced
no visible  effect on the habit,  yet  there was ample evidence
of so full an operation on the lymphatics and kidneys that no
hazard ought  to have been incurred by persisting in its use af-
ter my first visit on the 14th.    Two doses only had been tak-
en after this period ;  yet had  my injunctions been rigidly ob-
served, none ought to have been used;  as  the patient began
to be affected  a few hours after  my departure, though  his
symptoms did not assume  a  serious aspect till the following
morning.
   While I have thus, I hope,  candidly stated the error which
I apprehended to have been  committed in this case,  I may
now be suffered to affirm that this was the only one which oc-
curred  in  my practice, either  in hydrothorax or any other 
APPENDIX.
7$
jpecies of dropsy, where there was reason to suspect this medi-
cine of any injurious  consequences.  And I have been* the
more particular in detailing its symptoms, which were com-
mitted to paper as delivered by the patient in the presence of
his surgeon apothecary, as a caution to the young practitioner
not to persist in  the use of the medicine after the urine has
flowed profusely, although  the habit  be not otherwise  affect-
ed by it.
  The history  of the  following  case appears so interesting,
and  the symptoms of effusion in the pericardium, as well as
the other cavities of the chest, so strongly marked, that I have
thought  it  worthy  of being recorded,  though the patient
died, before the medicines,  which  were prescribed, reached
her.

                      CASE XLIII.

  October 27.—Mrs. C. of the parish of Hartcst, Et 35.   Of
very short stature ; and prior to her present illness corpulent,
with a lax fibre, and always of a delicate constitution which has
been  considerably increased since her marriage  by  frequent
parturition and abortions, succeeded generally by profuse pale
menstruation and leucorrhcea.  Respiration short, quick, and
anxious,  increased on  the smallest mental emotion or bodily
exertion.  While describing her symptoms as I sat by her bed
side, it was exceedinly quickened and interrupted,  so as to
oblige her to pause frequently ; she every now and then sigh-
ed, or rather made a sudden full inspiration in order to recov^
er her breath.  On first going  to bed, or on  inclining back-
wards in a chair,  the  difficulty in breathing is considerably
increased, but after some time it is somewhat relieved, provid- 
14
APPENDIX.
cd her shoulders are very  high.   In the act of turning from
the right to the left side, she has a peculiar sensation about the
heart as  if a fluid were  " pouring or dropping from a vial,"
and she even  thinks she can hear it at times passing from one
part  to  another.   Constant  fluttering, or weak palpitation.
P. 108, feeble, unequal,  but not intermitting, and-varying
considerably  in frequency by  the exertion of talking.   Com-
plains of a  sense of numbness,  alternating at times with pain,
of the shoulders, extending down the arms.  Urine  for several
days  very scanty with reddish sediment.  Legs anasarcous •
and one hand was oedematous  a few days since, but this now
gone.  Extremities, especially the lower, very cold, as indeed
is the whole  body, without due  precautions.  Her face has
been  in general pale and  sallow, but of late it has  assumed a
leaden aspect, the lips being of a darker tiue.   T.  very pale,
dry and clammy,  with intense thirst.  Bodily strength and
appetite very much impaired, having been chiefly confined to
bed for some days, and unable for some weeks to eat solid nu-
triment.
  Has had at different times  for a few years back slight at-
tacks of dropsy, together with enlargements  of the liver and
mesenteric glands, also frequent diarrhoea and lientery, which
were considerably relieved by medicine ;  but  the same causes
beiiag more or less constantly applied, it is probable they never
were completely subdued.
  Soon after the surgeon  apothecary who attended with me
left her, symptoms of dissolution came on suddenly, in conse-
quence of which a messenger was  dispatched for him, bat she
died before he reached her.—Leave was not given to open the
150 dy after death. 
APPENDIX.
75
                     CASE XLIV.

  November 8.—Mrs. H. of Lavenham, Et 43.   The mother
of six children, the last four years old.  No menstruation for
seven months, from which she dates, and to which she attri-
butes her present illness.   Together with the ordinary symp-
toms  of hydrops pectoris,  in a striking degree, there is a con-
stant violent throbbing of the heart, carotids, and at  the pit
of the stomach, increased considerably on motion, or on at-
tempting to lie down ; yet the pulse is weak, and very irregu-
lar ; great coldness of the face and extremities, together w ith
general chilliness: A dry cough.
  Her complaints have been gradually coming on since she
ceased to have children, but of late only have they assumed
their present formidable  aspect;   and they are now making
rapid progress.
  Her constitutioml strength being nearly exhausted, with-
out ai;y appetite for food, the  lelief experienced from medi-
cine th.;u^h at first considerable, was not of long duration,
She died some weeks afterwards.  I saw her only once.

                      CASE XLV.

   December 1.—Master Sewell, Et 3.  A few weeks ago had
universal dropsy, of which he was nearly cured, when he was
attacked with measles three weeks since : was nearly recovered
from these when he was suddenly seized with very, violent
cough attended with fever and extreme difficulty in breathing.
These symptoms have continued  without much interruption
for about ten  days.  P. extremely quick ;  T. and lips very
dry,  and covered with a dark brown incrustation ; takes very
little nourishment;  B. Costive ;  pupils much dilated : head 
r6
AFPENDI-X.
seems pretcrnaturally large ; feet generally cold though tt»
heat of the body is increased ; comatose for the most part.1)
   Had a blister applied betvveen his shoulders a week ago,
and an enema administered last  night.   I suspect water in
the head.  As every kind of medicine had  been refused, I di-
rected five drops of the  Tinct. Dig. P. to be  given in any
drink or food that might be taken* three times a  day, the dose
to be gradually increased, and a blister applied to the breast.
   December 14.—The family practitioner  writes  me  he is
mending.
   December  28.—Reports him to be  perfectly well;  is in
doubt whether his recovery is to be attributed entirely to the
Tinct. Digitalis or not; as he appeared better a few days after
my visit; but says  he  was  much quieter, slept better and
longer after taking it.
   January 8, 1800.—Was desired to see him.   On inquiry I
was informed that his appetite returned  soon after  my last
visit,  that of late it  was craving and voracious, that it was
freely indulged, and that his body increased proportionally in
size, though not in strength.   His general aspect resembled
more that of a person at the age of 40, oppressed with bloated
fat, than that of a child three years of age.   His  countenance
was much swollen, bloated, and of a livid hue, as was his whole
body, but  the head and abdomen were larger in proportion.
His breathing was extremely difficult and laborious, especially
after eating.  B. regular, and urine in full quantity.   He was
brisk and lively at intervals,  but was totally  unable to  walk,
his legs not having  strength to sustain  the the great weight
of his body.  Flesh or rather fat soft and flabby.
   By having  him frequently drawn about  in the air in a car-
riage made on purpose, by constantly presenting amusing ob-
jects before him, and thus diverting his attention from  food,
the quantity was gradually reduced, the redundant  fat was
absorbed, the body was strengthened, while its bulk was pro 
APPENDIX.                      7?
poftionably reduced, he was in a few weeks restored to per-
fect health, and is at this time* a strong healthy youth.

                      CASE  XLVI.

  January 17,1800.^Miss Harrison, Et. 41.  Tall and  slen-
der.   Being a mantua maker, has for the most part lived a
sedentary life.  Subject for several years in the winter season
to severe attacks of cough attended with great dyspnoea, and
copious yellowish viscid expectoration, which have gradually
increased in violence every succeeding year.   Breathing at all
times affected by slight causes.  Some weeks ago  was attack-
ed with unusual severity, and for more than a fortnight the
symptoms have been extremely alarming.   Her expectoration
is now evidently  purulent, very copious, and mixed with a
viscid yellow mucus.   Breathing extremely difficult, together
with a sense of stricture and oppression across the chest, and
inability to lie down in bed.   P. 112, and very feeble.  Urine
small in  quantity, high coloured  with reddish sediment.
Great debility, and no appetite.   Profuse sweats break out on
the fits of coughing*
  Having repeatedly prescribed for this patient before, I ap-
prehended these attacks would eventually lead to dropsy  of
the chest, and for the most part prescribed the foxglove  in
combination with such other remedies as were deemed neces-
sary,  both with  the  view of  preventing this, and  relieving
present  symptoms.  This medicine was productive  of much
benefit, of which she was so sensible, that she always kept a vi-
al of  the tincture, and to which she invariably resorted on
any return of cough or dyspnoea.
  My predictions were now fuily verified, and so  alarming
did her situation  appear as almost to preclude all hope of re-
lief from medicine; yet by the following means aided by ap-
                       * January, 1809,
                           34 
?8
APPENDIX.
proprlate regimen she was restored to her usual state of health
m a few weeks.
   ft.  Tinct. Benz. C. 31J. Muc.  G. Arab. Mannae la.  3jfi.
tere simul, Aq. Menth. P. Svijfl. Tinct. Dig.  P. g.40. M.
Sum. coch. tria 4tis hor.
   ft.  Fol. Dig. Purp. P. Opii aa.  gr.ft. Muc. G. Ar.  q. s. ft.
Pil. sing. noct. h. s. s.
   January 22.—Urine increased  in quantity; expectoration
more free, copious and improved in appearance.   Cough and
difficulty in breathing proportionably relieved.  P. 108.
   Mist,  oliin praes.: Adde Tinct. Dig.  P. gt. xx. et Pergat
U.A.
   January 24.—Began the mixture with Tinct. Dig. only yes-
terday, and is already affected with slight nausea and  impair-
ed vision, which she knows by  former experience arises  from
the digitalis.  Symptoms much as before.
   February 2.—Expectoration much less purulent; more free,
copious,  and thinner.  Sometimes  brings up from the lungs
mouthfuls of a thin  frothy mucus without coughing  or any
difficulty, which I attribute  to the digitalis,  under whose in*
fluence she has been more or less  since  last report; the dose
has been varied accordingly.  She has likewise taken an ano-
dyne at bed time.
   Omitt. Haust. Anod.  Pergat in  usu Mist. Balsam: cum
Dig. P. pro re nata.
   From  this period  Miss H.  continued  gradually to mend,
and by the beginning of the summer she thought herself re-
turned to her usual state of health.
   The following winter,  however, she had a  similar  attack,
attended with  purulent expectoration,  and more strongly
marked symptoms of serous accumulation in the cavities of
the chest.  The legs became oedematous, and the secretion by
the kidneys was still more defective, assuming more the cha-
racters of dropsical urine.  From this and from several at- 
APPENDIX.
79
tacks  equally alarming  she  was rescued by similar  means.
At  length, however, her constitution being gradually under-
mined, she was taken ill in the  winter of%1803, in the usual
manner, and was suffocated by the quantity of pus and viscid
mucus which accumulated in the bronchial vessels.

                     CASE XLVII.

  January 31.—Mr. Boldero, a grocer, late of Bury,  now of
Cavendish, Et 36, B.   Has all the symptoms of hydrothorax
very strongly  marked.   The  most peculiar  are, a  violent
throbbing of the  heart, and carotid arteries; a strong hard
tense, but regular pulse, 124  in  a minute;  a severe  dry
cough ; a pain, and sense of great oppression about the epi-
gastrium, extending to the right side, much increased after
eating; extreme restlessness  at night; appetite not much im-
paired ; bowels generally costive.   The  disorder  began to
assume its  present character about three weeks ago, since
which time it has advanced  very rapidly.
  Has been in  the habit for some years  of losing blood from
the arm three or four times, and of taking salts six or seven
times, every summer, for a drowsiness he has been subject to,
always with relief.  Last summer  was  let blood only once,
and discontinued  the salts  entirely.  Had a  blister  to  the
chest with temporary relief.
  Of late has lived a more sedentary life than usual.
  Sit V. S. et Mitt. Sanguis ad 3 vj. et Rept. si Opus ft. Appl.
Empl. Canth. inter Scapulas.
  ft. Kali pp. 36. Succi Limon 315- Aq. 3yj. Sp. Eth. Nitr.
Mell.  Scillae aa. 3J- T.  Dig. Purp. gtt. xx. M.  ft. Haust. ter
ind. s.
  ft.  Calom. pp.  gr. j. Kali Vitr. §r. iv.  Muc. G. Arab. q. s.
ft. bolus sing. noct. h. s. p. 
80
APPENDIX.
   The usual directions were enjoined  with respect to diet,
drink, &c.
   To  the sudden transition from an active to the sedentary
life of a shop, and the discontinuing the evacuations to which
he had been long accustomed, the disease is in this case to be
attributed; and as there was reason to suspect disease of the
liver, and organic  affection of the heart, I held out no hopes
of permanent relief.
   February 2.—Immediate relief from V. S. pulse softer and
less frequent.  Blood was not buffy, nor firm; a very large
proportion  of serum.  Urine not much increased in quantity.
Directed half a grain of the Pulv.  fol. Dig. to be added  to
each  bolus, and the same  quantity of opium if  the  bowels
should continue too lax,
   February 25.—Finding himself almost well after pursuing
the above  plan for about 12 days he discontinued his medi-
cines.  For some days has been getting sensibly worse.  The
throbbing  of the  heart  is so violent as not only to be seen
through his clothes but to be distinctly heard by a person sit-
ting near  him.  It extends to the carotids and epigastrium.
Urine high coloured with sediment but not much diminished
in quantity.  Meeting him on the 23d, on horseback on his
way to call on  me, I directed another blister to  be applied.
Is now so ill as to require my attendance at his house.  P. 94,
extremely hard.
   ft. Infus. fol. Dig. P.  (3J6- ad 3viij.) 3x. Kali pp.gr. xv.
Sp. Eth. Nitr. 3j.  M. ft. Haust. mane et vesperi s.
   ft. Calom.  Opii a. gr.ft. Kali Vitr. gr. iv. Conf.  Arom. q. s.
ft. bolus sing. noct. h. s. s.
   March 6.—Speedy relief from the bolus and draught pre-
scribed and taken on the night of the 25th, having slept with-
out being roused once, the  whole night: voided much urine
of the natural colour next day;  in a few days every unplea-
sant symptom vanished,  insomuch that he thought himself 
APPENDIX.
81
again almost well.  The digitalis having produced  sickness
and reduced considerably the frequency of the pulse, with an
intermission every tenth stroke, together with heaviness, giddi-
ness, and drowsiness, it was laid aside, and tonics substituted.
The pulse was observed to be from 10 to 15 strokes slower in
the afternoon than in the morning; having as before taken
his medicines very irregularly he is again worse.
   Tonics with  Diuretics, Calomel, and Digitalis had been
taken and varied according to circumstances.   It is remarka-
ble that while taking the medicines he says his urine is less in
quantity, higher coloured, and with more copious sediment,
and that it becomes more natural on laying them aside.
   April 13.—Since last report has fluctuated much, having
been sometimes considerably relieved, at others worse; of late
the disorder has evidently gained ground. Pulse now inter-
mits frequently ;  but the regular strokes are very strong and
hard.  Feet and  legs began to swell some time since ; and
the swellings are now very considerable, extending  to the
thighs.  No thirst; urine not much diminished, of the natu-
ral colour, and without sediment,   Has a very hard tumour
in the epigastric region,  extending to near the umbilicus and
some way into the right side.   The  action of the heart and
large arteries is so violent as to agitate the whole chest, so as to
be seen distinctly through the clothes, and to give the swelling
the appearance of a large aneurismal tumour.   I consider this
tumour as  an enlargement of the liver,  which most probably
existed  from the beginning, and together with every other
symptom of this singular case, tends to  confirm the prognos-
tic delivered at first, that no lasting benefit was to be ob-
tained.
   Bitters, Diuretics, Digitalis, Calomel, and Opium in various
combinations, were continued.
   April 18.—Since the 16th has been much better, able to lie
down in bed and sleep sound ; breathing very much relieved. 
S2
APPENDIX.
P. regular, but very full.   Urine as usual high coloured with
copious sediment while taking medicine.  Tumour as before,
   ft. Ung. Hydrarg. fort. 3j. Camphorae 3j. M. Inung. Epig.
et Hypoch. Dextr. nucis avellan. mag. sing. noct. h. s.
   ft. Cryst. Tart. P. gr. vj. Calom. gr. j. Opii gr.jft. Fol. Dig.
P. Pulv. gr. ij. Muc. G. Arab. q. s. ft. bolus sing. noct. h. s. s.
   April 21.—Since the 18th has coughed up large quantities
of thick florid blood, with much viscid phlegm ; on the 19th
had a violent pam of one side, which is now  abated, and was
hot and feverish last night.   Pergat U. A.
   April 26.—The Calomel was  increased on the 23d to gr. ij.
Homoptysis less, and he thinks himself munh better. Mouth af-
fected.   Expectorates much viscid mucus.   Tumour softer
and more flat.  P. hard and tense.  Urine much increased in
quantity and without sediment.  Continues to lie down, to
sleep  well, and to  breathe with freedom in every  posture.
Takes four grains of the Digitalis daily without any apparent
effect.
   Aug. Dig. ad gr. ij. ter ind. sed min.  Opium ad gr. j. h. s.
Mitt.  Sang, ebrachio  ad 3 iij-—iv. vel vj.
   May 2.—The  blood was not sizy ;  continues to  mend ;
mouth sore;  the blood expectorated is darker; has taken two
grains of Opium and two of Calomel daily.   Pergat U. A.
   May 6.—Opium and calomel  reduced to half the quantity,
and the ointment discontinued for two days, his gums and
mouth being worse; now better.   Very little expectoration
of blood.  Urine  natural; some  purgative motions; pulse
full and quicker;  in every respect better but gains no strength.
Swelling of legs and thighs much reduced.
   Iterum Inung. U.  A. et  Sumt.  Opii et Calom. aa. gr. j.
sing. noct. h.  s.
   Digitalis not mentioned in this report.
   May 22.—Has been getting weaker since last report;  but
ui other respects very little alteration except  that the tumour 
APPENDIX.                     83
is larger.  Urine in full  quantity.   B. costive.  Mouth still
sore.  Swellings nearly gone.  Appetite good, but much op-
pressed after eating.  Has been taking for some nights a bolus
of Digit. P. gr. vj. Opii gr. j. Calomel, gr. iij.    •
  Appl. Empl. Canth. Epigastrio.
  A tonic diuretic mixture, and a bolus with Calomel, Opi-
um, and Crystals of tartar h. s. were prescribed.
  May 30.—Since last  report  has been  getting  gradually
worse.   Eyes, whole body, and urine, of a deep yellow colour.
Tumour soft and nearly gone.  P. regular.   Died soon after
this; leave was not obtained to open the body though I very
much wished it.
  On a review of the above case,  I could not help thinking
that, had bloodletting been used largely at first, and repeated
occasionally ; had the plan laid down been conformed to more
regularly, and the habit charged with mercury  in the begin-
ning, life might have been protracted much longer, though a
permanent cure could scarcely be  hoped  for.   I suspected
from the first some serious mischief about the heart and lungs>
as well as disease of the liver, before this last shewed itself ex-
ternally.   There seemed at the same time every reason to be-
lieve that the violent  action of the heart was in some degree
occasioned by the pressure of the tumour on the aorta, as well
as by some organic mischief within the chest.
  This case fully verifies Dr.- Withering's  observation, " that
the digitalis seldom succeeds in men of great natural strength,
of tense fibre, of warm skin,  of florid  complexion,  or in those
of a tight chordy pulse."
  Although the habit was repeatedly under its full influence
the urine  seemed not increased by it :  and  it rendered the
pulse intermitting. 
84
APPENDIX.
                     CASE XLVIII.

  February 7.—Mrs. Smith of Thurlow, Et 45.  Of a very
delicate constitution, and the mother of several  children, the
last four months old.   Has all the symptoms of the disease
very strongly marked.  The breathing is so much impeded as
to prevent her from  walking or lying down  in bed without
being threatened with  immediate suffocation ; has constant
palpitation; the pulse is small, extremely irregular, and inter-
mitting ; legs and  feet oedematous,  though she has been con-
fined to bed for some time owing to extreme weakness.  After
her last lying-in, her strength was much reduced by a profuse
lochial discharge, about ten days after which she was seized
when in bed with violent palpitation, which continued with
short  intermissions  for some time without any  dyspnoea; at
length the breathing became so much affected that she is often
suddenly  roused when awake as well as  when asleep.  No
preternatural thirst.  Appetite tolerable.   Received some re-
lief from squills and other medicines she took about ten days
since;  but they  weakened her very much by  acting violently
on her bowels.
  1 consider this as a case arising from mere debility, concur-
ring with  extreme anxiety of mind to which her domestic con-
cerns constantly expose her.  Has been taking no medicines of
late.
  I prescribed  a blister to  the seat of the heart, the infusion
of foxglove in the usual form, moderate doses of squills, opium,
and calomel, h. s. with  the addition of tonics as soon as the
water was removed.
  I saw the  patient no more; but was informed that the me-
dicines  disordered her stomach and bowels at first; that by
occasional variations she  was in a short time restored to her
usual health; and that after being indisposed in a trifling de- 
APPENDIX.
85
 gree for a day or two she died suddenly in the night of the 30th
 of June following.

                       CASE LXIX.

   February 8.—Mrs. A. of Nayland, Et. 60.  Has had sever-
 al children.   For some years disposed to corpulency, and has
 lived a very sedentary life.—Palpitation or fluttering of the
 heart more or less  constant,  increased on motion, exertion,
 surprise,  or  emotion of mind, when  her breathing  is at the
 same time impeded;  but on rest breathes with freedom ;
 can lie  down in bed and on either side without inconvenience,
 and is not roused  from sleep; pulse extremely irregular and
 intermitting, now and then two regular full pulsations  ; urine
 natural ; bowels open, with  flatulency; no  thirst ; appetite
 unimpaired;  no swelling of the lower extremities, a sense of
 weight  and constriction at the lower part of the sternum.  Has
 been subject to palpitations and to swellings of the ankles occa-
 sionally, for some years.   I consider this case in the  incipient
 stage.   No cough.
   Empl. Canth. regione cordis.
   ft. Infus. Dig. P.  (3j. ad 3 viij.) 3j- Sp. Eth. Vitr. C. 3.(5-
 Muc. G. Arab. 3j. Kali pp. gr. xv. M. ft. haust. bis ind. s.
   February 11.—In  every respect better,  though, the urine
 has not been increased ; palpitation less, and pulse more regular.
 Uneasiness under the sternum gone.
   ft. Scillae P. Opii  aa. gr. ft. Kali Vitr. gr. iiij. Muc. G. Ar.
 g. s.  ft.  bolus sing. noct. et mat. s. cum Haust. olim. praes.
   Tonic diuretic medicines were directed to be given after-
 wards.
   August 13.—Sent for me.  After having derived much be-
nefit from the above medicines she discontinued them.   For
some weeks has been very weak and languid; respiration quick,
hurried, and anxious, together with palpitation of the heart,
                           3r> 
36
APPENDIX.
 sense of fluttering about  the pit of the stomach, very trouble-
 some on walking and going up stairs.   Functions of the sto-
 mach, bowels, and kidneys natural and she continues to lie
 down without inconvenience.  Ankles and feet oedematous,
 and pitting on pressure.
   Having been in town some weeks  ago,  she consulted Dr.
 Reynolds, who prescribed the following medicines with evi-
 dent relief while taking them.
   ft. Fol. Digit. Purp. gr. ij. Confect. Ar. q. s. ft. bolus h. s.
 quaque nocte s.
   ft. Mist. Camph. Lact. Ammon. a. 3vj. Sp. Ammon. faetid.
 Sp. Mheris Vitr. C. a. 3 ft. Syri Croci 3J. M. ft. Haust. mane.
 et h. s. s.
   I prescribed thus,
   ft. Fol. Dig. P. gr.j. NitrL Camph. a. gr. ij. Muc. G. Arab.
 q. s. ft. bolus mane et h. s. s.
   ft. Tinct. Tolut. 3ft. Bals. ejusd. gr. x. cum Ovi Vitell. vel
 Muc. G. Ar. q. s.  trit. Infus. Gent. C.  3x. Kali pp. 9j. Sp.
 Athens Nitrosi 3j. M.ft. Haust. mane et meridie s.
   August 23.—In a few days after using these medicines, the
 above symptoms were completely removed, and the urine was
 so much  increased in quantity as to alarm her, lest it  should
 weaken  her too much.   Being desirous of again having re-
course to tonics, she was directed a combination of bitters, steel,
and diuretics,,  with much advantage, and to go to the sea side,
from which she returned  in the autumn much improved in
every respect.
   From the above  period it may be sufficient to observe that
 she continued  to have returns occasionally,  which assumed
 more and more the true character of the disease ; and left her
always weaker.  At length her strength gradually declining
she died of exhausted constitution in the spring of 1803. 
APPENDIX,
8<"
                       CASE L.

  February 8.—Mrs. B. of this town, ./Et. 46.   Naturally of
a florid complexion, but her face now livid.   For some years
very corpulent.   Constant dyspnoea  of the laborious kind, as
well when sitting  up as when in bed, but always increased on
motion and in a recumbent  posture;  incessant palpitation and
fluttering of the heart; urine scanty; pulse intermitting and
oppressed ; for twenty-four hours has expectorated much pure
florid blood.  When able to  lie down in bed,  lay with most
case on the right side, the opposite to that she has been accus
tomed to  ; had a sense of weight and suffocation when she
attempted to lie  on the left side ;  now  obliged  to sit up in
bed ;  no appetite, thirsty at times; extremities and face either
hot or cold.  Bowels costive, though in health they were ge-
nerally open.  For  some time before the present attack has
sat up very late, and been much fatigued.
   Has been subject  to paroxysms of asthma  and spasmodic
affections of the lungs, sometimes with, at other times without
cough, for several years, always aggravated  in frosty weath-
er.   Somewhat relieved for the two last days by the  Fox-
glove, Saline Draughts in a state of effervescence, and other
medicines administered by a relative, a medical practitioner of
experience and respectability,  at whose house she resides.  A
blister was applied to the chest, and the  same medicines, with
occasional variations were directed to be continued, for a time
with considerable benefit.   At length, however, every remedy
ceased to  produce any salutary effect ;  the digitalis affected
her  head in so  peculiar and unpleasant a manner that she
became strongly prejudiced against it, and earnestly intreating
 is not to prescribe it, her wishes were gratified, as the case ap-
peared hopeless*  She died some weeks afterwards. 
33
APPE-NDri,
                        CASE LI.

   March 25.—Mr. Bond, .Et. 60.  Tall and thin ;  for acverai
 years, till of late, has lived a very active life as a farmer; for
 some months having been turned out of the farm, he has lived
 a sedentary life, and suffered much disappointment in conse-
 quence of  being thrown out of business, as he thinks unjustly,
 to which his present illness  is to be attributed.   The disease
 is  very  strongly marked with some unusual symptoms.  He
 complains of violent headach to which he has been subject for
 years; extreme watchfulness and  restlessness;  face and low-
 er extremities swelled ;  difficulty in breathing does not com-
 mence till a few minutes after lying down, which obJigeshim
 to get up  and sit in bed ; appetite impaired ; cannot eat so-
 lids, and his stomach is very irritable.
   In this case there appears to be anasarca pulmonum as well
 as water effused in the cavities of  the chest.  Prescribed the
 usual remedies.
   May 2.—Was desired to visit him-   I  found that his sto-
 mach had been very much affected by the medicines, and
 that he vomited considerable quantities of water  ; that his
 breathing  became perfectly free,  that  he could lie down  in
 bed as  usual, and that all the dropsical symptoms vanished,
 but that he did not recover strength.
   For  sometime has neglected himself, and used  no means
 for his  relief though he has been getting worse very rapidly.
 Has now a violent diarrhaea and voids considerable quantities
 of blood, attended  with very severe pains  in the hypogastric
region, which has succeeded a constipated state of the bowels,
having been a fortnight without a motion.   Spirits much de-i
 pressed from the disappoinment and ill treatment he has ex-
 perienced. 
APPENDIX,
89
   From these symptoms he was relieved ;  but after this peri-
 od I did not visit him more than once, and giving way to a
 state of despondency,  he neglected the means that were re-
 commended, and died  in the course of the summer.

                        CASE LII.

   April 14.—Mary Montague, Et. 53.  Came to me on the
 9th, labouring under severe cough attended with yellow viscid
 expectoration, and  great dyspnoea, threatening suffocation in
 a recumbent posture ;  palpitation and a sense of fluttering at
 the pit of the stomach  as well  as in the seat of the heart, in-
 creased on the slightest motion, or on lying down ; together
 with the ordinary symptoms of this disease.
   Being unable to procure medicine I furnished her with a
 vial of the tincture of foxglove, with directions to take twenty
 drops twice a day,  and to increase the dose gradually.
   Has received considerable benefit from the tincture.   PuLe
 128, feeble and fluttering.  Sumt. gt. xxv. bis ind.
   April 29.—Every symptom very much relieved.  Pergat.
   August 24, 1801.—Was nearly restored to health by perse-
 vering in the use of the tincture, and occasionally a diuretic
 laxative, till lately, when her symptoms have  returned  with
 great violence, assuming more  distinctly the characters of hy-
 drothorax.  The cough comes on in  severe paroxysms.  On
 attempting to walk, even slowly, is obliged to stop suddenly;
and is frequently roused from sleep.  Pain in the region of the
heart, with a sensation as if something were turning or roll-
ing.   Palpitation and fluttering; can only lie on the left side;
intense  thirst;  countenance livid.   Urine in  full quantity,
very high coloured  but without sediment.   Feet neither cold
nor oedematous.
  Had nine children and as many abortions, the last general-
ly attended with profluvium, to which the disorder, as well as 
90
APPENDIX.
 to the violent attacks of cough to Avhich she was subject is to
 be attributed.
   Prescribed an expectorant diuretic mixture, Avith infusion
 of foxglove.
   August 29.—Came to me in every respect much better.
 Urine considerably increased in quantity.   Pergat.
   Continued to call on me after this period till she was re-
 stored to her ordinary state of health.   There can be very lit-
 tle doubt that there was water in the cavities of the chest,
 and probably in the pericardium, though  it wanted some of
 the characters of the disease.

                       CASE LIII.

   April 14.—Ann Jones, Et 53.  (The mother of the sub-
ject of case 36.)   Incipient symptoms  of the disease, attended
 with severe headach, vertigo, tinnitus aurium, imperfect vision,
 and acute  pains in the chest, stomach, and  bowels.   Being
 unable to defray the expense of medicine or  medical  attend-
 ance, I  gave her a vial of tincture of foxglove, with directions
 to take  tAventy-five drops twice a day.
   April 22.—Headach and breathing much relieved; Sumt.
 Tinct. Dig. gt. 30 bis ind.
  April 24t.—In every respect  better; very much under the
 influence of  the digitalis; constant distressing nausea, but no
 vomiting ;  pulse 52 feeble and  intermitting ; urine increased
 in quantity.  Omit. Tinct, Digital.
   August 18.—Remained free  from the dropsical  symptoms
 till Avithin a fortnight, since Avhich her breathing very much
 affected, and unable to lie down in  bed, frequently roused
 from sleep though she  sits up  in bed ; urine  scanty, high cot
 loured with sediment;  legs and abdomen much swelled;  pal-
 pitation and fluttering of the heart; pulse very quick, small,
 and irregular; no appetite. 
APPENDIX.
9i
   ft. Irtfus. Dig. P. (3ij. ad 3xiv.) 3xiij.  Kali  pp. 3IJ. Sp.
 iith. Nitr. 3 iij.  Sp. Junip. C. 3 v. M. ft.  Mist. Sumt. coch.
 rij. ter ind.
   August 21.—The first few doses of  the  mixture produced
 sickness and  vomiting, Avith relief of every symptom, and in-
 crease of urine.   Omitt. Mist, was directed mild laxatives,
 and to take two table spoonfuls of the mixture only as soon
 as the sickness subsided, evening and morning.
   August 28.—No material amendment though the urine is
 much increased in quantity.  Was prescribed calomel, squills,
 and crystals of tartar in pills, desired to continue the mixture,
 and to drink freely of cream of tartar punch.
   By these means all the unpleasant symptoms vanished, and
 she called on me several times after this to say she continued
 free from them.   For some years have not heard of her,  but
 believe her to be Avell.#

                       CASE LIV.

   May 14.—Mrs. Clarke, of Ashen, Et 56, the mother of 10
 children.   Has all the symptoms  very distinctly marked.
 The most peculiar are, an incessant throbbing of the  heart,
 carotids, and about the  epigastrium, so violent as to be dis-
 tinctly seen through the clothes ;  a pulse so irregular and in
 termitting that no  tAvo pulsations are  alike, and so quick as
 not to be  numbered; a sense of sinking about "the region of
 the stomach " as if her life were going from her ;"  at times a
 sensation as if a great weight were  placed  there ;  a peculiar
 wheezing noise in respiration, « as  if her breath  passed
 through  a metal tube," to use her own words; sickness and
 vomiting every evening at 7 o'clock, in which a quantity  of
 viscid pale ropy matter is thrown  up,  which coagulates like
felt;  extreme oppression after eating; frequent eructations of
• Heard from her son she was well iu January. 1809. 
92
APPEN'DlX.
wind ; a considerable elastic swelling not only filling the epi-
gastrium but descending nearly to the umbilicus; swelling of
the ankles and legs;  urine natural in every respect.
  About  14 months since had a tertian ague, of Avhich she
soon recovered; but from Avhich she dates her present illness.
Has been subject to cough*, and last \\ inter had a  severe at-
tack Avhich lasted some months; as well as to violent nervous
complaints, much fatigue and  anxiety of mind, in conducting
the concerns of a large family, and from  other causes.
  Before the present illness was very corpulent, but now much
reduced  in flesh, and bodily  strength.   From the peculiar
anxiety painted in her countenance, the quick and hurried re-
spiration, the nature of the disease Avas sufficiently obvious on
my entering her chamber.
  An  infusion of digitalis Avith the usual diuretics,  a grain o{
calomel night and morning, and a blister to the left side, Avere
prescribed.
  May 18.—Was very soon relieved of the urgent symptoms,
but uie digitalis in full quantity not producing any sensible
effect on the habit I suspected the leaves Avere not good.  Per-
gat.
  June 13.—Continuing to receive benefit from the  medi-
cines, and thinking her complaints removed, she judged it un-
necessary to  take a  tonic diuretic mixture ordered for her ;
nor were the calomel pills persevered in.   A feAV days since
began again to complain, and her symptoms are Uoav  as urgent
as before. -
  From this period medicine Avas not persevered in  with any
degree of regularity, or  so as to give the most distant chance
of recovery; nor Avasher mouth affected by the calomel, an
effect without Avhich no permanent benefit could be derived.
She died some months afterwards universally dropsical. 
APPENDIX.
93
                       CASE LV.

   Symptoms of Anasarca Pulmonum  as Avell as of Hydrops
 Pectoris.
   May 10.—Mr. Eburn, a stone mason, from Colchester, B.
 Et 44.   Of stout thick make, and short stature, is hoav corpu-
 lent, but has been much more so. Extremely laborious* but sIoav
 breathing, increased not immediately, but soon after, and ve-
 ry gradually oh lying down in bed so as to prevent him from
 remaining for any length of time in a recumbent posture; is
 sometimes obliged to get up suddenly ; of late has been una-
 ble to sleep Avithout being placed nearly in a sitting posture
 by piiloAvs; has a very severe  convulsive dry cough; pulse
 96, regular, but very hard ;  violent palpitation on quick mo-
 tion, or sudden emotion, Avhen the difficulty in breathing is
 increased, also a sense of sinking at times at the pit of the sto-
 mach ,  urine scanty, high coloured, with copious pinky sedi-
 ment ; legs and thighs very much swelled, hard and tense, and
 of a livid hue ;  not reduced in size in  the morning; feet
 cold; abdomen distended Avith Avater; face sallow and bloat-
 ed, btit not swelled; the conjunctiva of a dull yellowish cast;
 the liver feels hard and enlarged; appetite impaired, and he
 is much oppressed after eating; T. clean;  very little thirst;
 bowels costive; great prostration of strength.
  Has not been addicted to excesses in drinking; but in the
censtant habit of taking spirits and water;  subject to  great
depression of spirits  ; and to coughs for some winters.
  Mr. Newell viewing the case as extremely interesting and
demanding particular attention, recommended Mr. E. for my
advice, and writes me, that many years since he had a severe
pain of the left side, attended with a most singularly full and
strong pulse; that blood draAvn exhibited no signs of inflam-
mation, nor produced any relief; that  he conceived the dis»
                           30 
<H
APPENDIX.
ease to be organic affection, or alteration of strutture   f Ih*
heart or some of the parts immediately connected Avith it;
producing anasarca pulmonum at well as general  anasarca
Entertaining the same opinion of the case with Mr. Newell,
J held out no hopes of success in my letter to him.
  Appl. Empl. Canth* pcctori.
  ft. Calom. Seillfc Pulv. a. gr. j. Kali Tart gr. iij. Confect.
Aromat q. a ft. bolus sing, noct et mat. s.
   ft. Tinct. Bens. C 3ij»Muc. G. Arab. 3j. tere simul; In-
fus. Dig. Purp. (3i» ad  3vh'j;). 3vij.>  Sp.  JEth. Vitr. C. Sp.
jEtji. Nitr. a. 3ij. M. Sumt. coch. duo, ad trisfter ind.
   I  directed the  use of  crystals of tartar  largely diluted  in
the form, of cold punch or negus.
  J.%gu&I3.r-Mi. Ne»?«ll. informs, me that in a few days af-
ter beginning the above medicines the mouth Avas affected by
the calomel, soon succeeded by salivation; that the urine was
increased in quantity; the swellings subsided, all the dis-
tressing  symptoms soon  vanished; that in compliance with
my Ayisbes tonics combined with mild diuretics Avere adminis-
tered ; that, his health was better than for years before; that
the disorder sheAving a disposition  to return  was again com-
 pletely removed by the  same means;  and that he was begih-
 »iftg again to complain.  .
   I heard afterward* that after a  few relapses the disorder
 seemed to have been subdued; but that in  the spring of
 18Q3yhe dropped.down in a fit, while talking to another per.
 son  in the street, w& died iainnediately, having been previ*
 ously in gQ9& health. .

                       CASE LVI.

   September l§.—Mrs.  Robinjon, of Glare, £t. 68.   A very
 itrongiy marked case, having- every symptom of the  disease.
 #. irregular ami intermitting, now and then a regular pulsa, 
APPJS^DIX.
95
tion.  Iu the very advanced stage,her strength being' much
reduced.              • ..  .  -
  Directed  the Infus*. JOigL  (3J13- to g viij.) with the Sp;
£th. Nitr. Sp. jEth. Vitr. C. Kali pp. and Cream of Tartar
j>unch.   Calomel was notihougiit necessary.
  September 22.—On the night of the 17th, from voiding not
more than half a pint of high coloured turbid urine, in 24 hours
passed three quarts, natural in  every respect, with complete
relief.   Since the 20th has been very  much under the influ-
ence of the foxglove.. P. full and only* now and then an infer-
inission.  Tonics and diuretics  Avere prescribed, with nourish-
ing food.  Appetite improved.                 *.
   September 29*—-Swellings  entirely  gone; .urine more than
in full quantity ;  gams strength slowly; pulse very full and
almost regular.  Wishes to lay aside medicine:.
   October 0»~Recovers  her strength, but has  discontinued
medicine.
,  She lived a considerable time after this although the meatsf
,of relief were entirely neglected.
  The subject of the following .case was the wife of a medical
man of respectability, in tftistowatry, and is marked by many
,peailiariti«ft worthy of beingrecorded.  Jt Avas not only re-
garded by the husband,, who Aught naturally be supposed to
have  attentively watched the  progressive changes of every
symptom, but by two other physicians, as well as myself, as a
distinctly marked<case el* general dropsy, having at the  same
time most of the symptoms  of Hydrops  Pectoris. Willing
perhaps to imagine that I saw farther into the nature of the
case than ray brethren of the profession, I delivered it as my
opinion that the disease Avas probably combined Avith Angina
Pectoris.   The termination, bojvever# was  such as induced 
96
APPENDIX.
 many to suspect that the case had been mistaken, and that the
 patient had not laboured at any time under  dropsy.   The
 symptoms are faithfully detailed, having been committed to
 paper by the patient's 6ide, and afterwards submitted to the
 husband's inspection; the reader must therefore form his oAvn
 conclusion.

                      CASE LVII.

   October 17.«—Mrs. H----, of-------, .fit. 42, of short sta-
 ture and disposed to corpulency. Has had five children and
 as many abortions.   Breathing quick, hurried, and  anxious,
 especially on sudden motion or surprise ;  has a peculiar sense
 of sinking, fainting, or fluttering  about the heart, " as if her
 life were going from her," amounting sometimes to palpitation;
 is obliged to lie down in bed with her chest much elevated by
 pillows; can lie on either side but not on her back ; her sleeps
 are short and disturbed, and she  is sometimes suddenly roused
 by a sense of suffocation; P. from 68 to.  72, extremely small;
 and irregular, but without any complete intermissions; a pain
 in the epigastrium  " as ifa stake Avere passing through her,"
 sometimes as if a cord Avere drawn tight round her; face and
 nose very cold and pallid ;  frequent drowsiness, but the only
 comfortable sleep she enjoys  is in  her chair  after  dinner ;
 whole body chilly, and the extremities cold,  of a livid  hue,
with a sense of numbness;  urine scanty, high  coloured, with
dropsical sediment;  abdomen preternaturaliy enlarged; a
sensible induration  in the right side of the hypogastrium at-
tended  with constant uneasiness, increased on pressure; appe-
tite impaired ; T. dry and clammy;  B. costive; a slight oede-
ma of the legs lately, but none now.
  Was  first taken ill two months since, with oppression and
 difficulty in breathing, and cough,  which she attributed to
cold.   After dinner, while I was with her, had a fainting fit 
APP£NDI"..                      97
 Avhich lasted ten minutes; it Avas preceded by a violent pain
 in the epigastrium; the pulse could scarcely  be felt.   Cata-
 menia appeared last on the 19th Sept.
   Has taken various  medicines,  such as digitalis, calomel
 ather, bark, steel, &c. under the direction of her husband and
 two respectable physicians.  Was let blood lately, Avhich Avas
 extremely thin and pale.
   I directed digitalis and calomel, combined with bitters and
 diuretics, and a stimulant plaster to the epigastrium.
  The disposition to fainting; the peculiar sense of sinking about
 the heart; the extreme feebleness of the pulse, led me to suspect
 that there Avas Avater in the pericardium, probably combined
 with Angina Pectoris ; and  the unequality  in the left side
 that one  ovariu m was  diseased.   She persevered in the above
 medicines, and rubbed in mercurial ointment for some time
 with various success$ sometimes Avith apparent relief, at oth-
 er times without any.  Her body gradually increasing in size,
 her  knoAving female friends began to suspect " she was in the
 family way," of Avhich neither her husband nor herself enter-
 tained the most distant suspicions ;  at length,  however, she
 was seized Avith severe pains,  which, under different circum-
 stances she would have imagined to be labour pains, and to her
 great surprise was  delivered of a full grown healthy child,
 about  eight months  from my  first  visit, after Avhich all her
 complaints vanished.   I had not seen her  for some months
 prior to her delivery.
   Having adopted it  as a maxim to detail unsuccessful  as
 well as successful  cases, and any errors or omissions  L may
have committed,  when they Avere likely to lead to any useful
inference, I  trust I may be excused for having  inserted the
above case.   Many of the symptoms indicating the presence
of water  in  the pericardium and other  cavities of the chest
Avere present; but Avhether or not any fluid Avas really effused;
or whether  all these are  to be referred to a sympathetic af
 fection, the candid  and intelligent reader must determine. 
98
APPENDIX.
  At the time  of copying this, August 1807, the lady is iu
perfect health.

                     CASE LVill.

                   Hydrops Pericardii.

  November 28.—Mrs. Vaisey, of Maplestead, Essex, Et 33,
married; has had  five children and one miscarriage ; of a
thin slender make ; naturally of a constitution extremely de-
licate, from  early infancy,  and often ailing.  Has been  let
blood frequently, about a week ago by her own desire. From
her feelings and from her sister having died of a similar com-
plaint, thinks she has Avater in the chest.
   Breathing at all times quick,  hurried, and difficult; but
more especially on walking quicker  than usual, on going up
stairs, or on attempting to lie doAvn in bed ; at times not till she
has  been in bed some time.; is often suddenly  roused from
sleep,  and is immediately obliged to go to a Avindow Avhere
she  remains  sometime strugging and gasping for breath, at-
tended with a most distressing sense of oppression and anxiety
about the  precordia ;  in these paroxysms she makes frequent
laborious efforts with the mouth open and the  alas nasi  ex-
panded, throwing the  arras at the same time over the head
a before she recovers  her breath ;" sometimes a  sense of
choaking as if a cord were tied round her throat; at others
as if an  immense weight or load were plaeed on the heart;
and not unfrequently a sense of sinking and fluttering ; palpi-
tation of the heart; pulse 100, very small, varying much, and
from the slightest causes; appetite pretty good, but she eats
very little from a most distressing oppression produced by the
smallest  quantity of food; some degree of swelling about the
epigastrium at times ;  urine very scanty, high coloured, with
3 pink coloured sediment; has frequently voided large quan,- 
APPENDIX.
99
(Sties of pale urine, which weakened her much ; since her pre-
sent illness has done the same with relief.   Bowels costive of
late, but formerly lax ; great stupor and droAvsiness at times,
but a peculiar restlessness which prevents her from sleeping.
No oedematous swelling of any part; but her feet and legs up
to the knees, as well as her hands, are unusually cold ; at times
complains of an aching pain and sense of numbness  about the
shoulders extending doAvn the arms.
   In  this case all the symptoms of the disease are very strong-
ly marked, and there  appears every reason to suspect the serous
effusion is principally confined to the pericardium; but there
is room to hope that debility is the principal cause.
   Appl. Empl. Canth. pectori.
   ft. Fol. Dig. nostr. incis. Cort. Aur. contus. is. 3jftrlnfunde
in Aq. ferv. $x. per hor. iv. dein cola;
   ft. Infus. Colat 3x. Sp. Eth. Vitr. C. Sp. Eth. Nitr. aa.
gt 50. Kali pp. gr.  xv. M. ft Haust. cum Pilul. infra prftf,
No, ij. mane et hor. v. P. M. s.
   ft.  Ferri Vitr. Myrrhae aa. 3fi.Kali pp*gr. xv. tere simu!
 et Cont Ar. q. s. ft. Pil. xx.
   I directed the digitalis to be watched with close attention,,
 as soon as it produced the slightest effect on the habit to be
 discontinued, and the Infus. Gent. C. to be substituted, Avith
 (he pills.
   The usual restrictions in diet, drink, and exercise were more
 particularly enjoined in this case, as the extreme weakness
 and  natural  delicacy of constitution required every atten-
 tion.
   With the view of recruiting the almost exhausted strength-•
 tonics Avere at once  combined Avith the digitalis, and the  im-
 poverished state of the blood seemed peculiarly favourable fop
 the exhibition of steel: by their aid  I had no doubt but the
 salutary operation of the- digitalis and  other diuretics would
 be promoted. 
)00
appc:,im.\'.
   Calomel was not prescribed for the same reasons, and on the
presumption that there Avas no organic aiilction.
   March  19, 1801.—Saw her no more till this day.
   She gave me the following account of herself.—That she
Avas restored to her ordinary state of health by the medicines
prescribed,  " a  peculiar sense of sinking and fluttering at the
pit of the stomach, and a troublesome pain of the left side ex-
cepted."
   That about a month since she Avas seized with acute pain of
the left side of  the head and face, attended Avith irregular ri-
gours, succeeded by fever,  extreme debility,  and the sense of
sinking, &c. about the pit of the stomach in a greater degree
than before.  She  has noAv this symptom in a most distress-
ing degree, together with frequent returns of palpitation, so
violent that her life is despaired of while it lasts.   P. very fee-
ble, quick, aud somewhat unequal, but without intermissions.
Can lie doAvn in bed. but only on the back, inclining to the left
side.   When she attempts to lie on the right, the pain  of the
left side is much increased, with " a sense of dragging."  A
swelling in the left iliac region Avhich appears to be the kidney,
very painful on pressure ; subject for years  to nephritic com-
plaints.  Urine scanty, high coloured Avith sediment.  No ap-
petite; B. costive.
   Trusted  the  cure here to mild tonics, diuretics  and very
small  quantities of calomel.
   March 21.—'Soon after my last visit was seized  Avith sick.
nessand vomiting which have conlinued ever since Avith very
little intermission, and reduced her to the lowest state of Aveak-
ness.
   Anodyne Glysters, liniments, and medicines calculated to
allay the irritation of the stomach, and afterwards mild tonics,
with diuretics,  Avere  prescribed, Avith  such  success that she
Avas in the course of a few weeks restored to her ordinary state
ofhealth. 
APPENDIX.
101
   In May,  1807, I attended her husband, when she Avas in
 better health than usual ; nor had she any return of the drop-
 sical affection, though she had a severe attack of cough in the
 6pring, Avhich continued for some Aveeks.%

                       CASE LIX.

   December 29,1800.—Mr. Coldham, of Cavendish, Et 58.
 Though a publican, yet temperate in his habits; of a florid
 complexion, very corpulent, but strong and muscular.  Has
 been in the habit of using great bodily exertion in moving his
 beer casks Avhen full.  Complains of Avhat he calls the vapours,
 Avhich seems to be fits of yawning, together Avith a peculiar
 sense of fluttering and sinking at the pit of the stomach.  P.
 intermits occasionally.   B. and other functions natural.
   Though I did not as yet consider him as labouring under
 hydrothorax, I confidently predicted its approaches; and the
 mode of treatment which Avas directed for  him was intended
 to prevent it.  After this period he consulted me several times,
 and invariably derived benefit from the means recommended,
 insomuch that he had been  free from complaint for several
 months  together.  Finding,  however, that the  disorder in
 spite of all his precautions  assumed more and more the charac-
 ter of dropsy of the chest, I urged the necessity of giving up
 his business.  This he  complied with ; at length, however,
 the fluttering became more constant, Avith occasional palpita-
tion ;  his breathing difficult, together  with inability of bearing
the recumbent posture ;  scanty high coloured urine; oedema-
tous feet and ankles, and every confirmed symptom of the dis-
ease.   From these attacks  he was repeatedly relieved  by the
usual remedies: but in January, 1806, being  seized with an
inflammation of the lungs, attended Avith fever and cough, the

    * I h^.ve reason to believe she is well at this time, March 1809.
                           37 
dropsical symptoms  returned, and he died the latter end of
March.
  This case shows that the most  vigorous constitution, even
Avith temperance, if attended Avith corpulency, and exposed to
;auscs Avhich produce sudden interruptions to respiration and
pulmonary circulation, is not exempt from Hydrothorax.   I
foretold the disease in this instance Avhcn the patient first con-
suited me in 1800, some years before effusion commenced.
   The subject of the foIloAving case owed his disease to similar
causes,  concurring with the relaxing effects  of a sedentary
life.

                       CASE LX.

   January, 1801.—The Rev. Mr. P.  of----, about 45.  Na-
turally of a strong robust constitution,  tall, but very corpulent.
Having a seminary for the education of young men, has lived
a studious  and  sedentary  life for some years; and in order to
obA'iate the disposition to corpulency, and other inconvenience,
thence occasioned, has been in the habit of digging in his  gar-
den, and using other violent exercise, generally till he was in a
profuse perspiration.   He began  at  length to find  not only
such exercise, but even that of a quick walking irksome,  and
to complain of sense of fluttering about the heart and epigas-
trium, succeeded or attended at times Avith palpitarion;  ina-
bility to lie down in bed,  and ultimately of symptoms of A\a-
ter in the chest,  finally succeeded by  universal dropsy, under
which he lived  upAvards of two years, deriving occasional re-
lief from medicine.  I Avasnothis physician, but saAv liim oc-
casionally as a friend.   I suspected from  his appearance that
the heart Avas loaded with fat;  and the circulation being ir. 
APPENDIX.
103
ierrupted through the lungs  in health, the sudden transition
from a quiescent state to that of  violent muscular exertion,
Avith the body bent downwards in digging, might  readily be
supposed to produce the disease in a habit still farther predis-
posed by the laxity of fibre occasioned by confinement.
   The foxglove, squills, and mercury relieved and repeatedly
unloaded him of the Avater ; and  a salivation* at onetime ex-
cited under the direction of Dr. Clarke, of Newcastle, he vain-
ly flattered himself had effected a complete cure.

                       CASE LXf

   January  22.—Mr.  II- surgeon of C---h,  Et  about 65.
Naturally of  a florid  complexion, and corpulent.  Has lived
Avell and committed  occasional excesses in  strong beer and
wine.   For some years has complained, occasionally, of diffi-
culty in breathing, especially in  winter, attended frequently
Avith cough, and copious yellowish expectoration.  For more
than 12 months these  attacks have been frequent and violent,
so as to prevent him from following his professional vocations,
and from lying down in bed, attended generally Avith diminish-
ed secretion of urine, and oedematous ankles.   The  lac ammo-
niacum and squillstaken freely were hisconstant remedies; but
ceasing noAv to afford  him any relief, he requested me to pre-
scribe for him.  The urine  Avas very small in quantity, the

  • It has heen  mentioned in the history, p, 121- that salivation has
sometimes cured this disease.  When attending a gentleman in October
last, at Fordhara,  a  young man, a  blacksmith, cirne to consult me, la-
bouring under universal  dropsy of the most unpromising kind.  I pre-
scribed digitalis, squills, and calomel, in combination with  other icme-
dies.  In the  course of a  few days, from neglecting my injunctions, he
was in a most profuse salivation, attended with alarming symptoms, from
which he was rescued with difficulty.  The dropsy,  however, was com-
pletely cured, and he said he  was in good health when I saw him  ii
"March, 18W 
104
AFf£XDIJ.
legs much SAvelled, and the breathing so difficult that he had
not ventured to seek repose in bed for several nights.  Having
repeatedly seen the good effects of my mode of treating drop-
sy in others,  he readily agreed to try it in his oAvn  case.  It
succeeded to our mutual Avishes; but no sooner was  the water
evacuated, and  all his sufferings at an end, than he disconti-
nued medicine ; nor Avere the earnest intreaties of his relatives
or myself of any avail in persuading him to persevere in any
plan of medicine or regimen likely to effect a permanent cure.
The only remedy  he  Avould consent to use for several months,
Avas pills of digitalis and calomel, Avhich he generally took for
three or four nights successively, till the water Avas evacuated,
and the urgent symptoms  relieved, Avhich, for a considerable
time they never failed doing.  But having refused every medi-
cine for several Aveeks his symptoms have increased to a most dis-
tressing degree; and having been of late entirely confined to his
chair by night as  well as by day, the legs have swelled to so
great a degree as to burst the cuticle, from avhich considerable
quantities of water have been constantly discharging. Has al-
most constant drowsiness, Avithout any refreshing sleep;  is fre-
quently roused suddenly, attempts to get up, and  talks for some
hours incoherently, in such a manner as to betray symptoms of
mental derangement.   Though confined to his chair and una-
ble to walk for some time, yet he got up in the night in one of
these paroxysms, v hen the family Avas asleep, Avalked up stairs
in great agitation,  alarmed them, not only by his unexpected
presence, but by vociferating that some thieves had broke in-
to the house and were going to murder him.
  At length  the legs becoming extremely inflamed, and ul-
cerated ; the discharge so offensive and troublesome, he once
more yielded to my intreaties of taking medicine; the follow-
ing Avas prescribed.
  ft. Calom. Dig  Purp. P. a. gr. j. Cryst. tart. P. gr. iv. Conf.
Ar. q. s. ft.  bolus sing. noct. et mat. cum haust.  infra praes. & 
appendix.
105
  ft. Infus. Gent. C. 3*. Tinct. Benz. C. gt. 60. cum Muc. G.
Arab, prius trit. Sp. Elh. Nitr.  3j. Kali pp. gr. x. M.
  February 2.—Saw him.   In the course of a Aveek the swell-
ing of the legs and  discharge of water had entirely subsided,
the ulcerations were nearly healed, the urine having increased
to a profuse degree;  the breathing became easy; his mind
was  composed, and he had  been  able to lie down in bed,
and to enjoy refreshing sleep for several nights.   About the
29th ult. being carried out in the air, he Avas in consequence
seized soon  after with inflammation and swelling of the throat,
attended Avith difficult deglutition and a copious discharge of
saliva and  viscid phlegm  from  his mouth and throat, since
which his mind has been again repeatedly agitated by mania-
cal ravings, so as to require coercive  means at times to keep
him within bounds.
  I found him perfectly calm, but during my visit he betray-
ed at times evident symptoms of mental derangement.   The
dropsical symptoms having been removed, the secretions go-
ing on well, and refusing to conform to any restrictions no me-
dicine was prescribed,  and he died soon after.
  From the sudden and complete relief 60 repeatedly experi-
enced in this case from medicine, it is but reasonable to infer
that much  more permanent advantage a\ ould have been ob-
tained, had the patient conformed  regularly to the plan en-
joined.

                      CASE LXII.

   January 12.-<-Miss  Dickson, of Bumstead, Essex, Et So.
Hydrothorax, Ascites, and Anasarca, attended with an acute
pain and swelling of the liver, which prevents her from lying
on the right  side, and from which  the  dropsy  appears to
anee. 
106
APPENDIX.
  Has been ill some months, and taken squills, digitalis, calo-
mel, and saline diuretics, without advantage.   Strength and
appetite much impaired:
  Prescribed similar remedies, but in different combinations,
together Avith crystals of tartar largely diluted.
  January 18.—In a feAv days the urine began  to increase in
quantity, the SAvellings to abate, the appetite and strength to
improve,  and she is hoav  mending  rapidly.   Directed  the
same plan, Avith tonics, to be persevered in for some time after
every symptom disappeared, and the calomel to be continued
till the mouth was affected.
  March 22.—Was desired to see her.  I Avas informed that
after my last visit she continued to mend ;  that the swellings
had entirely subsided, but that some degree of tumefaction
and uneasiness remained in  the right side; that  in a fort-
night, contrary to my injunctions, thinking herself  perfectly
well, she discontinued the medicines;  and that in a feAv Aveeks
all her complaints returned and continued to increase since.
  The abdomen is now  much larger than  it Avas at my first
visit  in January;  the legs  are  more swelled; the difficul-
ty in breathing greater;  and she is unable to lie only on  her
back Avith the  shoulders much elevated.   Voids very little
urine ; hands and feet  cold  and livid Avith a sense  of numb-
ness.  Liver sensibly enlarged.  Prescribed similar  remedies
as before.
  March 30.—The disorder  has gained  ground; the abdo-
men more swelled and  tense.   No sensible effect either from
the digitalis or calomel.
  Directed the digitalis in infusion in combination Avith aro-
matics, tonics, diuretics, and calomel, in the usual form.
  April 4—The  surgeon  reports that no amendment had
taken place, that the abdominal and;other swellings are larger,
that the family begin to be  impatient because the lady  did
not experience the same speedy relief Avhich she received be- 
APPENDIX.
10:
fore, and noAv begin to listen to the importunities of some
kind neighbours to consult Professor Harwood, of Cambridge.
At my former visit I suggested the propriety of letting off the
water by tapping if the disorder should not soon be checked,
but Avas desirous  of charging the habit Avith mercury first, in
order to make an impression on the disease of the liver, while
it was exciting at the same time the languid absorbents to a
more vigorous action, Avithout Avhich no important advantage
could be hoped for.  I noAv urged the operation, after Avhich
I hesitated not to hold out strong hopes of success, provided
a reasonable time Avere allowed me to pursue the principle I
had  laid down.   Confident that  this was the most  rational
mode of proceeding, and perhaps the only one likely to ensure
success, and knoAving at the same time that the most umvor-
thy  arts Avere used to supplant me in the family, I expressed-
a perfect readiness to resign the  patient  to any other physi-
cian  Avho  might  be proposed.   Professor Harwood  Avas ac-
cordingly sent for on the 9th.   I Avas afterwards informed
that  he disapproved of the digitalis in pointed terms as a de-
letereous drug, accompanied with  observations  which I ara
willing to hope,  for the credit of the celebrated University
of Avhich he is a member,  Avere not correctly stated to me.   He
prescribed as folloAvs,
  ft. Cremor. tart. 3fi. Conserv.  Cynosbat.  q. s. ft. bolus ho:
10. Mat. et 4ta. P. M. s.
  ft. Opii Colat. gr. j. Sperm. Cet.  3J. Solve in Vit.  Ov. Sp-.
Cinnam. 3j. Aq.  pur. 3j.fi- Syr. Bals.  3fi. M. ft. haust. O,
N. s.
  The patient lxad no cough; and it is but justice to remark
that before his visit I understood the medicines began to ac*.
on the kidneys.
  At his next visit, a feAv days afterwards,  the Professor pre-
scribed gamboge  in  full  doses ;  but the lady getting rapidly
worse, Dr.  Kirkland, of Chelmsford, Avas next consulted.   He 
108
ArrnNDix.
approved of the plan I had been pursuing, and after a feAv vi-
sits,  finding the  medicines prescribed of no avail, proposed
tapping.  The Avater was draAvn off several times aftenvards,
but nothing having been done towards a permanent cure, she
died in the course of the summer.
  Had the calomel, aided by the other medicines, been perse-
vered in at first, as particularly enjoined, or even after my se-
cond  attendance, till the mouth was affected, or till slight sa-
livation Avas produced, it is highly probable the event Avould
have been very different, as happened in cases 5 and 6, and in
some of those  Avhich follow.   But the practitioner has too of-
ten to deplore that his best endeavours are frustrated by such
causes.

                     CASE LXIII.

  March  23.—Mr. Mills, of Preston, a publican, Et 53.
Has indulged freely in the use of intoxicating liquors, more
especially in strong beer.   Has been subject to attacks of gout;
but in other respects till  lately enjoyed good health.
  Together with most of the symptoms of the  disease in  a
painful and distressing degree, I find by my report  book, that
he has pains alternating with a sense of numbness, of the shoul*
ders, extending doAVn the arms, sometimes all over the chest,
and  under the sternum ; frequent cramps or  spasmodic con-
tractions, and great coldness of the lower extremities; that he
often  talks  incoherently when suddenly  roused from  sleep ;
that  the urine is Avithout sediment, sometimes pale, and in-
creased in quantity ;  that the sense of sinking  at the stomach
is so distressing as to  prompt him to the frequent use of Avarm
cordials.  Has no appetite, and his strength is very much im-
paired.   The difficulty in breathing has been  coming on for
several Arecfce, within a month more particularly, since he had 
APPENDIX.
109
a severe cough, to  Avhich he attributes the sudden increase of
all the symptoms.
  ft. Calom. gr. iv. Cryst. tart. P. 3fi« Myrrhas 3j. Digit, et
Scillae  Pulv. sing.  gr. viij. tere  simul  et Conserv. Cynosb. q.
s. ft. Pil. xxxvj. Sumt. tres ter ind. cum Mist, infra pras. coch.
No. iij.
  ft. Tinct. Benz.  C. Muc. G. Arab. a. 3 iij. tere simul. Infus.
Gent. C. 3 vij. Sp.  Eth. Nitr. 31J. Kali pp.  3J. M.
  Appl. Empl. Canth. pectori.
  From the sallowness of the countenance, and yellow hue of
the conjunctiva, though I suspected derangement of the bilia-
ry secretion, yet I apprehended no serious disease of the liver.
The extreme debility, especially of the vital organs, induced
me to blend tonics in the first instance with  the diuretics.
  April 4.—The contrast between his appearance to day and
at his /ormer visit was such that I  did not at first recollect
him.   His countenance looks florid and healthy, with a pleas-
ing smile upon it, instead of that distressing anxiety which
marked it before.   Breathing free ;  cough relieved; urine na-
tural ; is not roused at night, and enjoys refreshing  sleep ; ap-
petite  and strength much improved.  Perceived no  amend-
ment till the 29th ult.   Pergat. U. A.
   From the-above period he continued to mend, was  restored
to perfect health in a fevv weeks, and being more circumspect
in his mode of living has had no return of the dropsy since.*

                       CASE LXIV.

   March 26.—Mr. Wing, of Colne, Mt 63.  Fat and corpu-
 lent Avith a lax fibre.   Has the disease strongly marked, Avith

   * Was in good health in March 1809, at which time I was informed by
 his surgeon he had prescribed occasionally for him under dyspeptic com-
 plaints, to which from his mode of living he was subject.
                             38 
110
APPENDIX.
tension and hardness of the abdomen.   Has been able to bear
the recumbent posture till last night,  Avhen he Avas suddenly
roused from sleep and threatened Avith suffocation, in  conse-
quence of Avhich the family were  so much alaimcd  that]
Avas sent  for.   Has a dry cough, Avith great prostration of
strength.
  Empl. Canth. pectori.
  ft. Cryst. tart. P.  Bj.  Calomel.  Scillse, Dig.  P. a. gr. j.
 Syr. Zing. q. s.  it. bolus sing. noct. et mat. per dies tres vel
iv.  s.
  ft. Bals. tolut.gr. x. T. Benz. C. gt. 80. tere cum Muc. G,
Arab. 3J. Aq. Menth. P.  3x. Sp. Eth. Nitr. 3J. Kali pp. gr.
xv. M. f.  haust ter ind. s.
   April 6.—Every symptom is much relieved; but the bolu-
ses  having acted on his bowels, and been continued longer than
Avas directed he  is Aveak' and low.
  Prescribed a tonic diuretic mixture, with Steel, Myrrh, Bals,
toiut. and Kali pp. in pills.
  May 7.—Called upon me to say he has recovered his ordin-
ary state  of health.  On examining his pulse it was full, some-
what unequal, with hoav and then an intermission.
  December 12,1802.—My immediate attendance was desir-
ed : I found him labouring under strangulated rerotal  hernia
since the seventh.   Having had a hernia for  forty  years the
protruded parts were A'ery considerable, and the scrotum was
hoav very large,  containing apparently intestine, but neither
tense, hard, nor painful.   He had incessant sickness and vo-
miting, Avith great hardness and distention of the abdomen, a
quick pulse, and a train of unpleasant symptoms.  The ordin-
ary attempts at reduction had  been used in vain,  by his sur
geon, and he was in a tub of Avarm water on my arrival.   I
directed a pail of iced water to be procured, and after  apply-
ing Avet clothes to the part for some time, succeeded very rea-
dily in reducing the intestine—But though repeated ^'vster* 
ArrExrax.
Ill
and other means had been used no  evacuation followed, and
he died on the 14 Ji.
  He had had tAvo or three slight attacks of the dropsical af-
fection, Avhich Avere always removed by the means originally
prescribed, Avithout my farther attendance.

                       CASE LXV.

  May 20.  Mr. S. surgeon, Wickambrook, Et 71.  Prior to
the present illness \va;: of a full corpulent habit; and for many
years partial to good strong air, in \Vhich as Avell as in other
intoxicating liquor; he  frequently indulged to excess.  H;is
been subject for some years, especially in winter, to cough, at-
tended with copious  yelloAv expectoration, difficulty in breath-
ing, and palpitation on quick motion.  In  the Avinter i 793,
had a very severe attack in which I attended him ; and last
winter one still more violent, of longer duration.   About  20
years since owing to a fall from his horse  he broke  two of his
ribs, and was otherwise much bruised, for Avhich he bled him-
self to the  enormous quantity of  near 40 oz. by measure.
From this period has been occasionally subject to  palpitation
of the heart, and dyspnoea, which obliged hira frequently to
stop  for some minutes when Avalking  to recover his breath.
Since the last attack of cough, the  dyspnoea., and palpitation
have increased  to such a degree as not only  to prevent him
from Avalking, but, for a fortnight, to oblige him to sit up  in
bed.   He is threatened Avith immediate suffocation Avhen lie
attempts  the recumbent posture; has constant droAvsiness;
but though he  seeks repose principally in a chair, his sleeps
are short and hurried, being constantly roused by a most dis-
tressing sense  of oppression about the prascordia, for some
time after Avhichthe breathing continues extremely difficult;
and the muscles of respiration are agitated  by  convulsive
-pasms.   Has the usual sense of fluttering about the heart and 
113
APPENDIX-
epigastrium.  P. exhibits a rapid succession of irregular feeble
vibrations, Avith noAv and then a complete intermission.  Urine
very much diminisked in quantity, at first Avith, noAv Avithout
sediment.  Abdomen of late someAvhat swelled ; feet and an-
kles oedematous and cold.  No appetite. T. furred, with thirst.
B. regular. Strength much reduced.  Complexion Avhich be-
fore was florid, is noAv livid.   Has almost constant yaAvning.
  He suspects from  his peculiar sensations Avater in  the peri-
cardium,  Avhich  seems very  probable both from the present
symptoms, as well as from the causes and preceding history.
Has taken but feAv medicines.  I prescribed the following,
  ft. Infus. Dig. P. (3jfi. ad  3 viij.) 3j^ Tinct. Benz. C. 3j.
cum ov. Vit. q. s. trit. Sp. JEtlj. Vitr. C. 3j. Kali pp. 9j. M
ft. Haust. ter ind s.
  Appl. Empl. Canth. pectori.
  Directed cream of tartar punch  to be  drank freely.
  May 25.—Has derived very great relief from the medicines,
and last night had several hours natural  refreshing sleep, Avith-
out being once roused, nearly in  the recumbent posture, Avhich
lie had not experienced before for several weeks.  The urine
has become natural in  appearance, but  is not much increased
in quantity.   Pulse beats a few regular strong pulsations.
Thinks himself slightly under the influence  of the foxglove.
Omitted the foxglove, and prescribed tonic  expectorant diu-
retic medicines.
  June 2.—Since my last visit the amendment has been unu-
sually rapid ; the urine having been increased to six times the
former quantity,  the cough and expectoration, the SAvellings
of the  abdomen and legs, and indeed every other  distressing
symptom, being  nearly  gone.   He  can now Avalk about the
room without  assistance, breathes  and talks  with  freedom,
whereas he could only express himself before in short hurried
abrupt sentences,  having been constantly interrupted either by
yawning, cough, or spasmodic laborious breathing.   His coun, 
APPENDIX.
113
tenance too has lost its livid hue.   With the view of removing
any organic  affection which might be connected as a cause
with the serous effusion, and of keeping up a vigorous absorp^
tion, as well as of restoring lost tone, I prescribed as follows,
  ft.  Calom. gr. v. Dig.  Purp. Scillse P.  a.  gr. x.  Cry stall.
tart.  P. 3(3. Myrrhas 9ij. tere simul  et Syr. Zing. q.  s. ft.
Pil. xx. Sumt. duas sing. noct. et mat.  cum haust. infra praes,
  ft.  Infus. Gent. C.  3X.  Sp.  Eth. vitr. C.  3j. Kali pp.  gr,
xv. M. ft. Haust. mane, meridie et vesperi s.
  From this period it may be sufficient to remark that he in-
variably  derived benefit from, and Avas repeatedly unloaded
of the Avater by  these medicines, but could not be persuaded
to persevere in them for any  length of time, till the calomel
produced its full effects  on the habit.  At length he ceased
to use any means, and died on the 5th  of January  1802, his
whole body being enormously distended Avith Avater.

                      CASE LXVI.

  June 18.—Master Johnson, of Earls Colne, Essex, Et.  15.
Is much distorted about the chest, spine, and lumber region.
Had an enlargement and distortion of one of the  lumber verte-
brae at two years of age, succeeded by lumber abscess, Avhich
discharged for some years.  Has never enjoyed good health ;
and for more than a year has laboured under universal dropsy,
deriving occasional  relief from medicine,  chiefly drastic pur-
gatives.  For some Aveeks, however, these  aided by  digitalis,
calomel,  and squills, have failed.  The whole body is noAv
very much SAvelled ;  but more especially the legs, thighs, scro-
tum and penis, (the latter being tortuous  in a great degree,)
insomuch that he is unable to walk or even move from a couch
on Avhich he is placed in the morning.   The face  and neGfe
are much swelled in  the  morning, but the swelling subsides
towards  evening.   Breathing not so much affected as might 
Ill
APPENDIX.
be expected.   Urine small in quantity, but not high coloured,
and  Avithout sediment.  B. very loose.   P  regular.   Appe-
tite unimpaired.  T. dry, with thirst.   Anasarcous SAvellings
soft;  skin pale, thin, and transparent.
  He was directed full doses of digitalis, calomel, and squills,
combined Avith saline diuretics, aromatics, and bitters.   In a
feAv days the heart Avas under the full influence of the former^
the pulse being much slower, with frequent intermissions ; but
no other organ Avas affected by it.  The amendment, hoAvever,
was much  sloAver than I had generally experienced, several
days having elapsed before the swellings subsided.
  August 8.—By  persevering  in the  plan  laid down,  the
swellings of the  scrotum and  penis gradually disappeared;
that of the legs Avas nearly subdued; his strength was so far
recovered as  to be able to ride out daily, the distance  of ten
miles this day to my  house, which he bore  Avithout  any in-
convenience.
   In this case, howeArer, as in every instance of dropsy which
has  fallen under my care accompanied avith distortion of the
body, the advantage derived from medicine  was of short dura-
tion, as must naturally be expected under the circumstances
producing the disease.  The combination did  all that  could
be hoped for by repeatedly evacuating the Avater.

                     CASE LXVII.

  July 27.—Mr.  SteAvart, of Halstead, Et 59.  Had lived
freely.—Though extremely weak and emaciated, in  the last
stage of the disease, expectorating large coagula of florid blood,
voiding scarcely any water,  his legs much swelled, cold, and
livid, unable to lie down, and threatened Avith suffocation for
several weeks; and  though he  took  the medicines  prescribed
very irregularly, yet the dropsical symptoms were for  a time
entirely removed, with proportional relief. 
APPENDIX.
115
  I saw him no more, but heard from his surgeon that he di-
ed of exhausted constitution about a month afterAvards.

                     CASE  LXVIII.

  September 16.—Mr. B. Smith, of Colne, a carpenter, EA. 51.
Had been in the East-Indies, Avhere he suffered severe attacks
of the liver complaint.  Together with the ordinary symp-
toms, he has been for several nights constantly roused sudden*
Jy not only from sleep, but even on attempting to lie  down in
bed, by a sense of suffocation together with palpitation, which
obliges him to run to a windoAV, where he remains for some
time struggling for breath  before he is relieved.   A profuse
sweat breaks out about his face  and neck.   Face livid ; no
swellings of the legs.  P. occasionally intermitting ; a cough,
with viscid expectoration.  On account of these complaints,
Avhich have been coming on for three years, of late increasing
rapidly, has been obliged to leave London.  The usual reme-
dies, and a blister to the chest.
  September 24.—Can lie down in bed, walk, and  breathe
with perfect freedom  in all  postures.   Cough still trouble-
some.  Has been very much  affected by the foxglove,  espe-
cially with vomiting and purging.
  June 2d, 1804.—Heard no more of him since last report till
this day wlv-n he came to consult me for the same complaint,.
of Avhich he had been cured by folloAving the  plan recom-
mended, and from Avhich he remained free  till lately.   Is not
eo ill as he was before.   Eyes yellow.   P.  regular.   Veins of
his  hands black and very mush distended.   Sin ilar means
were equally successful in removing the disorder, for hoAV Ion3
a period I have not  sine:  acceriaii   ;, 
n*«
APPL.vnii
                     CASE LX1X.

  April 24, 1802.—Mr. Kemp, a farmer, of the parish of
HaAvkedon, Et. about 51.  Of a  very full habit  and florid
healthy complexion, before the present  illness, but thick and
short, and though very fat yet not  of lax fibre.  Indulged
freely though not to intoxication in good ale.  Has been  sub-
ject for several months to headach, giddiness, and droAvsiness,
with constipated boAvels, OAving evidently to plethora, Avith
particular determination to the head, for Avhich he occasional-
ly consulted me.  Of late he has complained of great languor,
difficulty in breathings Avith cough and scanty expectoration;
and he is sometimes  suddenly roused from sleep; pulse full
and laboured but regular.  Urine not much diminished, at
times only  Avith sediment.  B.  costive;  some thirst.  No
oedematous swellings as  yet.
  I considered the case  as incipient hydrothorax and treated
it accordingly.
  May 8.—Came to  me much better.  Directed  a continu-
ance in the medicines, till his mouth should be slightly affect-
ed with the calomel.
  August 21.—My immediate attendance  Avas desired.   I
found him labouring  under the disease in its genuine confirm-
ed form, Avith some of its worst symptoms.  He  was extreme-
ly weak, languid, and ranch reduced in flesh, with soft flabby
fibre;  his countenance of a livid hue and • expressive of great
anxiety ; though unable to  walk or lie down his breathing
was at all  times extremely quick and difficult, with a sense of
sinking, fluttering, or  palpitation ; no natural sleep, being con-
stantly aroused suddenly when he  attempted  to sleep.   P.
quick and hard ; B. regular; urine natural in quantity ; legs
swelled;  had a pain and tightness across the chest extending 
                       APPENDIX.                   117

under the arms;  much oppressed after eating; very little
cough.
   On inquiry he  acknowledged that he had not persevered
in the medicines  or adhered to the other restrictions as en-
joined. ' Thinking his complaints removed he discontinued
them, and could not refrain from indulging in his oAvn home
breAved.   Of these distressing symptoms he Avas again reliev-
ed for some time.
   Did not see him till,
   November 23.—I found him now in the last stage of the
disease, accompanied with universal anasarca, his Avhole body,
thighs, and legs, being very much swelled.  He died soon af-
ter, not having given himself a chance of recovery from  the
first, by conforming with any degree of regularity in the plan
laid doAvn for him.
   This case affords another example of the consequences of in-
ordinate corpulency, and a full plethoric habit, in a constitu-
tion previously strong and vigorous, when produced by a par-
ticular mode of living, and when no means are used to coun-
teract them.
   When this man first consulted me, some years before the
dropsy commenced, for complaints evidently arising from ple-
thora, he might have enjoyed many years of good health, and
probably escaped  dropsy entirely, had he laid aside malt li-
quors, abridged himself in  the  quantity of animal food, and
 used more exercise, as directed.  It seemed at  one time an
equal chance  whether he was attacked with apoplexy or
dropsy.

                       CASE LXX.

   May 22.—Mrs. Beedle, of Melford, Et about 65.  Of short
 stature.   Has every symptom  of the disease very strongly
 marked, so as to have been unable to lie down for some time.
                            39 
113
APPENDIX.
Urine very small  in quantity ; legs oedematous;  a trouble-
some cough, at ith yelloAv viscid expectoration.
  Appl. Empl. Canth. pectori.
  ft. Infus. Dig.  P. (3J. ad 3 viij ) 3v. Tinct. tolut. 31'j. cum
ov.  Vit. q.  s. trit. Mell. Scillae 313- Sp. Eth. Vitr.  C. 31J- M-
Saint, coch. tria ter ind.
  ft. Calom. Scillae a. gr.fS. Cryst. tart. gr. iv. Cons, cynosb.
q. s. ft. bolus sing. noct. h. s. 6.
  Was permanently cured  by persevering in the above reme-
dies, succeeded by tonics as long as they Avere thought  neces-
sary.*  The success of the plan in the above case exceeded
my most sanguine expectations, the patient having  been so far
advanced in years, and the strength so much exhausted.

                      CASE LXXI.

  June 7.—Mr.  White, of Colne, a blacksmith, Et 51. Ve-
ry stout and corpulent.   Has indulged freely in beer.   Toge-
ther Avith the ordinary symptoms of the disease in  a most dis-
tressing degree, has pains of the neck and shoulders, and the
difficulty of breathing is increased on first going to bed, and
on  getting up in the morning.   Was prescribed  calomel,
squills, and crystals of tartar largely diluted, beside a  diure-
tic  mixture of foxglove, &c.
  On the 26th, came  to me to say he was immediately reliev-
ed, and thought  himself nearly cured till within a few days
when the symptoms began to return.   SaAv him no more.

                      CASE LXXII.

   March 20.—Mr. Parsons, of Dudley, Worcestershire, JEt.
 about 30.   Extremely fat of his age ; Avith a soft flabby fibre,
 but of a healthy  florid complexion prior to the present  illness.
'• Was in good health in March, 1809. 
APPENDIX.
119
*las lived very intemperately at times for some years, and hav-
ing occasion to travel for several Aveeks twice a year, to collect
orders for an extensive mercantile house, of which he and an
elder  brother are the principals,  he drinks Avine freely at all
times, especially at night, with his employers, and indulges in
hot suppers.—Had a severe rheumatic fever last year in Sud-
bury, attended with considerable  swellings of the joints, but
which was removed Avithout being  relaxed or weakened  by
bleeding, or other evacuations, chiefly by the antiphlogistic
treatment,  of Avhich moderate doses of calomel  and James's
powders formed a principal part.  Has the symptoms of the
disease very strongly marked; the urine is not always- dimi-
nished in quantity nor high coloured, nor  are the feet or legs
swelled; but the breathing has been for a considerable time
more  or less affected; noAv so much so as to prevent him from
walking or lying  doAvn  Avithout great inconvenience  ; is  fre-
quently routed from sleep  by a sense of suffocation attended
with  palpitation.  The pulse is full with occasional intermis-
sions.   Countenance  now  sallow and bloated.   Has a trou-
blesome cough.   Has not conformed to regimen recommend-
ed  after his late illness.  The disorder has been coming  on
gradually for several months.
  I am disposed to attribute the symptoms as yet as  much to
interruption of blood through the lungs from extreme corpu-
lency, concurring perhaps Avith some organic defect about the
heart itself, as to serous  effusion.   Being  determined to pro-
ceed  on his journey in a day or two, I earnestly urged the ne-
cessity of a complete change in his mode of living, and  advis-
ed him to go his rounds on horseback, instead of indulging in
an open carriage  as he had hitherto done.
  I put him upon a plan of medicine and  regimen calculated
to keep up a vigorous absorption, to remove organic affection,
to reduce redundant fat, and ultimately to give  strength  and
tone to the whole frame.   I furnished  him at the same time 
120
APPENDIX.
with copies of my prescriptions, requesting him to shew them
to any practitioners he might have occasion to consult, and to
correspond with me as he found necessary.
   September 29.—Came to Sudbury on his round and con-
sulted me.   By taking  the medicines  prescribed in March
last, though very irregularly, the disorder had been kept in
check  for some time.   Has been of late getting Avorse.   No
external SAvellings as yet, nor is the urine regularly diminish-
ed in quantity.  Is frequently roused from sleep ;  the breath-
ing is  at all times more or less difficult; and profuse sweats
frequently break out on  the upper parts of the body.   After
this period I do not find by  my reports that he returned to
Sudbury.  I however frequently corresponded Avith himself,
and about tAvice Avith the medical practitioner Avho attended
him at Dudley.   His brother, a very intelligent man, called in
March, 1803, for my advice on his OAvn case, observing at the
same time that I was the only one of the many practitioners
whom his brother had consulted who pronounced correctly on
the nature of his case, as the appearances after death, which
he obligingly favoured me with,  would shew,

                   DISSECTION.

  " A large portion of the cavity of the thorax was occupied
by the heart and its pericardium, the latter  containing  from
half a pint to ten ounces of Avater tinged with blood.
  The heart was enlarged to a  monstrous size.   The length
from the apex to the  extreme point of the right auricle nine
inches.
  The circumference at  the basis eighteen inches.
  The left auricle and ventricle of the natural size.  But that
portion of the heart forming the  posterior side-of the left ven-
tricle was one inch and a half thick. 
APPENDIX.
121
  The right auricle and ventricle  were much enlarged, the
former thinner than natural, and distended  Avith fluid black
blood, about a pint by computation.
  The sides of the right ventricle were as thin as Avriting pa-
per, very tender and easily torn; it contained a small quanti-
ty of coagulated blood.  The right lobe of the"lungs was dis-
eased, of a purple  colour, and distended ; the left lobes less
diseased, in a contracted state, of a natural colour, except a
few purple spots.   The vaives of the heart sound.  A small
quantity of water in the abdomen.   No disease of the liver."
  There is no date to the above interesting account;  nor is
the name of the surgeon who furnished it mentioned,  Avhich
precludes me from acknowledging my obligations to him.
  The  great fulness of the pulse, the  occasional palpitation,
and laboured  action of the heart in the early stage of the dis-
ease ; the enlargement of the right auricle and ventricle, and
the great disproportion between the thickness of their coats
and those of the left side of the heart, may be accounted for
by the incessant increased action of the former, which was ne-
cessary to overcome the resistance constantly opposed  to the
transmission  of the  blood through the lungs.  The same
causes produced the effusion into the pericardium.
  Having seen the patient only twice; other practitioners hav-
ing likeAvise prescribed for him, who did not regard the disor-
der what it really proved to be, and having conformed very
irregularly to  the course of regimen and medicine judged ne-
cessary for him, a  successful  result could not  be expected;
nor could this have happened under the most judicious ma-
nagement unless it had been rigidly adopted at an early peri-
od, before the enlargement of the right auricle and ventricle
commenced. 
U2
APPENDIX.
                      CASE LXXIII.

   November 22.—Mrs. P. of Lavenham, jEt. 36.   'Ihe mo-
 ther of six children;  has been getting corpulent for some
 years, for  the last twelve months very rapidly; is iioav very
 fat with soft flabby fibre; countenance much bloated,  inclin-
 ing to a livid hue.  Has indulged freely in malt and other
 strong liquors, at all times, especially Avhen she suckled, Avhich
 she did all her children; the youngest, six weeks old, now at
 the breast.   Has the disease strongly marked, attended with
 great prostration  of strength, and depression of spirits;  a total
 want of appetite, and a feeble, quick, fluttering pulse.
   Was permanently cured by the folloAving medicines, aided
 by appropriate regimen, and died  in 1806, of a cancer of the
breast.
   ft. Infus. Dig. P. 3vf5. T. Card. C. Sp.  jEth. Vitr. C. aa.
 3ij. Kali pp. Bij. M. Sum. coch. duo ad tria ter ind. cum Pil.
 infra praes. No. ij.
   ft. ferr. Vitr.  3J- Myrrhae 9ij. Zing. P. gr.  xv,  Confect.
 Ar. q. s. ft. Pil. xxiv.
   Appl. Empl. Canth. pectori.
   She was directed to Avean the child.
   The weakness being  so great, tonics Avere at once combined
with the other remedies, and as soon as the water was evacu-
ated, the digitalis Avas omitted  and bitters substituted, toge-
ther with small doses of calomel to complete the cure.

                    CASELXXIV.*

   December  16.—Mr.  Mumford,  of  Thorpe  Hall, Et 66.
Brother to the subject of case 9.  Tall, of a florid complexion

  • Having taken exact minutes of this interesting case at every visit,
they shall  be correctly detailed as I find them in my report book. 
APPENDIX.
123
naturally; but his countenance now of a dark red inclining to
a leaden hue.  His life has not been marked by intemperance
or any excesses; has live 1 Avell and used regular and sometimes
violent exercise.   Incipient, but clearly marked symptoms of
hydrothorax.  Breathing quick and hurried, more especially
on any  sudden exertion  or emotion which  has for some time
obliged him to  lie doAvn in bed  with his shoulders high ;
aAvakes from sleep  generally much hurried, and is obliged to
sit up suddenly in bed, owing to a distressing sense of anxiety
and  oppression about the praecordia; a sense of fluttering,
amounting at times to palpitation, about the heart and epigas-
trium ; ankles only are slightly oedematous at times toward
night ;  but his face, feet and legs are much colder than natu-
ral, and of a livid hue ; thinks the urine is not much affected j
pulse extremely feeble and fluttering Avithout any regular ac-
tion ; some cough, with difficult expectoration.  All the oth-
er functions are natural except that the strength is somewhat
reduced and that he is less equal to bodily exertion.  He how-
ever hunted yesterday, and his breathing Avas sensibly relieved
Avhen he became  uniformly Avarm and began  to perspire,
though before he laboured extremely for breath.
   Has been  subject to severe colds, and about two months ago
had a violent attack, from which he dates the present iliness.
For several  months, hoAvever, he has remarked that his breath-
ing has been at times affected,  and that he felt himself lest
equal to bodily exercise.
   It is  probable  that there is incipient  ossification, or some
defect of the  valves of the heart; and though  the disorder
may be checked for seme time, a permanent cure is not to be
hoped for.  On the whole I apprized the  family that  I con-
sidered the  case as  indicating a  breaking up of the constitu-
tion. 
 124                    APPENDIX.

   ft. Tinct. Tolut. 3jft. tere cum Muc. G. Ar. q. s. Adde
 Infus. Gent. C. 3x. Sp. Eth. Nitr. gt.  30.  T. Dig. Purp. gt,
 xv. ad xx. Kali pp. gr. vj. M. ft. Haust. ter ind. s.
   ft. Mass. Pil. Scillae 3j. Myrrhae 3f3- Flor. Benz. $]. Muc.
 G. Arab. q. s. ft. pil. xxiv.  Sumt. tres  sing. noct. h. s.
   ft. Picis Burg. Empl. Canth. 5a. p. a?. Liqt. simul et ft.
 Empl. satis amplum pectori appficand.
   A proper regimen Avas enjoined.   Calomel was not judged
 necessary here.
   December 25.—Is very much improved in strength, appe-
 tite, and in his looks ; can Avalk Avith  more freedom,  and lie
 down and  sleep Avithout inconvenience ; urine  very much in-
 creased in  quantity ; pulse less frequent and now beats a few
 regular pulsations in succession.  No oedema of ankles since
 last  report;  feet, and  Avhole  body Avarmer.   Digitalis has
 been increased to tAventy drops ; the plaster  has produced ex-
 tensive vesication.  Pergat IJ. A.
   From this period he continued gradually to  recover ;  and
 during the folIoAving year enjoyed tolerable health.   He found
 it necessary, however, to conform strictly to regimen, and to
 have recourse occasionally to his medicines, especially during
 the cold winter months Avhich affected  him very much.
   On the 4th of May, 1804, my attendance was  again desired.
 He had been ill some Aveeks, the usual remedies not having
 succeeded.   The disease had uoav assumed a more formida-
 ble aspect, all the former symptoms returning with greater vi-
 olence, the legs being sAveiled, and the urine less in quantity
 than before.
   From this  attack,  and from  similar returns,  he was again
 and again relieved, the medicines having to the last succeeded
in evacuating the Avater.  He died the folIoAving year, not of
 dropsy, but of completely exhausted constitution. 
APPENDIX.
125
                      CASELXXV.

  March, 25, 1803.—Mr. C.# of S----, of very short stature,
thick make, and  corpulent* Et. about 35.  Subject for years
to coughs,  with copious expectoration.   After a very severe
attack of the Epidemic Influenza of this spring, has the symp-
toms of the disease very clearly marked ;  the cough is extreme-
ly harassing, and the expectoration though copious, very vis-
cid ; pulse irregular and sometimes intermitting.  Has indulg-
ed freely in the  use of wine, and frequently at night after
supper.
  Was permanently cured, by persevering for some weeks with
great attention in a course of digitalis,  squills, calomel,  and
the  warm expectorants, with suitable regimen.

                      CASE LXXVL

  May 4.—Mrs. E. the subject of case 12.  I find again in my
report  book, labouring under the  disease, of which she was
speedily cured.f

                      CASE LXXVII.

  June 12.—Mr. C. of Bromley, Essex,  Et. 62.   Had been
very corpulent for some time before the present attack; and
indulged frequently to excess in the use of intoxicating liquors
of every kind.   Has been subject for several  years  to attacks

  * The case referred  to p. 70 of the history.  Was  in his  usual
state of health in March, 1809, except that he had not lost his cough, ac^-
companied with copious yellow expectoration.
  f She had several  attacks, but in a slight  degree, after this period,
 which invariably  yielded to the same remedies ; and while correcting
the  present sheet for th« press she is under  my care, and recovering
                             40 
120
AITESDIX.
 of hard dry cough, and for about tAvo years has observed In-
 breathing  at  times to be short and difficult on any unusual or
 sudden exertion.  Had the influenza last spring with great seve-
 rity since Avhich the symptoms of hydrothorax have commenc-
 ed and of late increased to so alarming a degree, that for several
 nights his life  has been  despaired of.   He is struggling inces-
 santly for  breath, by day as well as by night, but more espe-
 cially on attempting to sleep, Avhen lie is suddenly roused and
 threatened with immediate suffocation.   The head, neck, and
 chest, are for  the most  part covered Avith profuse sweats, ap-
 pearing in large drops; pulse  quick,hard,and at  times une-
 qual ; frequent palpitation ; urine very little altered in quan-
 tity or quality, but on cooling becomes turbid ;  a severe hard
 dry cough, Avith expectoration sometimes tinged Avith blood ;
 legs much SAveUed, especially toward night, and readily pitting
 on pressure.  The disorder was not regarded by his physician
 as hydrothorax, but being considered as such by the  intelligent
 practitioner, Mr. Silke, of Manningtree, Avho constantly attend-
 ed him, and the various remedies prescribed proving of no
 avail, my attendance Avas urgently desired in the night.
   Few cases occurred to me more distinctly marked, more im-
 mediately alarming, or marked by greater anxiety or suffering.
 I hoAvever held out a prospect of relief provided the medicines
 reached him in time.
   ft.  Infus. Dig. P. 3j. Sp. Jith. Nitr. gt.40. Tinct, Benz. C.
gt* 40. cum Muc. G. Arab. 3j.  trit. Mell. Scillie 3J. Kali pp.
 9j. M. fiat, haust. ter ind. s.
   ft.  Cryst tart.  P.  9j. Calom. gr. j. Scillae P. grft. ad gr.j.
 Syr. Zing. q. s. ft. bolus, sing. noct. h.  s. s.

from a  formidable attack of  paralysis  hemiplegia, attended at first and
for  seme days, with alarming symptoms of compression on the brain.
The power of voluntary motion of one side is entirely lost.  April
6th, 1809. 
APPENDIX.
12?
   Weak gin punch,  free dilution, and appropriate regimen
Avere enjoined.
   June 17.—Almost immediate relief of all  the  symptoms
from the medicines; breathes with perfect freedom, and can
lie doAvn without inconvenience ; cough and expectoration
nearly gone; urine much increased ; legs  only a little swell-
ed at night.  On the 14th,  being sensibly under the influence
of the foxglove it Avas  discontinued.   His sleeps are uninter-
rupted  now in a  recumbent  posture.  Complains of great
Aveakness, especially of the lower extremities.
   Was  put  on  a course  of tonics, diuretics, and expectorants,
with calomel, till the  gums should be affected.
   From the aboA-e period  he  continued  to mend ; came to
Sudbury, the distance of more than twenty miles tAvice in the
course of the summer, and recovered so far as to follow his or-
dinary occupation ; but laying aside medicine, and disregard-
ing the rules laid down for him, as soon as the  Avater Avas eva-
cuated, and the disorder,  as he imagined,  cured, the symp-
toms after a certain time returned.   He continued to  have
relapes from these causes, but Avhich always yielded to medi-
cal treatment.  At length, hoAvever, becoming extremely im-
patient  under  the restraints Avhich Avere imposed  upon him,
he refused all medicine,  and giving full scope to his propensi-
ty for drinking, he died in the  course of the  following year,,
as far as I recollect,  Avithout  any  external signs of dropsy,
though at different periods of the disorder the legs, thighs, and
Avhole body  Avere  enormously  swelled.  For  several months
prior to his death, h* might be  said to have lived principally
on sherry and spirits,  in Avhich he  indulged at all hours of
the day. 
128
APPEJJD1X.
                    CASE  LXXVIII.

  July 16.—Mr. Pratt, of Belchamp, a farmer, Et 4G.   Cor-
pulent ; in the habit of using much exercise, but of living free-
ly at times.  Came to me with hydrothorax, and from the
peculiar fluttering about the heart, and  feeble irregular pulse
I was led to suspect water in the pericardium.  He was pre-
scribed the usual remedies.   He continued to call for my ad-
vice for some years,  always receiving relief from medicine ;
but the disorder returned after a certain period.   In the year
1806, he  consulted Dr. Bailey, of London, Avho prescribed
among other remedies,  calomel, by which he was salivated.
During, and for some  time  after the  salivation, the dropsical
symptoms Avere so far suspended that he fancied  himself cur-
ed.  I had not seen or heard of him for several  months till
the 16th of February,  18Qf, when his surgeon apothecary
called to say he Avas again extremely ill, but he though not in im-
minent danger, and that I was desired to attend him.  My en-
gagements being at that time urgent, I could not fix an earlier
day than the 20th, for visiting him.   As I  was setting off for
that purpose a messenger arrived to say he died in the night,

                     CASE LXXIX,

  July 31.—Mr. Manning, a farmer of Sible Hedingham, Et
about 22.   Strongly  marked symptoms of anasarca pulmo-
num, hydrothorax, and general anasarca*  together with urg-
ent cough.   His  father died a few years before of a similar
disorder.  I once prescribed for him.
  ft. Infus. Dig. P.  3vii. Tinct. tolut. 3ij- cum ov. Vit. q.
s. trit. Sp. Eth.  Nitr. 3iij. Kali pp. 9ij. M. Sum. eoch.  tria
ter ind. 
APPENDIX.
12&
  ft. Cryst tart. 9j. Calom. gr. i j. Scillas P.  gr. j. Syr. Zing.
q. s. ft. bolus sing. noct. h. s. s.
  Cold gin punch ad libitum.
  August 28.—Came to me to  say that the  disorder was
speedily removed by the remedies prescribed, but that Avithin
a few days his breathing  has been again affected.  Was di-
rected a similar mixture, and the following.
  ft. Calom. Gambog. G. aa. gr. ij. Cryst. tart. SJ.Syr. Zing.
q. s. ft. bolus sing. noct. per  Sept.  integram s.  When the
Avater Avas evacuated, the folIoAving Avas directed for him.
  ft. Infus. Gent. C. 3vij. Sp. Bh. Nitr. Tinct. Cort. Aur.
a. 3 ft. Kali pp. 3j. M. Sumt. coch. tria mane et merid. cum
Pilul. infra prass. No. ij.
  ft. Calom. gr. vj. Scillas P. gr.  xij. Cryst. tart. 9j. Myrrh*
£ij. Syr. Zing. q. s. ft. Pil. xxiv.
  Was permanently cured by these remedies,*

                      CASE LXXX.

  January 2d,  1804.—Mr.  S. Avine  merchant,  of Colchester,
Et 66.  Tall; and not corpulent.  Has lived well, but not
addicted to excesses in drinking, and has used much exercise.
Till lately enjoyed good health.   Has the ordinary symptoms
of the disease very strongly marked, together with  an irregu-
lar  intermitting pulse;  fluttering,  and palpitation  of the
heart;  inability of lying down, and  great prostration of
strength.  Face,  hands, and  feet, livid and cold; the ankles
only are oedematous.
  His complaints were repeatedly removed, and he thought
himself cured, by the usual remedies; but after  a  certain
time  they returned, on laying them  aside; and finding there

  * I heard from Mr. Holdich, the practitioner who attended with me,
 (hat hr was in good health, in M-'rcb, 1^09- 
130                      APPENDIX.
Avas no prospect of permanent recovery, he at length  retired
into the country, and died I think the folIoAving av inter.

                     CASE LXXXI.

  February 15, 1805.—Mr. Firrain, a farmer, of Maplestrcet,
Essex, jEt. about 65.   Of short thick make,  and  corpulent.
Has  the disease in a most alarming degree, Avith  considerable
swellings  of  the  legs.   Was quickly relieved, and remained
free from the disorder, for several months.
  I Avas informed that he relapsed aftenvards, and died sud
denly, before the family practitioner Avho had been in  attend-
ance could reach him.

                     CASE LXXXII.

  February 28.—Mrs. F. of Colchester, Et about 65.'  Was
permanently cured of the disease, under the most unpromising
and even  hopeless circumstances.*

                     CASE LXXXIII.

  June 20.—Master Good,  Et 12.   Of a remarkably fair
complexion, and delicate constitution; extremely weak and
emaciated.   Breathing  short and  difficult, body very much
distended, with fluctuation; thigh.6, legs, and  scrotum much
BAvelled ;  scanty urine; no appetite;  pulse regular.

  * This interesting case having been communicated to the late  Dr. Ha-
milton, of Bury, and published in bis Observations on Digitalis,  p. 1U9. 1
must refer the reader to that work, in which he will meet  with much use-
ful information on this subject, and  the opinions of (he different authors
who  have  written upon it, brought into one view: it was intended to
bhew the inefficacy of the foxglove  alone, in certain instances of tbe
disease. 
APPENDIX.
1S1
  The dropsy supervened to an illness he had at school; and
there is reason to suspect mesenteric affection.
  ft. Scills P. Calom. aa- gr. vj. Cryst. tart. 9j. Conf. Ar. q
s, ft. Pil. xij. Sumt. ij. sing. noct. h. s.
  ft. Ferr. Vitr. 9ij. Kaii pp. 9j. Myrrhas 3ft. Extr. Gent. q.
s. ft. Pil. xxiv. Sum. ij.'inane et merid. cum Mist. seq. coch.
No. ij.
  ft. Infus. Gent. C. 3 vft.  T. Cort.  Aur. Sp. Eth.  Nitr. aa.
3ij. T. Dig. P. gt. xxx.
  Here it Avas judged necessary  to begin at once Avith tonics in
combination Avith calomel and the usual diuretics, and the pe-
culiar  paleness, or rather whiteness  of the skin, pointed out
the propriety  of the preparations of iron.  The hair was per-
fectly white also.
  June 29.—Came  to me in  every  respect much  better.
Pergat.
  July  6.—Continues to mend rapidly;  and  his  mother
thinks he gets  flesh as Aveil as strength;  the swelling of the bo-
dy so much reduced that he can button his waistcoat.
  Adde Kali pp.  9j. Mist. olim. prass. et pergat U. A.
  July 13.—Mends progressively.   Had a fall Avhich has oc-
casioned a pain of the side.
  Adde ol. M. Pip. gt. ij. Mist,  et pergat U. A.
  July 30.—His mouth having been affected by the calome
on  the 25th,  it  was  discontinued ; its effects  now gone.
Swellings entirely disappeared,  and all the  functions natural.
Was desired to lay aside the medicines gradually.
  Called  upon me  several times  afterwards perfectly reco-
vered.

                     CASE LXXXIV.

  July 30.—Mrs. R. of Pentlow, Et. about 55.   Somewhat
deformed about the chest. . Came to consult me on the 4th. 
132
APi'ENMX.
with symptoms of general debility, and slight osdeiua of the
ankles;  and again on  the 8th, labouring  under  universal
dropsy;  the breathing being very quick and hurried, with
inability to bear the recumbent posture ;  pulse feeble, quick,
and irregular; the urine scanty ; legs and thighs much swell-
ed ; boAA'els very irritable.   The progress  Avas extremely  ra-
pid.  The disorder evidently arose from fatigue, and confine-
ment Avith her husband during a tedious illness, of  Avhich he
had recently died, as well as to grief and ill treatment experi-
enced since his death.  By the aid of steel, myrrh, bitters, crys-
tals of tartar, and calomel, all the unpleasant symptoms were
quickly removed, and she is recovering her strength rapidly,
her appetite being, as she says, too good.    The breathing is
perfectly free;  the pulse full and regular;  the swellings  en-
tirely gone.
  ft. Ferri Vitr. Myrrhae aa. Bij. Kali pp. 9j. Extract. Gent.
q. s. ft. Pil. 24. Sum. ij. mane et mericL cum Mist, infra pra?s.
coch.  iij.
  ft. Inf. Gent. C. 3vft. T. Cort. Aur. Sp.  Eth. Nitr. a. sij.
T. Dig. P. gt. 60. Kali pp. 9ij. M.
  August 18.—Has  been constantly under the influence of
mental  depression and  irritation from the  ill treatment she
continues to experience from her husband's  relatives.   With-
in a feAv days threatened \?ith a relapse, having been sudden-
ly roused from sleep  by a sense of suffocation.   P. full and
laboured; has much  feverish heat and thirst.  To return to
the medicines prescribed the 30th  of July.
  October 26.—After deriving equal benefit from  the medi-
cines they Avere as before discontinued ; the disorder has again
returned.
  She was repeatedly relieved  by the same means, but died
some months aftenvards, of exhausted constitution.
  In this case the boAvels Avere so irritable  that squills were
not used.   The other  remedies performed  all that could be
hoped for from medicine. 
APPENDIX;
m
                     CASE LXXXV.

   July 22.—Mrs. P. of Middleton,  Et 67.  Very corpulent
 for some years.   Has laboured under the disease for several
 weeks; but in consequence of sitting up constantly in a chair,
 and of medicines she has been  regularly taking, the breathing
 has been of late much relieved, but the legs and thighs are
 enormously swelled, and so hard and  tense as not to yield in
 any degree to the pressure  of the fingers.   The cuticle is burst
 in some places about the legs, and discharges much serum. In
 this case the foxglove Avas productive of no beneficial effect,
 though she was repeatedly under its  full influence both be-
 fore and after  my  attendance.  By the aid of the calomel,
 equills, crystals of tartar in full doses, with now  and then an
 active  purgative, the kidneys and lymphatics were at length
 with great difficulty acted upon, and she was more than once
 unloaded of the water. She lived several  months after my first
 Visit.

                    CASELXXXVI.

   September 20.—Mrs. Cook, of Stoke, Et. 70.   Of short sta-
 ture.   Has lived a  sedentary  life for some years.  Had the
 disease in a violent  degree, together with ascites and anasar-
 cous legs ;  unable to lie doAvn  in bed for several nights; and  f
 when she attempts to sleep in her chair is suddenly roused and
 obliged to  go to the window for breath.  B.  costive ;  urine
 very scanty with the usual sediment.   Pulse intermitting^
 Has been treated judiciously, and placed under the full influ-
 ence of the foxglove, Without any benefit, before I saAv her.
 She Avas prescribed  the usual  combination; but  on  my next
visit the 25th, finding she derived very little advantage and
was unwilling to persevere in medicine, I did not urge it
                           41 
13*1                       AI'PENjj!-

and discontinued my visits.  She did not survive iong'alter-
wards,

                   CASE LXXXVII.

  October  26.—Mr. Davy,  a farmer, of  Toppesfield, Et
about 55.  Incipient, but distinctly marked symptoms of the
disease.  Has lived intemperately.   Strength and flesh much
reduced; and has no appetite.  Was prescribed tonics, saline
diuretics, and squills Avithout the digitalis.
  November 8.—Deriving  but little benefit he was directed
the infusion of  foxglove  Avith the  ordinary diuretics, and
a blister  to the chest.
   By these means the disorder  Avas removed ;  but has been
obliged to  have recourse to them frequently  since, always
Avith success.
   In March last, 1809, he Avas in tolerable  health.

                   CASE LXXXVIII.

   April 22,  1806.—Mrs;  P. of Belchanap Often, Et  about
30.  Naturally of a very delicate constitution, of low stature,
and much deformed about the chest.  The mother of two chil-
dren.  Has the symptoms of the disease very strongly mark-
ed, together with  cough,  anasarcous legs, and extreme de-
bility..
   By means of tonics, digitalis, saline and other diuretics, the
Avater  was repeatedly evacuated, and the symptoms relieved;
 but, as I have almost invariably experienced in circumstances
of distortion of the body, this was effected with difficulty, and
a permanent cure could not be performed.   The disorder
 Avas kept in check for several months, but at length triumph-
ed in spite of every effort to subdue it.   She died universally
 dropsical. 
APPENDIX.
135
                    CASE LXXXIX.

  June 21.—Mr. K. of Ovington, a farmer.   Of very short
stature, thick  make, and corpulent.  Et. about 50.  Has
been  accustomed to drink spirits and Avater, and beer, at all
times of the day, but not to intoxication, as is too much the
practice in the country.   Has likewise suffered much mental
anxiety and uneasiness.   Has the disease distinctly marked,
but as yet in a mild degree, and may be said to be in the inci-
pient  state.   He has been, hoAvever, for some time unable to lie
doAyn in bed; the urine is scanty, and the ankles are slightly
oedematous.  The  appetite and general  strength are much
impaired; and  the muscular fibre is soft and flabby.  The
complexion is changed from a florid red, to a bloated leaden
aspect.  Yet he still pursues his ordinary occupation.
  ft. Calom.  gr. j. ScilheP. gr. jft. Cryst. tart. P. gr. vj. Conf.
Ar. q. s. ft. Bolus sing noct. h. s. s.
  ft.  Inf. Gent. C. 3ix. Kali pp. gr. x. T. Cort. Aur. 31J. Sp.
/Eth.  Nitr. 3J.  M. ft. Haust. mane et meridie cum Pilul. in-
fra prass. No. ij. s.
  ft.  Ferri  Vitr. Kali pp. Myrrhae a.  9j. Conf. Ar.  q. s. ft.
Pil. xvj.
  ft.  Calomelan. Resin. Jalapii aa. gr. iij. Cryst. tart. P. 9j.
Confect. Ar.  q. s. ft. bolus bis terve in Sept. vel pro re nata s.
  The digitalis was not judged necessary here, and the cure Avas
completed Avithout it; not hoAvever Avithout an intire change in
all his habits.  Has had slight returns, but by the timely use of
the medicines, especially of the boluses, and by more than ordi-
nary circumspection in his mode of living, they have been readi-
ly removed,  and he has for some time enjoyed better health
than for many months before the attack. 
*36
APPENDIX
                        CASE XC.

   November  18.—Mrs.  Chandler, of Sommerton,  E\. 50.
Naturally corpulent ; and has lived a very sedentary life, be-
ing much confined to a shop.   Universal anasarca, every part
of the body, except the face and neck,  being aifected.  The
legs, thighs, hips, and arms are  euormously distended, hard,
tense and resisting.  Breathing extremely difficult and labo-
rious,  so as  to have prevented her from  lying doAvn for
several Aveeks; has constant droAvsiuess,  and though she sits
up in bed is frequently roused and awakes hurried;  urine
very scanty and high coloured ; pulse 80 full and laboured ;
face livid; the nose, hands, and feet  are extremely cold ;  B.
costive Avith flatus; T. of a florid red colour and aphthous;
" she could eat" she said, " but had no room for food."  The
only exercise she had been able to take  for Aveeks, has been
from the bed to the chair and back again, and this not Avith-
out assistance.
   In February last had a severe acute rheumatic affection  of
the right thigh and hip,  from Avhich  she recovered sloAvly,
and to Avhich she attributes the present complaint, having been
confined ever since, the difficulty in breathing and swelling  of
the legs having commenced soon after.
   On observing to Mr. Harrington, the practitioner Avho attend-
ed Avith me, that this was not a case for the foxglove, he said
she had  taken  40 drops of a tincture made Avith 3 ft. of the
dried leaver to  3 viij. of proof spirits three times a day,  he
thought with  some relief.   She Avas prescribed calomel and
crystals of tartar, at bed time, a cordial diuretic draught with
three drops  of the  Tinct. Dig.  three times a day, and fric-
tions with the Lin. Camph. to the swellings.
   On  my next visit the 23d, I found her sensibly relieved t
but on seeing her again on the 27th, not receiving that sudden. 
APPENDIX.
w
benefit Avhich she expected from medicine, which however Avas
taken very irregularly, she signified her determination to lay it
aside and to submit to her fate.
   On the 19th of May I was desired to see her.  I  Avas  in-
formed that after my last visit the SAvellings and her sufferings
continued gradually to increase ;  that at one time she vomit-
ed almost incessantly for several  days, during Avhich her life
was every hour looked for ; but that, however,  to the great
surprise of her relatives, the swellings abated, during the vo-
miting ;  that the stomach had of late retained more food, and
that she signified a desire of taking medicine, provided it Avas
compressed in the smallest possible compass.
   The Avhole body was now enormously  sAvelled,  even the
face and neck, Avhich Avere before free ; the  pulse could not
be felt till the Avater Avas pressed out of the cellular membrane
at the Avrist ;  and it was now extremely small and frequent.
She was entirely confined to her chair,  being unable to move
any part of the  body, even her  arms, both from their  great
bulk and weight, as well as from the rigidity and hardness of
every part.  Tongue, insides  of the lips and cheeks covered
with painful apthae, from which a ropy  matter  Avas constantly
discharged ; gums soft,  spongy and livid.   In short she exhi-
bited a picture  of tfie greatest misery I had ever beheld.
   Precluded from prescribing any thing except in the form of
 a small  pill, she was directed to take tAvo grains of calome?
and one of elaterium every night, and a quarter of a grain oi
 opium to be added if necessary.
   May 27.—The pill has operated powerfully either on  the
 stomach or boAvels or both, and has brought off considerable
 quantities of water, Avhile the secretion by  the kidneys, which
 was before nearly suspended, is at  the same time greatly  in
 creased also.  The swellings of the face, neck, hands and arms,
 nearly gone, and that of the rest of the body much reduced
 and softer, with  proportionable freedom  in breathing in so 
i38
APPENDIX.
much that she was able to lie down in bed yesterday three
times without inconvenience.
  Having directed cabbage leaves to be applied to  the legs
and  feet a copious exudation  of water has been the  conse-
quence ; and the cuticle has separated in many places, in the
form of vesicles filled with water.   Pulse felt more distinctly ;
and she takes liquid nutriment freely, but SAvallows with great
difficulty, the apthous affection being worse and extending
down the oesophagus, attended with  profuse salivation, but
Avithout that foetor attendant on mercury.
  I  directed a continuance of the pill with a quarter of a grain
of opium.
  June 8.—The pill continues to operate powerfully with
proportional reduction of the swellings and relief of every
symptom.   The discharge from the legs  profuse also ; the
urine in full quantity and natural in colour.  The opium Avas
omitted as she thought it checked  the salutary operation of
the pill.  Spirits, strength, and appetite  improve; she  lies
down in bed, takes food more freely and Avith a relish.  The
elaterium  continuing to act too violently it Avas reduced to
half a grain.  The amendment from this  time was so rapid
that hopes were entertained of her permanent recovery.  She
Avas able not only to ride  out daily in an open chaise, but to
walk about the house; and the only swellings which  remained
were about the ankles in a trifling degree towards evening, the
discharge having nearly subsided.   The stomach and bowels
 became so susceptible of the action of the elaterium that it was
 found  necessary to reduce it to a quarter of a grain, which
 produced a full effect.
   Towards the end of the month, hoAvever, having  discontin-
 ued the pill, the bodily strength and appetite began gradual
 ly to decline,  and she died in July, literally of worn out con
 stitution. 
APPENDIX.
139
  ' Is it not.reasonable to infer that had a proper plan of medi-
cine aided by regimen been conformed to in the first instance
in this case the relief would have been more complete and per-
manent ?  Though the foxglove had not a fair trial yet I am
confident it  would have been productive of no good.  Theef-
fects of the elaterium as a hydragogue Avere very conspicuous;
yet, the objection to all such violent  medicines of this class
was evident also,  the Avater having accumulated rapidly af-
terwards ; but our efforts having  been confined Avithin such
narrow limits, little more could have been expected than Avas
effected.   It is my intention to  give this medicine a full trial}
properly qualified and  supported by other remedies, I enter-
tain sanguine hopes of it, especially in such cases as the present,
where the judicious Withering has told us, and Avhich my own
experience has amply confirmed, the foxglove is not to be de-
pended upon.
   This case  as Avell as 82, Avas transmitted to the late Dr. Wil-
liam Hamilton, as of this description ; but was not published
lest, as he afterwards acknowledged to me, it should increase
the prejudice which existed against this berk

                       CASE  XCI.

    January  4, 1807.—Mrs.  K.  of Boxford, Et. 58.  Very
corpulent; of a bilious habit, with lax fibre.  Dyspnoea of the
quick hurried and  anxious kind,  with  a  peculiar wheezing
noise, increased on the slighest motion, so as to  oblige  her to
stop several   times Avhen going  to  her  chamber ; of late has
been confined entirely up stairs ; is frequently awoke suddenly
from sleep with a sense of suffocation, attended Avith violent pal-
pitation ;  has at all times a constant sense of fluttering about
the heart; pulse extremely feeble,  irregular and intermitting;
a constant harrassing cough, by Avhich hard viscid lumps of
condensed mucus are expectorated, sometimes streaked ^ ith 
140
APPENDIX.
  blood; urine very scanty,  Avith thick sediment.   Legs antf
  abdomen have  been much swelled,  but for a feAv days  the
  swellings have nearly subsided, owing to an incessant sickness
  and vomiting as Avell as diarrhaea, with Avhich she has been af-
  fected, and to her having been chiefly confined to bed.  Every
  thing she takes, she says, is either quickly vomited or passes
  through the ooAvels,  generally  Avith much  bile.   Cheeks at
  times flushed, but the  conjuctiva is yelloAv; nqse, feet, and
  hands cold* and of a livid hue.  During the  paroxysms-of dif-
  ficult breathing, the chest, neck, and head become hot, and a
  profuse perspiration breaks out upon them.  Of late unable to
  lie on the right side ; no appetite, and Aveakness extreme.
    I  suspect water in  the pericardium as well as in the other
  Cavities of the chest.  No case could be more strongly marked;
  and  appearances could scarcely be more hopeless.
    Took about 5u drops of the tincture of foxglove, and as ma-
  ny of the Sp. iEth. Nitrosi since last night.
    Appl. Empl. Canth. pectori.
    ft. Inf. Dig. P. (3j. ad 3 vij.) T. Card. C. 3j. Sp. jEth. Vitr.
• C. Sp. Eth. Nitr. a, gt. 30. M. ft. haust. ter. ind. s.
    ft. Calom. Scillas a.  gr. j. Muc. G. Ar. q. s. ft.  bolus h.
  s. s.
    January 7.—Nothing could exceed the  contrast between
  her  situation to day  and on the 4th.  Every  organ is now
  performing  its function  nearly  as in  health.  She breathes
  with freedom, can lie down in bed on either side,  and goes to
  sleep without the dread of being suddenly aAvoke as before;
  the  cough does not disturb her  much, and the expectoration
  is free,  thinner, and copious; has no palpitation; but the
  pulse, though more distinctly felt, is as irregular as at first.
  Urine increased, from  a quarter of a pint of a thick turbid
  yellow mixture, to three pints daily of the natural appearance*
  The temperature of the face and extremities natural;  and the
  countenance  has lost  that expression of anxiety and suffering 
APPENDIX.
141
which tvere so strongly marked in it before.  Has taken suffi-
cient nutriment  without being once rejected since  the  5th,
and the boAvels are returning to their natural state, only two
motions yesterday and none to day;   Swelling  of the body
much reduced.   No unpleasant effect on the head or any or-
gan  from  the  foxglove.  Has not drank the quantity of li-
quids directed.
  Rep. Boli. sing. noct. U. A.
  ft.  Inf. Gent. C. gj. Tinct. tolut. gt. 40. cum Syr. Papav.
Alb. 3j. prius trit. Sp. ./Eth. Nitr. gt. 40. T. Dig. Purp. gt.
viij. M. ft. haust. ter ind. cum Pil. infra prags. No. ij. s.
  ft.  Ferri Vitr. Kali  pp. a. gr. xv. Myrrhas 9j.  Conf. Ar.
$. s. ft. Pil. xvj.
  Let the body be Avell rubbed  Avith the Lin.  Camph. and
at flannel roller applied tight round it.   The abdomen was ex-
tremely  pendulous and soft.  Her father and a  brother died
of dropsy.
  January 10—Continues'  t6 mend.   Cough and expectora-
tion nearly gone.  B. natural.  P. beats a  feAv regular pulsa-
tions, and is much stronger.  No sensible effect from the calo-  •
mel.   Has at times a sense of sinking and nausea at the sto-
mach.   Abdomen nearly reduced to its natural  size.
   Pergat in usu Bol. U. A.
   ft. Infus. Gent. C. 3x. T. Cort. Aur. 3j. Sp. Eth. Nitr. gt.
80. T. Dig. P. gt.  xv. M.  ft. haust. mane et merid. cum Pil.
olim. praes. No. ij. s.
   January 14.—Mends progressively.  Gums affected by the
calomel; a sense of sinking at the stomach,  together Avith gid-
diness and imperfect vision.   Though she has been able to lie
on either side yet she cannot remain long on the right.
   Omitt. Calom. sed pergat  in usu Scillas, haust. ac Pilular.
 U. A.
   I took my leave after laying down ample injunctions for hfr
 future conduct.
                             49 
\1'1
APPENDIX.
     ilfoy9.—My immediate attendance wa; desired, but being
   unable to Avait on her till the 12th, I met a messenger on the
   road to prevent  my proceeding, as  she Avas  thought to be in
   the act of dying.   1 Avas informed afterAvards by Mr. Wynne,
   the  medical man  A\ho attended Avith me, that she laid aside
   medicine soon after I ceased visiting  her ; but continued to-
   mend for some time ; that in April she began again to com-
   plain, but having  so great a dislike to medicine  the disorder
   made considerable progress before he Avas desired to see her ;
   and that for the same reason she resisted the intreaties of  her
   relatives to permit my being sent for.

                        CASE XC1I.

     January 20.—Mr. H. of Sudbury, Et. 75.  Has laboured
   under the disease for some years at intervals; but was invari-
  ably relieved by remedies similar to those recommended in
  the foregoing cases, prescribed  either by the family practi-
  tioner, or myself.   Has been subject to severe coughs, attend-
. cd with  copious yelloAv  expectoration, Avhich have for many
  years become habitual, and assumed the form of the Catarrhus"
  Senilis, subject to considerable aggravations  at  certain sea-
  sons.
    Has of late had a severe attack, soon succeeded by strongly
  marked symptoms of effusion  in the chest.  Is noAv in the last
  stage, threatened Avith  suffocation  every moment,  voiding
  scarcely any urine, coughing incessantly, but expectorating
  with extreme difficulty only hard viscid lumps of condensed
  mucus, with much florid blood   T. of a florid red colour, ve*
  ry dry, with a tendency  to apthse.   Legs oedematous.—Died.
  Ihe following day. 
.\PP>ENDIS.                     143
                      CASE XCIII.

  June 17.—Early this morning ray immediate attendance
was desired on the Rev. Mr.-------of-------near Hanvich.
His age 51, of tall stature, naturally robust and muscular, but
of late years disposed to corpulency.  His symptoms Avere, ex-
treme difficulty in respiration, Avhich has for some Aveeks pre-
vented him from lying down in bed, or from walking but with
great deliberation: when going up stairs, has been obliged to
rest some minutes to take breath, before he reached his cham-
ber ;  and although propped  up by pillows, nearly in a sitting
posture, in bed, he is suddenly roused  from sleep  by  a sense of
suffocation, and extreme anxiety about the prascordia, as hich
obliges him to get up and Avalk about the room; of late this
has happened three or four times every night, in so violent and
alarming a degree that his life has been  despaired of ;  urine
very scanty, of a  dark red colour, but. Avith very little sedi-
ment ; pulse extremely irregular and intermitting ;  legs oede-
matous up  to the knees,  and readily  pitting  on pressure  ;
tongue foul, Avith great thirst ; no appetite; bodily strength
much impaired; face and conjunctiva of a deep yellow tinge;
and he brought up some  yelloAv bile  this morning.   BoAvels
costive ; memory much impaired, with giddiness, and confu-
sion of ideas at times ;  constant drowsiness, amounting some-
times to stupor; hands and feet cold.  Has not been addicted
to intemperance in the use of intoxicating liquors, but in the
habit of indulging very freely in large draughts of beer, both
at meals, and at all times Avhen heated by exercise.   Has used
much  bodily  exercise till of late  years, Avhen his habits have
been sedentary and studious, frequently  sitting  up  till a late
hour.
   For nine years has been subject to  a peculiar  uneasy sensa-
tion in the lower part of the abdomen, from the umbilicus to 
i44                   APPENDIX.

the pubes, for which he has been in the constant habit of using
active purgatives three or four times a Aveek, as the only mean*
which, he fancied, relieved him.
   About two years since,  when stooping to measure timber,
Avas suddenly seized av ith a giddiness of the head, and confusion
of ideas, nearly amounting to a fit of apoplexy, for which he
Went to town, and put himself under the care of an eminent
physician.  It Avas treated as an attack of apoplexy, for Avhich
copious V. S. and cupping were frequently used.   He return-
ed to the country much reduced in flesh and strength.
   The first symptom of his present complaint Avas perceived
in February, 1806, Avhen he was  suddenly roused from sleep,
and thought himself in the act of  dying.  He had another at-
tack when doing duty some months aftenvards, and a third in
December following  : the pulse intermitted each time; reco-
vered  its former regularity after the first and second attacks,
but has been more or less irregular since the third.
   He has been attended by three physicians of the  first emin-
ence in town, and by one in the country.  Their attention ap-
pears to have been principally directed to the affection of the
head, and to the peculiar sensation of the abdomen, acknow-
ledging they could do nothing  for the disorder of the chest.
The result of a consultation held  by two of them in town, in
April last, Avas the recommendation of a seton in the neck, and
mild  inert palliative medicines.   On the  suggestion of Mr.
Nunn, of Manningtree, the digitalis  was once prescribed by
one of them, but soon abandoned.
   On the presumption that his  complaints originated from
Avater in  the chest, Mr.  Nunn and Mr. Silke his partner, who
constantly attended, prescribed the digitalis in January and
March last, Avith sensible advantage,  as the pulse recovered its
natural regularity both times: and Mr. Nunn reminding me,
of a case, apparently as hopeless as the present, in Avhich 1 re-
commended the foxglove, Avith him, with  complete success, 
APPENDIX.
145
lamented that the prejudice against it here Avas so strong, as
to preclude him from prescribing it again.
  On assuring the patient and his family, that the medicines
I should recommend Avould produce no violent or unpleasant
effects, they left me to proceed as I should judge fit, unfetter-
ed  by any  restrictions.   Had a blister applied to the chest,
and a calomel and squill bolus last night, which Avere  the
means of procuring some disturbed sleep.
  ft. Calom. gr. vj. Kali Vitr. Myrrhas Aloes a.  gr. x. tere
simul. et Conf. Ar. q. s. ft. pil. viij. quamp. sumat ij. et repr.
p. r. n.
   ft. Calom. gr. jft.  Scillse P. gr. j. Cryst. Tart. P. Bj. Conf.
Ar. q. s. ft. bolus sing. noct. s.
 . ft. Inf. Dig.  P. (3jft. ad 3 viij.) gj. Sp. jEth. Nitr. 3ft-
T. Cort. Aur. 3J. Kali pp. gr. x. 01. M. Pip. gt. j. M. ft. Haust.
mane, mer. et vesp. per dies tres, vel iv. s.
   He was directed to refrain from beer ;  but to drink freely
of negus or gin punch, acidulated Avith crystals of tartar; to
have a few  glasses of  Madeira daily ; and when his appetite
returned, to have solid  nutritive food, instead of  the slops to
Avhich he had been accustomed.  Mr.  Nunn Avas requested
not to continue the digitalis beyond the third day, if it should
occasion the slighest nausea or unpleasant effect; and to sub-
 stitute the Infus. Gent. C. for it ; at all events not to perse-
vere  in it after the fourth day, having appointed to see hira
on  the fifth.
  June 22.—From voiding only half a pint of urine daily for
some time prior to my first visit, lie passed, by measure,  five
pints every  day after the first 24 hours, Avith proportionable
relief of every symptom.  For tAvo days had been able to lie
down in  bed, and enjoyed sound  uninterrupted refreshing
sleep : swellings of the legs gone ; appetite and strength re-
turning; was able to  Avalk  without  assistance an hour and a
half yesterday in his garden.  Has had occasion to  use the 
AlO
APPENDIX.
pills only once, the boluses having procured tAvo motions daily
without  griping.  No sickness or any  unpleasant symptom
from the foxglove.   Took one draught to-day Avith the infus.
Gent. C.
   Pergat in usu Haust. cum Infus. Gent. C. vice Inf. fol. Dig:
Repr. Boli sing. noct. h. s.
   June 29.—By previous appointment came 12 miles to meet
me : Has continued to mend ;  rides out every day  in an open
chaise, and  drives himself; appetite craving, and he has in-
dulged it  too freely, especially  at  night, in consequence of
Avhich his stomach Avas disordered  one night; and he has
complained  of giddiness and confusion of ideas at times.
   Appl. Empl. Canth. Nucha:.
   ft. Inf. Gent. C.  3jx. T. Cort. Aur. 3j- Acidi Nitr. gt. jv.
ad. vj. M. ft. Haust. cum Pil, infra Prass, No.  ij. s.
   ft. Myrrhae, Colomb. P.  a. 9j. Zing. P. gr. x. 01. M. Pip.
gt. jv. Syr. Zing. q. s. ft. Pil. xjv,  Repr.  Boliu. a.
   July 8.—Came 17 miles to meet me, as previously agreed
upon, and drove himself; continues to improve  progressively;
appetite more natural; and digestion good ; head much re-
lieved by the blister ; has  transacted business, and  written
letters, which required mental exertion.  Walked up a hill
yesterday a mile from home,  and back  again without  incon-
venience.. Has recovered his natural florid complexion.   Me-
dicines to be continued, the draughts tAvice a  day only.
   July 22.—Came as before to meet me.   The day being ex-
cessively sultry, and being exposed for  near four hours to an
intense sun,  I Avas surprised to find him  very little affected by
the heat.  On the 13th he complained of great  pain in the
lower part of the abdomen, and in the  course of the evening
had three motions, consisting  chiefly of dark grumous blood
and a gelatinous like substance ; the last without any faeculent
matter. He  mentioned Avith much satisfaction, that he has been
since free from this painful complaint, Avhich  had more or less 
APPENDIX.
U:
 constantly harassed him for  nine years ;  and that for three
 nights the boAvels performed their functions regularly without
 any assistance.   The gums being  slightly affected, directed
 the boluses to be taken only occasionally.   Having been for-
 merly recommended the shoAver bath, I permitted him to try
 it  (especially as  the  weather had been  intensely hot) every
 other morning. AcknoAvledges himself very much improved in
 every respect, and talks of making an excursion to Westmore-
 land in an open carriage.   Was desired to go on as before.*
   It  may be sufficient further to remark that from this peri-
 od Mr. If. either continued to meet me occasionally, or that I
 visited  him at his oAvn house, for some months.   He became
 at  length extremely  impatient under the  restraints imposed
 upon him, and notwithstanding every endeavour on the part
 of  his amiable lady, the paroxysms of passion,  Avhen denied
 whatever he called for, Avere such as to render it hnpossible to
 keep him  within  bounds.  Yet all that Avas possible, that the
 most tender and  affectionate regard  could dictate, Avas done
 by  her.   She persevered to the last, and to the last the reme-
 dies did not fail to evacuate the Avater, and  afford relief.  His
 head, hoAvever, became more and  more affected, and the bil-
 ious attacks more frequent and violent.   He died on the 16th
 of July, 1808—Yet the Avater Avas completely evacuated no?
 many days before.

                      CASE XCIV.

  August  10, 1800.—Mr. Clover, a miller,  .flit. 53.  Of very
short stature, thick make, and corpulent.   Has worked hard,
lived well, but not addicted to excesses in drinking.   Has or-
thopnoea of the most distressing  kind, even Avithout any mo-
tion or exertion, being obliged frequently to raise his head sud-

 * To this date the case was published in Dr. Hamilton's Work.  p. -Oi 
148
APPENDIX.
dcnly, and to elevate his shoulders and arms at the saiilc time.
while he makes several  laborious efforts to draAv his breath ;
inability  of  lying doAvn  in bed for a  fortnight,  before
which he could Only lie on the right side.  Is frequently rous -
ed from sleep suddenly, though he is supported by  pillows in
a sitting  posture in bed.  Urine high coloured, diminished in
quantity, but without sediment; legs anasarcous to  the knees,
hard, resisting, and of a dark red colour; pulse full, and oc-
casionally an intermission during the paroxysms of orthopnoea;
face livid; no cough,  pain of the chest,  numbness  of  the
shoulders, nor swelling of  the abdomen; a peculiar oppres-
sion not only of the epigastrium but of the whole body; great
debility and no appetite;  much thirst.  Disorder  commenc-
ed about December last, Avithout any evident cause, and  has
been gradually increasing since.   Has used various medicines
without  advantage, and Avas prescribed the following lately
by  ajmysician of extensive practice avIio attended him.
  ft. Fol. Dig.  P. 3ft. Aq. ferv. 3xij. Infundeet ft. Infus.
  ft. Infus. Colat. 3j. Sp. JEth. Vitr. gt. 20. Tinct, Opii C.
9ij. Aq.  3»j- Olci M. Pip. gt. ft. M.  ft. haust. 5tis. vel 6tis.
horis s.
  No sensible effect or relief was  produced.  I prescribed as
follOAVS,-
  ft. Infus. Dig.  P.  (3jft. ad  3 viij.) 3j. Sp.  .Eth. Nitr. 3}-
Kali pp.  9j. M. ft. haust. ter ind. s.
  Appl.  Empl. Canth. pectori.
  ft. Calom. Scillae a. gr. j. Opii gr. ft. Crystal, tart. P. gr.
vj.  Muc. G. Arab. q. s. ft.  bolus sing. noct. h. s. s.
  I consider the case in every respect as very unpromising.
  August 15.—In 36 hours after beginning  the medicines wag
sensibly  relieved,  and has continued to  mend ever since, the
urine floAving in  full quantity, and the breathing  and every
other symptom being proportionably relieved ; though he has
taken his medicines very irregularly.   Pergat, U. A, 
APPENDIX.
149
   August 23—Improving in every respect, gaining strength,
 and able to walk out daily ;  lies down in bed, ahd breathes in
 every posture Avith freedom ; more so in bed than in any oth-
 er.  Was directed to persevere in the same plan.
   The water  was repeatedly evacuated,  and the symptoms
 Avere relieved  by these medicines, but he relapsed soon after-
 Avards, and at length laying  aside all medicine, the disorder
 increased and proved fatal, not many months after my first
 visit.
   Though this case was omitted in its proper place, yet it is
 thought  worthy of insertion here, not only as being in itself
 interesting, but as sheAving the inert practice  too generally
adopted in this disease.
  Several cases  are recorded in my report book besfde those
detailed  above, but  as  the results were the same, and it is
feared they may have already been multiplied and extended
beyond due bounds, I shall proceed to lay before the reader
those from Morgagni and other writers, which it is hoped may
be thought interesting, since they are accompanied with the
appearances after death.
43 
 
APPENDIX
        INTERESTING  CASES AND DISSECTIONS,

                         FROM

     MORGAGNI, VALSALVA, AND OTHERS

                BOOK II. LETTER XVI.

           FR OM  VALSAL VA.

               CASE  I.  Obs. 2, p. 378.

        Hydrops Pectoris, Pericardii, and Polypi.

      4 A WOMAN, Et 20.  Of a bad habit of body,
thirsty, having a slight cough, and spitting up a kind of ca-
tarrhous matter, was married.  Some days after her nuptials
she Avas compelled to take to her  bed.   Her pulse Avas fre-
quent, quick, and low ; her cough  troublesome, Avith but lit-
tle  expectoration ; and  her  thirst great.  Her feet SAvelled
and became oedematous; and so much the more as the disor-
der became the more violent: andjeven now her face also, her
arms, and her hands, Avere affected  with the same kind of 
152
APPEKDIX.
 swelling.   There was a sense of immoderate heat in the left
 part of the thorax; sometimes a tightness of the prascordia, ajid
 a difficult respiration ; so that she Avas obliged, as the disor-
 der increased, to breathe with her  neck erect.  Wherefore
 slie died Avithin a few days."

                    DISSECTION.

   " A little serum in  the abdomen; and the  spleen larger
 Chan natural.
   In the thorax the lungs were free from the pleura, but they
 were hard.   The quantity of water in each cavity was  such
 that a portion of it burst forth on cutting through the  ster-
 num ;  and the same kind of water was contained in the  peri-
 cardium, to the quantity of about five ounces. Being exposed
 to the fire the former coagulated, the latter did not.  There
 was a polypous concretion in both ventricles of the heart;
 that in the right the largest."

                    CASE II.  Obs. 4.

              Hydrops Pectoris, with Polypus.

   " A Avoman, Et 26, AA-ho had  been more than once preg-
nant,  swelled in her whole  body slightly;  but much more
in the abdomen, after great uneasiness  of  mind.   She also
breathed with great difficulty and with her neck erect,'lay
doAvn on either side laboriously, and felt a great  weight in the
thorax; she thirsted greatly; till  at length her  difficulty
in respiration getting more violent, she died." 
APPENDIX.
153
                   DISSECTION.

   ." A little water in the abdomen; the stomach being very
turgid and the liver large, had driven the diaphragm so far
upAvards, that the cavity of the thorax Avas much lessened
thereby.   The thorax was entirely full of water; the  lungs
red, in some measure hard, with black spots, but in other re-
spects sound.  A  polypus in the right ventricle of the heart."

                   CASE III.   Obs.  6.

    Hydrops Pectoris, and Pericardii, enlarged Spleen.

   " A man, Et. 40.   Had laboured under a sIoav fever for
some weeks.  To  this Avas joined a tumour of the feet, a dry
cough, and dryness of the fauces.  He breathed very  short
and quick, with his neck erect: his pulse was scarcely percep-
tible.   He died suddenly."

                   DISSECTION.

   " The spleen was three times bigger than its natural size.
   In both  the cavities  of  the thorax  a limpid serum  was
found.  Lungs sound, free, and unconnected, except a slight
adhesion of the inferior part of the left lobe.   The pericardi-
um Avas dilated, and contained more than half a pint of lim-
pid serum.   The  heart Avas enlarged, and in the right ventri-
cle Avas a lax polypous concretion; Avhich certainly is a circum-
stance not very rare in the heartof those Avho have Avater stag-
nating in their cavities.   The thoracic duct, and the lymphe-
ducts also in the  belly,  were so  far become empty that no
traces of them could be found." 
n%
APPENDIX.
                   CASE IV.  Obs. 8.

             Hydrops Pectoris, with Polypus.

  " A Avoman, Et TO.  Had a difficulty in breathing, and
could only lie on her back; she had a slight cough, spat up a
catarrhous  matter, and was  very thirsty: her pulse some-
limes scarcely perceptible ^ the right foot had an oedematous
SAvelling.  Before she died, she threAv up by vomiting, a fluid
of an asruginous colour.  In each cavity of the thorax serum
stagnated to the quantity  of three pints. Each lobe of the
lungs Avas connected anteriorly with the pleura.  In the right
ventricle of the heart was a small polypus."
  Some judicious observations are added: such as the not be-
ing able to lie on either side but on  the back, owing to the
water being equally collected in both cavities, but not so as \q
fill either.

                   CASE V.   Obs. 10.

        Dropsy of the Chest, and Water in the Head.

  ki A young woman (age not mentioned)[having been troubled
Avith a cough, thirst, and difficulty in breathing, was particu-
larly oppressed thereby in the last nights of her life: when she
coughed she brought up a cararrhous matter:  she could not
He down on the left side by reason of the straightness of the
praxordia; for which reason she  lay on the right.   Her feet
were turgid with an oedematous tumour; her face and belly
were also swelled, but the latter slightly only.  About three
days before her death she Avas in a manner lethargic, and had
a hesitation in her speech; and the last two days her pulse
was  entirely imperceptible." 
APFEXDIX.
IS/T
                   DISSECTION.

  " In the abdomen were three or four pints of serum; Avith
scarcely any traces of lymphatic vessels.   Lungs sound; in the
left side loose  and free;  in  the  right  closely adhering to
the pleura.  In the left cavity Avas a small quantity of se-
rum ; in the right,  AvJjatever space Avas left vacant between
the pleura and lungs Avas filled up Avith  a yelloAv serum.   In
the ventricles of the heart was a fluid blood, without any signs
of a polypous concretion.  Lateral ventricles of the brain con-
tained some serum slightly tinged Ayfth blood."
   Judicious observations are added on the Ratio Symptoma-
turn.

                   CASE VI.  Obs. 15.

                Hydrothorax of left cavity.

   " A woman,  jEt.  *0.   Of a sanguinous temperament, and
fat, while she Avas constantly attending upon her son, a\ ho had
a pleuritic fever, being seized Avith a pleurisy Iierself, got rid
of it after many days, Avithout any expectoration of matter.
But a sense of great oppression in  the left part of the thorax,
immediately succeeded to the pleurisy; so that she could not
breathe in bed, unless she  Tay on her right side.  She spat up
a catarrhous matter, was extremely thirsty, and had a swelling
in her loAver limbs.  To these  disorders, about four months
after  Avas added a violent diarrhsea, Avhich Avas troublesome to
her, frequently, every day, and lasted for three months.  In?
this space of time a fever returned at a certain period, with
cold,  heat, and  pain of the head.   All these symptoms conti-
nuing, she died at the end of the seventh month from the be-
ginning of the disorder." 
156                    APPEsnrx.
   The learned author attempts here to explain the reason Avhy
she lay Avith most ease on the side Avhich contained no water,
but not Avith his usual  success.   Unless the polypous concre-
tion was the cause, it is difficult to account for Avhat appears
an exception to a general rule.

                  DISSECTION.

   " In the right cavity of the thorax was no disorder at all,
but the left was full of water, in which some kinds of filaments
swam.  Yet the lungs were sound.   In the right ventricle of
the heart Avas a large polypus, which extended itself from
thence into the vena cava.

                  CASE VII. Obs.  14.

              Hydrops Pectoris, Polypi, Sre.

   " A woman Et 50.   Of a thin habit, and pale colour, hav-
ing laboured under a dyspnoea, for a  year, and the disorder
increasing upon her, was at length received into the  Hospital
of St. Mary de Vita, at Bologna.
  Her respiration was extremely laborious,  her thirst  great,
her pulse moderately quick and small; which faultering more
more every day, she died.   In the left cavity  of the thorax
the lungs Avere sound, and every  where free ;  but  sAvam  in
a pint and a half of saltish Avater.  And  the right lobe of the
lungs adhered so closely to the pleura,  as to be one continued
body with it.  In the heart Avere three polypous concretions,
resembling condensed mucus."   Some  very  interesting  re-
marks follOAV. 
APPENDIX.
157
                   CASE VIII.   Obs. 17.

        Water in the Chest, and Pericardium, Polypi.

  " A virgin Et 15.  Was troubled  with an acute fever, at-
tended Avith a dreadful pain of the head; for all her  other
symptoms were mild.  About the tenth day the fever  seem-
ed to remit.  But after a few days*  a great thirst, a labori-
ous respiration, and  a pain in the left part of the thorax, were
added to  the fever.  The two  last mentioned  symptoms
growing more violent Avithin a few days,  being perfectly  in
her senses, and having the free use  of her speech, she  died,
contrary to the expectations of those Avho Avere about her."

                   DISSECTION.

  " The lungs were sound: but the left cavity  of the thorax
was full of serum, like the urine of horses, in which some con-
cretions swam,  that resembled  the white  of  eggs.   In the
right cavity also was serum, though in very small quantity.
But in the pericardium Avas such a quantity, that it filled the
Avhole cavity, and Avas more thick,  than  that in  the thorax.
Polypous concretions in the ventricles, like condensed mucus."
  Very pertinent remarks are  added, among others, that
dropsies arising after acute disorders are bad, for they do not
free the patient from the fever, and are very painful and mor^
tal.
ii 
it&
AFPXNUfX.
                  CASE IX.   Obs. 19.

                Dropsy  of the Pericardium.

   "A virgin Et.22.  Was not able to breathe  unless with
her neck erect;  she had great thirst and a considerable cough,
and threAv up a kind of purulent matter from the lungs, Avhich
%vas sometimes  tinged with blood; she had a fever, her face
Swelled, and at length she died.  In the belly were some pints
of water.  The right cavity of the thorax Avas full of serum;
of which there Avas also a less quantity in the left.   The sub-
stance of  the lungs was in some  places  red, in others white,
but in other respects sound.  The whole pericardium Avas full
of water.  In the ventricles of the heart Avas nothing but a
fluid blood."

                    CASEX.   Obs. 21.

                   Hydrops Pericardii.

   " A certain man, whose feet had been  affected for some"
time, with an oedematous  tumour, Avas seized Avith a slight fe-
ver: his respiration became difficult, and more difficult every
day, so that he was forced to breathe with his neck straight; he
coughed, and spat up a catarrhous matter Avith it; he had al-
so a great thirst: at length he died.
   On Dissection the pericardium was found full of  Avater."
   The author very justly  remarks that there Avas no symp-
tom here Avhich does not attend dropsy of the chest, with or
without Avater in the pericardium. 
APPENDIX.                     159
                  CASE XI.  Obs.  24.

                   Hydrops Pericardii,.

  u A boy, from being in the beginning, a lively, brisk, and
well coloured youth, became sad,  slothful, Avith his eyes less
vivid than usual,  pallid, and his lips and eyebroAvs verging to
a leaden colour.   If he walked a little faster than usual, or
went up stairs, his respiration became difficult, and the  palpi-
tation of. the heart, with  Avhich he Avas constantly troubled,
more violent.  The disorder then greatly increasing, he lost
his appetite for food, and  the strength of his body, the ex-
tremities of which  were constantly somewhat  cold, and his
feet very much swelled; but his pulse was  ahvays very  soft,
weak, small, frequent,  and somewhat  unequal.   Finally, be-
ing taken with a  slow fever,  he died.   Water  Avas found in
the pericardium.   From Vieussens' Tratie du Coeur, Ch. I."

                   CASE XII.  Obs.ib.

               Water in the Pericardium only.

   ct A man of a  melancholic temperament, Avho had always
been extremely  well in health, till a year before he began to
labour under a difficulty in breathing,  Avhich had so increas-
ed by degrees, that at  length, for three or four months togeth-
er, he Avas forced to sit up in bed night and day, for fear of suffo-
cation. He was at that time lean, without any swelling at all;
but both his hands and legs Avere chill, for the most part. His
eyes were very dull and heavy; but his face and particularly
his lips, were of a dark iron grey, dyun gris defer obscur. He
 lay with equal uneasiness on both sides; but on his back with
 still greater uneasiness; and then the colour of his face be- 
160
APPENDIX.
came more dark, his pulse more small, frequent, and unequal,
and the extreme parts of  his body seemed still  more cold.
This man, though  he could go from the bed to the fire by
himself, yet the next day  he died suddenly, at dinner; Vieus-
sens having both foreseen, and foretold the disease and death.
   A considerable dropsy of the pericardium."

                  CASE XIII.  Obs. ib.

            Water in the Chest and Pericardium.

   " Vieussens by comparing the  symptoms  of the preceding
and another case, was led to distinguish the same disease  soon
after in a boy, though it Avas joined Avith others, and in particu-
lar with the dropsy of the thorax, from these causes; that in
the Avhole progress of the  disease, and a  little before the con-
clusion, there had been a  palpitation of the heart,  that the
lower eyelids, and the nails, Avere of a lead colour;  that the
patient was very sad, and frora  some other marks of  that
kind.  In the beginning he had a palish face;  the  ex?
tremities cold;  repiration  not  free, especially when he went
up stairs; his pulse soft and too frequent."
   The ingenious reasoning used here, and in Obs. 25, are high-
ly worthy the perusal of the reader.

                   CASE XIV.  Obs. 26.

           Hydrops Pectoris-—From Morgagni.

   *' A man at Bologna, had a difficulty of  respiration ; nor
could lie on the left side; on the right he not only could lie,
but even lay continually.  Although he neither lay  with his
head raised, nor had swelled feet, yet I inquired whether he
was ever waked in the first hours of deep, by a sudden seme 
APPENDIX.
161
of suffocation ? which he answered in the negative. He com-
plained also of a hardness at the upper part of the belly, which
might even be perceived, by applying the hand to that part
where the pancreas is generally supposed to lie,  so that any
one might have taken  it for the pancreas indurated.  When
the belly Avas opened, after death, it Avas discovered to be the
liver, sound indeed, but depressed on the right side, by the
diaphragm.  But the thorax, Avhen opened, shewed that so
great a quantity lay on  that part  of the diaphragm,  as to
have  driven the mediastrium much to the left side, though
become thicker in its coats."
   The author observes in  this case, Obs. 27.   " That the dia-
phragm has been sometimes so depressed by the lungs,  when
enlarged from a certain cause, that the liver has been driven
downwards, though in other respects sound, and  taken  for a
tumour by physicians, I have heard; and that from a quanti-
ty of Avater, accumulated in the left cavity of the thorax, the
diaphragm, in the part where it is perforated by the cesophaguSi
was protruded tike a bag towards  the left kidney, so that the sto~
mach lay over the liver.  I have read in the Sepulchretum, L.
II. S. 7. in Schol. ad  Obs. 25, in Additara.  This man could
lie only on one side, Avhether the right or the  left is not men-
tioned, but it is presumed on the latter.

                   CASE XV.  Obs. 30.

 Water in the Chest, with various  other singular  morbid appear-
                           ances.

   " A young man, without any  evident cause,  fell into a cir-
cuity of breathing, before the end of the year  1704. Beiug ou
this account, afterwards received  into the hospital of St. Ma-
ry de Morte at Bologna, he Avas treated in various methods of
sure, but in  vain.  Among other remedies  V..S. Avas more 
;62
APPENDIX.
than on«e used, with a little immediate, but temporary relief,
opening  medicines did not afford relief.   When I saw him,
not quite three days before his death, he Avas very pallid, and
breathed always with his neck upright.  When he inspired, I
observed that the lower part of the chest was raised very high *,
he had no thirst, no heat, nor feverish symptom ; yet the pul-
sation of the arteries was frequent, and the pulsation of the
heart, Avhich, when Ave applied our hands to the thorax, seem-
ed to palpitate,  was  much more frequent: and this compari-
son being often and accurately made, always answered in the
same manner, and the pulsations of the heart and arteries were
observed to be surprisingly unequal.   The difficulty of breath-
ing being much increased, Avith SAvelled face, he died about the
hundredth day from the time the disordethad begun."

                   DISSECTION.

  " The  omentum was blackish, and covered with glandular
globules.  Liver diseased and connected with the diaphragm.
There Avas a yellow and green water  in the abdomen.   Both
the cavities  of the chest were filled Avith water of the same
kind, mixed with thin  membranes.   The  right  lobe of the
lungs adhered to the pleura in some places; the left more ge-
nerally and more firmly."   See the case.

                 CASE XVI.  Obs. 34.

Hydrops Pectoris and Pericardii, with Polypi, from repelled
                        scabies.

  " A virgin of Bologna, Et 18.  Having repelled an erup-
tion of the scabies kind, by  ointment, was seized Avith a most
violent orthopnoea, Avithout  fever, cough, SAvelling of the feet,
oi' contraction of the nails.   Blood being taken from the arm, 
APPENDIX.
163
to the quantity of six or seven ounces, she became much Avorse:
and the same quantity being taken from her foot, some days
after, she sunk under it so much, that the difficulty of breath-
ing became more, and  she died on the following day.  The
body was not swelled in any part.

                   DISSECTION.

   The liver was livid, and harder  than  usual.   The whole
thorax was filled with  a bluish  kind  of  water, Avhich burst
forth on  cutting the cartilages of tbe ribs.  The left lobe of
the lungs Avas connected with the pleura posteriorly; the right
adhered very closely to the pleura, on the whole of its posteri-
or and lateral surfaces.   The pericardium was  also distended
to such a degree, that before I cut into it, it Avas very hard to
the touch, and made me almost imagine that the heart was
much enlarged.  It was nevertheless of its natural  size, and
sound.  A polypus was found in each ventricle, like fat that is
of a Avhite and yellowish colour."

                 CASE XVII.  Obs. 36.

      Water in the Chest and Pericardium, Polypi, Sec.

  * A woman,  Et. 50.   Had a dyspnoea for many  days, at-
tended with a wheezing ; yet it neither prevented her frora
lying doAvn or from sleeping.  One arm Avas painful and oede-
matous ; she felt a fluctuation in the thorax on motion, and a
Aveight even without motion.   Finally an oedematous swell-
ing of the feet was  added to that of the arm,  three or four
days before her death, Avithout the dyspnoea being increased;
yet she Avas carried off suddenly, as she was beginning to take
food.   She had neither been liable to fainting fits, nor had
ever complained of any straightness, or constriction, at her 
164
A-rrENDix.
 heart, nor yet of a pain in  her loins ; nor finally of any inco*
 venience that related to the  stomach, which I Avas willing to
 take notice of here for reasons that  a\ ill appear on dissection.
   The stomach was found contracted ; and within its cavity-
 near the mouth of the pyloris, was a large caruncle, fixed by
 an oblong stalk to  its internal coats.   Both cavities  of the
 thorax contained a great quantity of water, of a greenish co-
 lour.   The pericardium also was distended with water, ting-
 ed Avith the same colour ; nearly to the quantity of two pint6.
 The heart Avas almost Avholly covered Avith fat, and had poly-
 pous concretions in the ventricles.   In the head Avas water be-
 tween the meninges, and in the lateral ventricles."

                 CASE XVIII.   Obs. 38.

      Dropsy of the Chest, and Pericardium, with Polypi.

   « A country woman,  about 25,  and of very pale counte-
 nance, having been married four months before ; Avas already.
 past the third month of pregnancy, when  she Avas received
 into the hospital at Padua, in which she lay a month or more,
 with  a kind of small erratic fever.  Her pulse Avas neither
small  nor intermitting.  There wa* no thirst.  She.had no
SAvelling of her feet, and no fainting   Nor did she ever com-
plain of tightness, or oppression,  about the heart; nor yet of
an anxiety, or sense  of weight, nor, indeed of any  inconve-
nience, or difficulty,  in  the  thorax, Avhatever; except that,
now and then, she used to be  attacked with a little  dry cough,
to which she had been for along time  subject, in the same
degree, that is, but slightly.   She breathed in general  pretty
freely; nor was she roused in the night, by a sense of suffoca-
tion, or forced to sit up in bed.  She lay doAvn,  but  on her
right side only ;  and upon this she lay when she died., 
                       APPENDIX.                    l&S

  The spleen was a little enlarged, the liver much more so.
In the right cavity of the chest was a large quantity of yel-
lowish water, in Avhich were a thick mucous kind of mem-
branes.   And some water of this kind there Avas in the left ca-
vity ; but in the pericardium so much, that it was almost full,
with similar membranes  swimming in it.   In both the ventri-
cles of the heart were polypous concretions, as if of a kind of
mucus ;  but a little more dense in the left."

                 CASE XIX.   Obs. 40.

           Dropsy of the Chest, and'Pericardium.

  " A man more than 40, who travelled much on foot, carry-
ing goods  from one place to another, Avas used to drink much
when hot, and especially latterly, when he had a great thirst
oh hira;  and, being seized with a violent fever, and a deflux-
ion of rheum upon his fauees, was taken into the hospital at
Bologna.   He complained no  more of his fauces, but said all
his disorder was in his belly ;  yet complained of nothing more
than a pain in  the spine, about the lumbar region.  Some of
the physicians suspected that  the disorder Avas an  inflamma-
tion of the boAvels;  but Valsalva that it Avas m the thorax.
The  pulse Avas Aveak and  low; yet seemed oppressed.  He
would often rise up, as if he were going away ; and in this
manner he died, the third or fourth day from the time of his
admission."
   " In the thorax, and particularly in one part, an humour
stagnated, in which pieces, as it  Avere  of  the most  Avhite and
thin membranes swam.  The pericardium was so distended,
that  upon the slightest prick, it threw out a small stream of
fluid,  like a fountain, to a  very considerable height.  The
apex of the heart was a little more red than usual. Much w?
                            45 
160
APPLNDiA.
ter Avas found between the dura and pia mater: some of the
vessels of the former Avere tinged with blood."
   Some very ingenious observations on the case are subjoined.

                   CASE XX.  Obs. i-3.

              Dropsy of the Pericardium only.

   " There Avas at  Bologna a nun, of an illustrious  family,
whom a physician had cured of a defluxion upon her gums
and cheek6, by giving her sudorific decoctions of  the  woods;
and aftenvards, being seized Avith an acute fever, had been
restored to health Avith equal success.   She Avas strongly urg-
ed by the same physician, though in perfect health, to submit
to a  course of similar medicine the following spring, and at
length very reluctantly consented. With others  of the con-
vent she had taken as much of tbe syrupus aureus as occasioned
near fifty motions ;  by which an intolerable thirst Avas brought
on, that did not remit on drinking  a large quantity of  broths,.
and for this reason  she Avas ordered to drink freely of dilute^,
emulsions;  nor Avas the urine in proportion to the  quantity oJL
fluid she took iu.  The day afterwards, having sat  up  in bed,
with an intention to rise,, and having begun to put on her clothes
she was suddenly seized w ith a kind of oppression at her heart*
as if a stone was laid upon ii, to which a fainting fit succeeded ;
and from that time, this oppression never failed to be  exacer-
bated as often as she spoke or moved  too much.  Many phy-
sicians Avere consulted, Avhose opinions,  as generally happens
in disorders of this  kind, being very  different,  Albertini Avas
added to  the number.   One conjectured a  polypus, another.
an aneurism,- another a tubercle of  the lungs, and some a drop-
sy  of the lungs or  thorax.   Albertini after much caution
and deliberation, and visiting  the patient diligently several
times, pronounced the disease to be a dropsy of the pericardium. 
                         APPENDIX.                    Igf

    This virgin had a good colour in her face ;  her sleep was
 undisturbed ;  she was regular in her bowels, and in her men-
 strua ; her respiration was-equally easy, whether she stood up
 or lay on her bade, on the right or on the left side.   Her pulse
 was neither tense, nor hard, nor chord like, nor in the least ir-
 regular in any way.    She had no palpitation, or large pulsa-
 tion,,  in the heart; no pain about the region of the lungs ; no
 cough ; nor any other  unpleasant symptoms, except those
 mentioned.  When still and quiet, she had no oppression about
 the heart; but on motion, or on speaking for any length of time,
 she was tortured thereAvith immediately, or to use her own ex-
 pressions, « as if she Avas pressed and squeezed up," with a great
 concourse of people all round her, accompanied always by a
 slight kind of fainting; and  her pulse, even when she  was
 quiet, Avas alAvays Aveak.
   The virgin  at length died, as Albertini had  predicted.
 For Avhen she dragged  on life,  to about the end  of a year,
 from the  beginning of her disease; a momemtary sense of
 pricking began to be added to the  other symptoms, Avhich
 returned noAv and then  in the pact affected, attended with
 slight convulsions in the same place ; the pulse began gradu-
 ally to be more and more Aveakened, and in a manner obscur-
 ed ; Avhich were not fallacious symptoms of death  being now
 at hand.
  The pericardium Avas tumid with water, to the quantity of
 nine ounces, and the membrane of the  heart began to be erod-
ed, without doubt from the water, which Avas at length  be-
come  very acrid from its stagnation, from whence that sense
of pricking had been felt, and those slight convulsions had
happened."
  The  perusal of the whole of this extraordinary case is re-
commended to the reader.  It is given by Albertini. 
163
APPENDIX-
                FROM HOFFMAN.

                        CASE I.

  " A man Et 30.  Of a florid complexion, who, in the early
part of life, Avhen in the army, Avas much addicted to intem-
perance, and exposed frequently to cold, Avhich affected his
chest principally, was seized Avith a fixed pain of the left side,
and difficulty  in  breathing.   Having been  obliged  to quit
the army, and to change his active mode of living, for a quiet
and retired life :  to the pain and difficult breathing were add-
ed a cough, a great anxiety and straightness about the prae-
cordia, which increased to such a degree that he  could only
breathe freely at a window : the left foot,  leg, thigh, and
scrotum SAvelled ; the urine  was scanty and of a yellowish
colour.  At length  after an  immoderate fit of laughing he
complained of  a very great difficulty and tightness in breath-
ing, amounting nearly to suffocation ; the pulse Avas small and
unequal;  and after coughing violently he  brought up some
blood, and finally his strength being  exhausted he died in
three days after.
  In the left cavity of the thorax were near seven pounds of
Avater.  The vessels of the heart were of a white colour, dense,
and hard,  like a quill;  the lungs  Avere much contracted.
There was a polypus in the pulmonary artery."

     FROM HOME'S CLINICAL EXPERIMENTS

                       CASE I.

                   Hydrops Pectoris.

  February 11, 1774.—"  Francis Hardy, Et 60.   A smith,
and used  to drinking, has been affected for six years with 
APPEXDIX*
109
 cough, difficult breathing, pain of his breast, sense of weight
 betAveen his shoulders, and increase of his complaints when he
 lies on his back, or left side.  Some time ago his legs and body
 began to swell.  A sensible fluctuation in the abdomen. Pau-
 city  of urine.   Belly bound.   Pulse 100.  From a sense of
 suffocation, when going to sleep, he starts up in ^ an erect pos-
 ture.—17th, died.
   Three pounds of fluid in the thorax,  mostly in the right
 side, Avith some slight adhesions of the lungs Avith the pleura.
 Right lobe sound, but on cutting the left a good deal of pus
 issued out.   The pericardium was much fuller of fluid than
 it ought to be.  In the cavity of the abdomen six pounds of
 fluid  Avere found.  Liver harder than usual."

                        CASE II.

                     Hydrothorax, &e.

   March 4.—John Farguhar, Et 60.  About the beginning
 of January last, felt a pain in the region of the liver, especial-
 ly on being pressed.   His belly began  to  sAvell  about  the
 middle of the month.  In the beginning of February his legs
 became oedematous.   Can scarcely lie horizontally in bed, and
 starts for fear of suffocation, Avhen going to sleep.  Has  not
 been able to lie on his left side for two months,  as it occasions
the pain and difficulty of breathing.  Feels neither  Avcight,
oppression, nor fluctuation in his breast.  Dry cough.   Belly
bound.   Urine of a deep colour and diminished in quantity.
 Pulse 110 and  not  regular.  Has had nausea and vomiting
 for these four days.  8th, died this day, Avhen raised up in
 bed, and speaking as usual.
  In the abdomen was found one pound  of lymph ; and  the
 intestines adhered in  some  places to the  peritoneum.  The
 Vvev  wa« considerably larger than natural, but not srhirroys 
170
APPENDIX*
About one pound and a half of fluid Avas found in the  right
cavity of the thorax.  The under part of the right lobe of the
lungs,  and the diaphragm and pleura contiguous to it were in-
flamed.  Part of the pulmonary artery was ossified."

                       CASE III.

  May 24,1769.—« T. Keir, a taylor, Et  45.   For four
years, has had dyspnoea, cough, uneasiness on laying on the
right side, the sensation of something moving  in his breast on
turning in bed, and pain and sAvelling of the liver.  Of late as-
cites, anasarca, and scanty urine. Was relieved for six months,
but relapsed, and died.
  The lungs  adhered  almost wholly to the  pleura ; and in
the right cavity Mas found a pint of fluid."

                       CASE IV.

                    Hydrothorax, tec,

  February 10,1778—" M. Macculloch, Bt. 53.   Addicted
to drinking; had, five years  ago, a lever,  followed by three
relapses.  His legs afterwards swelled and  pitted,  especially
when he was exposed to cold and moisture.  Ajaionth before
he came in, was seized with dry cough, dyspnoea, and orthop-
noea, tightness and pain of the breast under the sternum, sud-
den starting when going to sleep,  as from suffocation.  An
evident swelling was observed in his breast at the extremity of
the  first and second ribs, on the left side, where he received
a stroke five years  ago, and which still continues painful on
pressure..  Urine  in natural  quantity but  high  coloured.
Pulse from  64 to  68,  and weak, but not irregular.  March
Ilth, dismissed cured, by means of cream of tartar." 
APPENDIX
171
                         CASE  V,

    March 16.—« Sophia Maok, jEt. 31.  Caught cold  three
 weeks  ago while taking purging salts.  Two days afterwards
 her legs, and then her body began to swell; and she is now
 very anasarcous.  These complaints were attended with dry
 cough, much hoarseness, pain of her head, dyspnoea, nausea,
 thirst, frequent shivering, severe stitch in her breast, difficult
 lying on the left side, and pulse from 70 to 80, and very strong;
 As these dropsical  symptoms appeared to rise from a local
 pulmonary affection, or at least to be attended Avith a general
 inflammatory state, which is uncommon in this disease,  V. S.
 mucilaginous pectorals, and ol. recini were ordered.
    The blood being  very buffy, the cough troublesome, with
 spitting of blood, and the pulse continuing very full, she Avas
 let blood afterwards six times, namely, the 19th, 21st, 22d,
 27th, 30th, and April  3d, to the quantity of 49 ounces, beside
 that on the 16th which Ave shall suppose eight ounces, so that
 in eighteen days she lost 57 ounces of blood (which was cover-
 ed with a thick inflammatory crust,) to which the  cure Aras
 principally  attributed  by the author."

                FROM HOFFMAN.

       CASE I.  Chap. xiv. obs, vi. vol. vii. p. 469

                      De Hydrope.

  " Vir, EX. 50, lautiori dhetae vitasque sedentaria; addicts
et lacticinia cum Jructibus  acidis honms in deliciis habene,
pragresso diuturniori moerore incidit in cachccticum corporis
habitum,  ex colore faciei Iurido, sublivido  et ad flavedinem
inclinante satis conspicuum ;  unde ciborum appetentia.  satis 
1'72
Arr£:;oir.
antea vcgeta una cum viribus valde concidebat, flatus et boi-i
borigmi in abdomine, obsegrtiorum alvum, miras creabant mo-
Iestias, respiratio cum prascordiorura anxietate reddcbatur dif-
ficillima, ut per intervalla morti prdximus aeger habertur, et,
quod maximum erat, pulsus micabat debilis, nonnunquam in-
termittens, plerumque inaequalis.  His tandem malis jungeba-
tur icteritius faciei color cuitt raajori pectoris angustia  pedum;
femorum, scrotique, intumescentia, donee omnibus in pejus
ruentibus  asger obiit.
  Cadavere  aperto in abdomine pariter ac thorace magna seri
extravasati conspiciebatur copia. In cordis et pulmonum va-
sts delitescebant cohcrementa polyposa, ex dextro cordis ven-
triculo per arteriaj pulmonalis ramos  dispersa.   Totum vero
hepar cum liene atro sanguine inveniebatur infarctum, &c."
   Interesting observations on the case follow.

                CASE II.   Ibid.  Obs. ix.

   Sfee  a very interesting case  which terminated  successfully,
in which,  says the celebrated author, " abstinuimus ab  omni-
bus fortioribiis hydragogis et diureticis, et potius injuncto ac«
curatiori vitae  regimine medicamenta dedimus balsamica ama-
ra, stomachica et carminativa, interpositis  subinde salibus de-
tersivis et  aperientibus," &c.
   In the  Monita and Prsecepta Medica of Dr. Mead, the fol-
lowing curious case is described, which I shall transcribe in
the author's Avords.
   " Virgo, Et. 17:  sensit sibi intumescere ventrem, parvaque
copia urinam reddi; a quibuscunque  remediis pejus  habuit,
et post annum  haud aliter ac gravida distendebatur abdomen.
Eo tempore nupsit, spe proposita, maritum' fore pro medico.
At longe  secus res evenit, per annos tres increvit sensim hy-
drops, ita ut tandem ventris disruptio formidaretur.  Cum
dolor jam intolerabilis premeret, a me petiit, ut  aquam  manu 
                        APPENDIX.                    173

chirurgi, qucm in Nosocomio eventu secundo hanc medicinara
fecisse audiverat,  quo  saltern levaretur cruciatus, educi cura-
rem.   Ergo, ne occidisse, quam servare non  potui, vlderer, in
corpore macie jam paene confecto,  id sine maximo vitae peri-
culo tentari non posse edixi.  Misera tamen instare, et  preci-
bus rogare, ne se desererem, assiduis tormentis et lenta morte
consumendam.  Cessi precibus  victus, et ilia, quam dixi,  via
eraissae sunt simul et semel humoris limpidi, et nullo  raodo
foetidi lib. 60.  Ex eo tempore indies auctae sunt vires, mor-
boque nunquara postea  revertente,  elapsis decem mensibus
filium robustum  peperit;  plurium etiam exinde foecunda
parens."
  In the folIoAving interesting case communicated by the late
Dr. Fothergill to Dr. D. Monro, the symptoms are so strongly
marked, and so accurately described, that I shall,  I am per-*
suaded, be excused in copying it.
  " A gentleman of a fresh complexion, full, lax habit, and a
large make ; in respect to liquors, for the most part temperate,
with a good appetite, and ample means of gratifying it; about
the 56th year of his age, perceived, upon a little unusual mo-
tion, an obstruction to his breathing, attended with a palpita-
tion of the heart*
  These complaints gradually increased so much as to in-
duce him to consult his physician, to Avhom he gave the follow-
ing account*
  That on walking one hot day, after having spent an hour
or two in business, in a room crowded with company, he found
such an uneasy straightnessof the wind pipe, just above the ster-
num, that it seemed as if a bur, as he termed, stuck there, and
hindered him from breathing with his usual freedom:  thaUtt
night, upon going to bed, he  had a palpitation of the heart
                              46 
17±
AfPEXDUL.
 and a greater difficulty in finding such a posttfre as h» could
 lie in with ease than he had ever before experienced.
   It Avas not  every  night he  found himself thus afflicted:
 sometimes he had three or four bad nights successively, in
 which he was either obliged to sit up most part of the night,
 or altogether prevented from sleeping when able to keep in
 bed.
   Things  had continued in this situation some months.  His
 countenance  was  then fresh and florid ; his breathing upon
 motion  somewhat laborious ;  he coughed but little, and this
 rather voluntarily, to fetch up something that to him seemed
 obstructing the wind pipe, than from  an irritation of the lungs
 themselves.  His  pulse Avas extremely irregular, never beat.
 ing five strokes alike, but varying incessantly, either in respect
 io frequency, or strength, or both ; his urine Avas high colour-
 ed,  depositing for the most part a copious  sediment, of a co-
 lour betwixt the lateritious and carnation ; his stools regular in
 every respect; he found himself commonly  easiest when lax,
 and his breath laborious if ever so little costive.   He  had nq
 heat, thirst, dry tongue, or  any symptoms of a fever, except a
 high coloured urine, which was  accounted for from its being
 in small quantities.  No peripneumonic symptoms, except la-
 borious breathing ; no appearance of a humoral asthma; nor
 was it apprehended that a  convulsive one could  produce just
 such appearances, especially as the  irregularity of the pulse
 was not less when the  breathing was  free and easy, than when
 it proceeded to such a pitch as to oblige the patient to rise out
 of bed at midnight, to avoid the danger of  immediate  suffo-
 cation.
   As the patient had lived in such a manner  as might seem to
 have entitled him to the gout, and he Avas then at an age when
 the first attacks of this disease are most commonly irregular,
this likeAvise was taken into consideration; though the constant
irregularity of the pulse rather seemed to indicate, that some- 
APPENDIX.
Ulf
 ihing more permanent was the cause than the gouty matter,
 which, whenever it attacks these unsuspected parts, most com-
 monly alloAvs  of some, though oft uncertain and short vaca-
 tions.  After moderate evacuations, by bleeding and purging,
 were first premised a course of gum pills extract of the bark,
 chalybeats in  very small doses Avas recommended, with some
 mild balsamicks^intermixed.   No increase of the symptoms
 being  observed from this method, is was persisted in some
 time;  the  air and moderate exercise on horseback proposed,
 and a due regard to quantity as well as the quality of aliments.
 A longer truce seemed to be gained by this method than had
 been perceived from the first attack j but as the winter ap-
 proached, this calm Avas often interrupted, frequently without
 any manifest cause ;  the patient being often obliged to rise af-
 ter he had been an hour in bed and spend the remaining part of
 the night.   This soon brought on an oedematous swelling of
 his legs, heaviness by day, inquietude by night, and the evident
 symptoms of an hydrops pectoris.
   By the use of the following remedy, viz.   R. Sapon. venet,
 scrup. i. g. aramon. gr. x. pulv. scill. sice. gr. iv. syr. simp. q.
 s. f. bol. s. 6ta. q. h.  near a gallon of urine was discharged in
 one night, which lessened the dyspnoea, abated  the anasarcous
 swelling  that  had spread even to his hips and belly, enabled
him to continue quietly  and easily in bed through the night,
and gave him and every one about him hopes of a speedy
amendment.    He enjoyed this tranquillity a month or six
weeks,  the  irregularity of his  pulse nevertheless continuing,
though remarkably less after this evacuation of urine; once he
seemed during the summer to have acquired firm health, his
pulse becoming somewhat less intermittent, and the  other
symptoms disappearing ; but this Avas only a longer interval
than ordinary.   The returning Avinter brought with it his for-
mer complaints : and though fontanels,  blisters, diuretics,
purgatives, corroborants intermixed, were tried, under tiiedi-* 
176
APPENDIX.
 rection of some of the ablest persons of the profession, his dta
order increased, and he was at last suddenly suffocated by the
load of water in the thorax."
   Many more interesting cases and dissections might be add-
ed ; but this part of the Avork having already exceeded the
bounds prescribed, I shall content myself Avith referring those
who may be desirous of  farther information, to the following
sources.  See Willis'' Pharm. Rat.p. 2. sect, cap, xiii. de hydrope
pectoris, in which an interesting case  is mentioned lo have been
cured by the operation, the canula being left in for a consi-
derable time.  Also, Memoir de Vacad. des sciences 1703, in
which tAvo interesting cases are detailed.   Bonetus lib. ii. sect,
i. obs. 60, gives an account of the dissection of a man  who died
of dropsy, in  Avhose pericardium Avere found  thirty  ounces of
water.   See also ibid. obs.  41.
  Since the Appendix  No. 1, has been printed, several inter-
esting cases have fallen under my care,  in which the results
have  been  highly satisfactory.   In one instance the disorder
yielded very slowly to the usual remedies till salivation was
produced, which Avas more profuse and of longer duration than
was intended, in consequence of inattention to the injunctions
laid down ; but the cure has been complete, the patient hav-
ing enjoyed  perfect health ever since :  The legs were hard
and tense.
  Of late I have used the nitric acid very freely  both before
and after the  water has been evacuated, and it promises to
prove a valuable auxiliary to the means recommended in the
foregoing pages, 
 
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