s S IAMA11 f M1YMOTY. | ! * I i f ibrarn of % Pass. Pebical College. , i! RULES AND REGULATIONS. 'j 1. Students attending any of the Lectures in ■ [ the Massachusetts Medical College may take i ,! books from the Library during the course, by i 1 depositing Five Dollars with the Dean; and , 1 the Students of any of the Medical Professors j may have the same privilege on the same terms \ j throughout the year. « I 2. The Library shall be open on the afternoon i j of every Saturday, from 3 to 4 o'clock, for the ! delivery and return of books. j. xne injury, as me case may ue, win oe ueuucted ' from the sum deposited; otherwise the whole ', amount will be returned to the depositor, when i he ceases to use the Library. OBSERVATIONS ON THE NATURE AND CURE OF DROPSIES, AND PARTICULARLY ON THE PRESENCE OF THE COAGJtLABLE PART OF THE BLOOD IN DROPSICAL URINE; , V ,i ' TO WHICH IS ADDED, ■4^" AN APPENDIX, CONTAIIIItS SEVERAL CASES OF ANGINA PECTORIS. WITH DISSECTIONS, &c. — 1 .. ' BY JOHN^ACKALL, M.D. PHYSICIAN TO THE DEVON AND EXETER HOSPITAL, AND V> THE I.UNATIC ASYLUM, NEAR EXETER. SECOND AMERICAN, FROM THE FOURTH ENGLISH EDITION WITH AN ADDITIONAL APPENDIX, TAKEN FROM THE MEDICAL RECORDER, #C. #*.. = '#(100 tv f} PHILADELPHIA: fc^y£ ^ / PUBLISHED BY JAMES WEBSTER, ^£vAR AT THE OFFICE OF THE MEDICAL RECORDEB 1825. EASTERN DISTRICT OF PENNSYLVANIA, to wit: BE IT REMEMBERED, that on the first day of November, (L. S.) in the fiftieth year of the Independence of the United States of America, A. D. 1825, James Webster, of the said District, hath deposited in this Office the Title of a Book, the right whereof he claims as Proprietor, in the words following, to wit: " Observations on the Nature and Cure of Dropsies, and particularly on "the presence of the coagulable part of the Blood in Dropsical Urine ; to " which is added, an Appendix, containing several cases of Angina Pectoris, " with Dissections, &c. By Johx Blackall, M. D. Physician to the Devon " and Exeter Hospital, and to the Lunatic Asylum, near Exeter. Second " American, from the fourth English Edition : with an Additional Appendix, "taken from the Medical Recorder, &c. &c." In conformity to the Act of the Congress of the United States, entituled "An Act for the encouragement of learning, by securing the copies of maps, charts, and books, to the authors and proprietors of such copies, during the times therein mentioned," and also to the Act, entitled, " An Act supplementary to an Act, entitled, ' An Act for the encouragement of learning, by securing the copies of maps, charts, and books, to the authors and proprietors of such copies, during the times therein mentioned,' and extending the benefits thereof to the arts of designing, engraving, and etching historical and other prints." D. CALDWELL, Clerk of the Eastern District of Pennsylvania. IYDIA R. BAILEY, PRINTER. TO THE PRESIDENT AND GOVERNORS OF THE DEVON AND EXETER HOSPITAL, WHICH HAS FURNISHED SOME OF THE MOST IMPORTANT OBSERVATIONS ■'•.-\ '- CONTAINED IN THE FOLLOWING PAGES, THIS WORK IS VERY RESPECTFULLY INSCRIBED, BY THEIR OBLIGED AND OBEDIENT HUMBLE SERVANT, THE AUTHOR Estimating, very highly, the ensuing work, as exhibiting correct views, in my opinion, of the pathology and treatment of Dropsy, I have caused a republication of it, with the hope, in doing so, that I render an acceptable service, more especially to such of my medical brethren in the United States, who on account of their remote situation, have no easy access to the sources of recent medical literature. N. Chapman, M. D. Professor of the Institutes and Practice of Physic and Clinical Practice in the University of Pennsylvania. January, 1820. TABLE OF CONTENTS. Pagr« INTRODUCTION. - .....9 CHAPTER I. Dropsies distinguished by the Urine, as it is coagulable by Heat, or not coagulable, and as it differs further in colour, sediment, $*c......17 CHAPTER II. Cases of Dropsy, in which the Urine, not coagulable by Heat, was pale, crude, and without sediment, some- times copious.—Remarks......19 CHAPTER III. Cases of Ascites and Hydrocephalus, in which the Urine was rather scanty, but in other respects appeared te differ little, or not at all, from the healthy state.— Dissection.—Remarks. ----- 26 CHAPTER IV. Of Dropsy, in which the Urine, not coagulable by Heat, is scanty and high-coloured, becomes extremely turbid on cooling, and deposits a copious sediment, more or less lateritious........SO Sect. I.—Cases with Dissections. - ib. Sect. II.—General Remarks on the Cases in the pre- ceding Section, and particularly on the Dropsy that attends the intermittent and Walcheren Fevers. - 44 Sect. HI.—On the Hydrothorax; its symptoms, causes, and cure by squill, mercury, $c» - * - * - 47 VI CONTENTS. CHAPTER V. Page Of Dropsies, in which the Urine is coagulable by Heat, including Cachexy, some Cases resembling Land- scurvy, Sfc. -_-_ . _ 54 CHAPTER VI. Of the Anasarca and general Dropsy, with coagulable Urine. ----___. 56 Sect. I—Cases of Anasarca, %c. after Scarlatina, with a Dissection.—Remarks. - - - -57 Sect. II—Cases of Anasarca, #c. after the use of Mer- cury, with Dissections, S^c. * - - -65 Sect. Ill—Cases of Anasarca, $c. after drinking Cold Water when heated and fatigued. 77 Sect. IV.—Cases of Anasarca, 8fc. from Cold, Intem- perance, Sfc. -----._ 79 CHAPTER VII. Of the Cachexy, with Cases and a Dissection. - - 88 CHAPTER VIII. Cases resembling Land-scurvy. 96 CHAPTER IX. Cases of Hydrothorax, with coagulable Urine, with a Dissection, Sfc. ------. jq2 CHAPTER X. Cases of Ascites, with coagulable Urine, with a Dissec- tion, $c. ........n2 CONTENTS. VII CHAPTER XI. Page Cases of Hydrocephalus, in which the Urine was coagu- lable, or contained a bloody sediment, with a Dissec- tion, <$fc. ---.....116 CHAPTER XII. Recapitulation........120 CHAPTER XIII. Observations on Dropsies with coagulable Urine, derived from the preceding Cases, <$*c. - 125 Sect. I.—General Appearances of the Urine. - - 124 Sect. II.—Symptoms of Anasarca and General Dropsy, including Cachexy, 8fc. - - - - -128 Sect. III.—Symptoms of the Hydrothorax, or Dropsy of the Thorax and Pericardium. - - - - 136 Sect. IV.—Symptoms of the Ascites, or Dropsy of the Belly, and of the Tympany. - 140 Sect V.—Of the Hydrocephalus Internus, or Dropsy of the Ventricles of the Brain. - 142 Sect. VI.—Of the Diabetes Serosus, or an excessive Discharge of Serous Urine. - - - - 143 CHAPTER XIV. The same subject continued. - Sect. I.—Of the remote Causes. - Sect. II.—Of the Appearances on Dissection. Sect. III.—Of the Proximate Cause. CHAPTER XV. The same subject continued. Of the Cure. - - - - -- IT I Sect. I.—Blood-letting.—Blisters. - - ib. Sect. II.—Purgatives; Elaterium, Gamboge, Jalap, 8{c. Tartrate and Supertartrate of Pot-ash, and tar- tarized Soda.—Antimonials. - - - - 174 - 148 - ib. - 154 - 158 Vlll CONTENTS. Page- Sect. III.—Diuretics; Squill; Oil of Turpentine ; Cantharides; Sulphate qj' Copper; Acetate of Pot- ash, &{c.; Tobacco; Digitalis ; Infusion of Broom- Tops, 8{C. ; Of Tincture of Opium—Tapping— Scarifications........179 Sect. IV.—Of Diet. - - - - - - 194 Sect. V.—Of Tonic Remedies, Peruvian Bark, Chaly- beates. Bitters........198 Sect. VI.—Of Mercury, and the Combination of it with Squills and Digitalis.—Conclusion. - - 199 Postscript. -------- 205 APPENDIX. On the Angina Pectoris, with Cases and Dissections, 8fC. 217 ADDITIONAL APPENDIX. No. I. From the Medical Recorder......247 No. II. From the unpublished Medical Writings of the late Caleb Hillier Parry, M. D., F. R. S., $c. $c. $c. - - 273 No. III. From the Clinical Report on Dropsies, by Dr. Venables, Physician to the Henley Dispensary, $c. 8$c. - - 297 INTRODUCTION. IT is my design in the following pages to treat of those accumulations of serous fluid, which take place in the cellular membrane, and circumscribed cavities of the body, and are denominated dropsies. Their great variety renders some arrangement of them necessary for this purpose; whilst the obscurity of their own nature, and their complication with other disorders, throw many obstacles in the way of such an attempt. There is one consideration, indeed, too obvious to be overlooked; namely, the seat of the accumulated fluid. Systematic writers have made great use of this distinction; and if a dropsy of the same cavity were al- ways the same disease, there would be no need for any other. But a very slight attention to the subject is sufficient to disprove this supposition, and to show, not only that local dropsies originate in different injuries of the affected parts, but that even those extensive effusions which inundate at once almost every cavity of the body, do not always arise from the same constitutional cause. Many of these are symptomatic of an unsoundness of the viscera, and, in not a few instances, seem to be connected with a mechanical obstruction to the circu- lating fluids. Others again are attributed with much probability to a watery state of the blood, and a feeble- ness of the exhalant and absorbent vessels; whilst prac- tical writers have noticed some cases oforiginal dropsy entirely at variance with this doctrine, and in which the blood has been found remarkablv inflamed, (2) 10 INTRODUCTION. The same conclusion may be derived from the ex- treme uncertainty and very inaccurate application of the remedies employed. Dr. Monro very candidly con- fesses this great defect. Dr. Cullen's words are still more remarkable. Speaking of diuretics, he says: "It happens un- luckily, that none of these are of very certain operation; neither is it well known, why they sometimes succeed, and why they so often fail; nor why one medicine should prove of service, when another does not." Such an inaccuracy in the direction of remedies can- not well be imputed to any thing but an obscurity in the disease: and that we confound, under the same title, different affections of the habit. The older physicians did not lose sight of this con- sideration ; and their writings abound with distinctions founded on proximate causes, but particularly on the supposed state of the circulating fluids. Hence the leucophlegmatia, the cachexy, the scurvy of some au- thors, &c. which denote edematous swellings differing from each other, and from the common anasarca. These terms have, indeed, on account of the fanciful theories connected with them, fallen into some neglect; but nothing satisfactory has been substituted in their stead; and it must be acknowledged that we still re- main greatly in need of some rational distinctions of this kind, derived from the constitutional circuinstances of the disease, as well as its situation. It has often occurred to me, that such an arrange- ment might be much facilitated, by a more accurate inquiry than has hitherto been made, into those remark- able properties of the urine, which characterize a large proportion of dropsies. Writers have spoken of the colour of that secretion, its quantity, its sediment; and it is a circumstance hardly credible that, amidst so much minute labour bestowed on these topics, the effect pro- duced on it by the application of heat should have been INTRODUCTION. 11 so greatly overlooked. Yet the experiment is the easi- est possible; and every practitioner may shortly con- vince himself, beyond the possibility of doubt, that in a considerable number of dropsical cases the urine coa- gulates, like diluted serum of the blood. So extraordinary a phenomenon cannot be investigat- ed with too much care; and the distinctions, which it seems capable of affording in nosology, are undoubtedly not to be neglected. But I wish, in the first place, to direct the attention of the reader to the fact itself, and to the notice which it has hitherto received. At St. Bartholomew's Hospital in 1795, there was admitted, under the care of my most respected precep- tor, Dr. Latham, a patient, whom he mentions in his work on Diabetes, as affected with a remarkable and copious discharge of serum from the kidneys.* In this person, at the time of his admission, I ob- served an emaciation of the whole body, with an oede- ma of the right leg only; a small and quick, but not frequent, pulse; an excessive feebleness and dejection of spirits; a sallowness of complexion; and a foul tongue. He complained, likewise, of a pain at the mar- gin of the ribs on the left side, great thirst, loss of ap- petite, and occasional vomiting; and his bowels were much obstructed. Two months before, he had been attacked by severe shiverings, and other febrile symptoms, with vomiting and constipation, and had hardly quitted his bed till the period of his admission. The vomiting in particular had been troublesome, and at first almost incessant, and he had sometimes thrown up in that way small quanti- ties of blood. * See Latham on Diabetes, p. 139. 12 INTRODUCTION. The urine was made in larger quantities than natural, and in the night more copiously than in the daytime. Altogether it rather exceeded the solid and fluid inges- ta, amounting to about seven pints in twenty-four hours. A parcel of it was subjected to evaporation, with some expectation of obtaining a saccharine extract. To my great surprise, when the heat rose to 160° of Fahrenheit, the fluid became uniformly opaque and white, and a considerable precipitate took place, which, when strained, but not much dried, amounted in weight to more than half an ounce, from two quarts of urine, or about one ounce from the quantity discharged daily. A similar effect was produced by nitrous acid. The filtrated liquor on evaporation gave a very small extract, which did not contain any saccharine matter. Dr. Latham, after exhibiting a few laxatives, which seemed to answer their purpose well, proceeded to the use of astringent medicines, and a blister to the loins, but without any good effect. This patient quitted the Hospital, after remaining there about three months; and six weeks afterwards he died. Facts of this nature have been but slightly alluded to by medical writers. Dr. Fordyce asserts in his Elements, that if the kid- neys be relaxed or stimulated, chyle, serum, coagula- ble lymph, and even the red part of the blood may be thrown out. This notice is so concise, that it is im- possible to say what species of cases he had in his mind in the description. Dr. Darwin, in the first volume of his Zoonomia, states, on the authority of Cotunnius, that there is a mucilaginous diabetes connected with the beginning of some dropsies. He adds, that it proves a temporary cure of the disorder. His words are as follows: INTRODUCTION. 13 " There is a third species of diabetes, in which the urine is mucilaginous, and appears ropy, in pouring it from one vessel into another; and will sometimes coa- gulate over the fire. This disease appears by intervals, and ceases again, and seems to be occasioned by a pre- vious dropsy in some part of the body. When such a collection is reabsorbed, it is not always returned into the circulation; but the same irritation that stimulates one lymphatic branch to reabsorb the deposited fluid, inverts the urinary branch, and pours it into the bladder. Hence this mucilaginous diabetes is a cure, or the consequence of a cure, of a worse disease, rather than a disease itself. " Dr. Cotunnius gave half an ounce of cream of tar- tar, every morning, to a patient who had the anasarca, and he voided a great quantity of urine, a part of which, put over the fire, coagulated, on the evaporation of half of it, so as to look like the white of an egg. De Ischiade JYervos. " This kind of diabetes frequently precedes a dropsy, and has this remarkable circumstance attending it; that it generally happens in the night, as, during the recum- bent state of the body, the fluid that was accumulated in the cellular membrane, or in the lungs, is more readi- ly absorbed, as it is less impeded by its gravity. " I have seen more than one instance of this disease. —Mr. D., a man in the decline of life, who had long accustomed himself to spirituous liquors, had swelled legs, and other symptoms of approaching anasarca: about once in a week or ten days, for several months, he was seized on going to bed with great general unea- siness, which his attendants resembled to an hysteric fit; and which terminated in a great discharge of viscid urine ; his legs became less swelled, and he continued in better health for some days afterwards. I had not the opportunity to try if his urine would coagulate over the fire, when part of it was evaporated, which I ima- 14 INTRODUCTION. gine would be the criterion of this kind of diabetes; as the mucilaginous fluid deposited in the cells and cysts of the body, which have no communication with the ex- ternal air, seems to acquire, by stagnation, this property of coagulation by heat, which the secreted mucus of the intestines and bladder do not appear to possess, as I have found by experiment; and if any one should sup- pose this coagulable urine was separated from the blood by the kidneys, he may recollect, that in the most in- flammatory diseases, in which the blood is most replete, or most ready to part with the coagulable lymph, none of this appears in the urine."* This great author would, without doubt, have modi- fied his opinion, had he made any experiments himself, and would have ascertained that the coagulation of which he speaks, takes place long before the boiling heat; that it is not a temporary relief, but a continued symptom of some dropsies, and not merely at their beginning, but through their whole course; and that the curative effort of nature is an urine not loaded with serum, but almost devoid of it. Vauquelin and Fourcroy, in two Memoirs on the Analysis of Human Urine, published in the Annales de Chimie,f have noticed the proportion of gelatinous mat- ter and albumen, which often abound in that fluid, as capable of furnishing considerable evidence of the state of the constitution. They inform us, that the urine, which is least gelati- nous, is most coloured, has a stronger smell, and more urinary matter, and is in consequence less susceptible of fermentation or putridity ; whilst that which is more gelatinous is likewise less coloured, "and more disposed to the formation of ammonia, more speedily deposits flakes both by evaporation and spontaneous decompo- * Darwin's Zoonomia, vol 1st. p. 316. t See Annales de Chimie, torn. 31 Sc 32. INTRODUCTION. 15 sition, and gives a cloud or precipitate. The former of these is a sign of good health, and the produce of com- plete digestion; the latter exists in weak subjects, and in cases where the digestive faculties are much injured. They add, there is reason to believe, that these two states will one day furnish us with facts of great utility in the healing art, and that a solution of tan will supply the means of distinguishing them. These remarks, valuable as they are, do not, however, apply to any particular disorder; and they refer more to the presence of an animal matter, detected by infusion of galls, than of albumen, as precipitated by less than the boiling heat. They come, however, from such high authorities, and are so nearly connected with my subject, that no apology can be necessary for inserting them in this place. Mr. Cruickshank, in his appendix toDr. Rollo's ex- cellent work on Diabetes, notices the serous urine more precisely than any other author has done.* He asserts, that it is a symptom of general dropsy, that sometimes this discharge differs but little from se- rum of the blood; and that he has known a patient car- ried off by it in a few weeks. Several writers on animal chemistry have since made the same distinction; but there is no author, as far as I am informed, who has discussed the subject in a prac- tical manner,t or applied these observations to the treat- ment of the disease. * See Appendix to Rollo on Diabetes, p. 447 and 448. t The very able papers of Dr. Wells on this subject form an exception to the above remark; but as they did not appear till the first edition of this work was in the press, they could be no- ticed in an appendix only. It was thought most advisable to reprint that appendix in its original form ; and to it I beg leave to refer the reader. CHAPTER I. DROPSIES DISTINGUISHED BY THE URINE, AS IT IS COAGULABLE BY HEAT, OR NOT COAGULABLE, AND AS IT DIFFERS FURTHER IN COLOUR, SEDIMENT, &C. IN the following remarks on dropsies, I intend to avail myself of the important distinctions suggested by Mr. Cruickshank. That ingenious author asserts, that, in the general dropsy, the urine coagulates like diluted serum of the blood ; whilst in that which proceeds from unsound vis- cera, it is usually high-coloured and scanty, deposits on cooling a pink-coloured sediment, and does not coagu- late either by heat or the nitrous acid. This doctrine must be received with those limitations, which almost every opinion in medicine requires. The former of these appearances is certainly often con- nected with visceral obstructions; the latter are some- times, I believe, independent of any such taint; and there are other states of that secretion, in which it is neither loaded with serum, nor scanty, high-coloured, and full of sediment, but occasionally, and in some particulars at least, runs towards the contrary extreme. These different conditions of the urinary discharge seem to indicate a corresponding difference in the con- stitutional affection, to which they belong; and I enter- tain hopes, that hereafter, and under a more accumu- lated experience, they may be found important guides in practice. I shall consider them not exactly in the order in which they have been here mentioned, but, for reasons which will soon appear more evident, treat—First, (3) 18 DROPSIES DISTINGUISHED BY THE URINE. Of those dropsies, in which the urine is not coagu- lable by heat. Secondly, of those in which it is so coagulable, in a greater or less degree. In looking at the former of these, our attention is na- turally directed to the other appearances of that secre- tion. It is in some cases pale, crude, without sediment, even copious; in some rather scanty, but otherwise differing little from the healthy state ; in many it is both high-coloured and scanty, grows extremely turbid on cooling, and deposits a copious sediment, more or less lateritious. These differences of colour and sediment, varying as they do with diet, exercise, and the peculiarities of the individual, may be thought, perhaps, very imperfect, as the distinguishing characteristics of diseases; I do not adduce them as such, but rather as a foundation for some practical remarks. Where diuretics are wanted, and a selection must be made, it seems but reasonable to look attentively to the actual state of the secretion. In dropsies it is rarely not concerned, and speaks forci- bly of the internal state. Van Helmont, in his chapter, entitled Ignotus Hydrops, has even pronounced the seat of this disorder to be the kindneys themselves. I have therefore thought it right, in the present inquiry, not to nesrlect even these minute circumstances of the o urinary discharge, although I acknowledge them to be of a value infinitely less than the result furnished by the application of heat; and my observations on them will be in some measure but a necessary introduction to this part of the subject. For these purposes, I must request the attention of the reader to some cases related in detail, which I have thought to be the only proper mode of presenting to him facts hitherto so little noticed. He will thus be enabled to judge for himself. ( 19 ) CHAPTER II. CASES OF DROPSY, IN WHICH THE URINE, NOT CO- AGULABLE BY HEAT, WAS PALE, CRUDE, AND WITH- OUT SEDIMENT, SOMETIMES COPIOUJH—REMARKS. CASE I. M. T., setat. 12, was just recovering from scarlatina, in which the inflammation of the skin had been severe, and the bowels unusually relaxed. She had quitted her bed a few days only, and on the evening preceding my visit, the ankles and knees had begun to swell. There was a considerable degree of languor and loss of appetite, a quick and weak pulse, pain of the left side, a loose state of the bowels, and swelling of most of the joints, particularly the left knee, in the large bursa mucosa, above which there was a very evident fluctua- tion. The urine was rather scanty, pale, and without se- diment ; it was coagulable neither by heat nor nitrous acid, and in the slightest degree by the oxymuriate of mercury. Some precipitate was produced by the infu- sion of galls, and a copious flaky one by the acetate of lead. True dropsical symptoms succeeded rapidly. In less than a fortnight she became universally anasarcous, and there was a fluctuation of water in the abdomen, with orthopncea and frightful dreams. At length she spent several successive nights in her chair, unable to lie down. It was impossible to entertain any doubt of the pre- sence of hydrothorax. During the whole of this time the urine, examined daily, gave no appearance of coa- 20 DROPSY WITH URINL gulum. When she was most oppressed, it was remark- ably diluted, and quite colourless. The tincture of digitalis, continued to such an ex- tent as to retard the pulse and occasion much pain across the forehead, afforded not the least relief. On the con- trary, the symptoms seemed to be aggravated under its use. The bowels at length becoming very costive, she took some smart purges of jalap and scammony. All the bad syfciptoms were speedily removed by this plan, and she wholly recovered under the use of Peru- vian bark. CASE II. Sarah Somerton, aetat. 45, Devon and Exeter Hos- pital, 1798.—Considerable anasarca, with a very feeble pulse, and loss of appetite; urine pale, rather scanty, not coagulable by heat or nitrous acid, and depositing no sediment, but a slight cloud. Six weeks before, she had been attacked by fever and a scarlet eruption, to which her dropsical symptoms had succeeded in a few days. She derived immediate advantage from the bitter infusion and alkaline salt, as recommended by Sir John Pringle, and soon recovered. CASE III. M. S., aetat. 50.—Anasarca, ascites, cough, urine pale, rather copious, without sediment, and not at all coagulable by heat or nitrous acid. These complaints had continued for some months, and she attributed them to cold. She was benefited neither by squills, nor calomel, nor digitalis. I understood that she afterwards became jaundiced; but I am not informed of the event. NOT COAGULABLE.—CASES. 21 CASE IV. J. T., aetat. 40, of a sallow countenance, laboured under cough, dyspnoea, pain in the region of the sto- mach, loss of appetite, and swellings of the legs. He had been much exposed to changes of weather during the preceding winter, and lately had suffered from fever and several bleedings at the nose. The sallowness of his complexion induced me to or- der a few doses of calomel, which purged and debilitat- ed him. His urine before and after this was uniformly pale, rather scanty, and without sediment. No coagu- lum was produced by heat or nitrous acid, and very little by the corrosive sublimate. The infusion of galls had some effect; and an unusually large precipitate took place on the addition of Goulard's Extract, After some time he had a nightly orthopncea, which made me suspect hydrothorax. His abdomen likewise enlarged. ** Squills rendered him not the least service. Digitalis greatly debilitated him, and increased his symptoms; and once, soon after the use of this drug, his urine gave a slight and loose coagulum when it reached the boiling heat. Purging with elaterium and jalap seemed to re- lieve his breathing most. The legs discharged freely, and all the dropsical symptoms were thus removed, ex- cept the ascites, which continues, very little affected by any remedies. He is, however, regaining his strength and colour. CASE V. • J. W., aetat. 70, of what is usually called a scorbutic habit, and rather asthmatical, was subject for two or three winters before his death to swelled legs, and a cough; he was unable to lie down in bed, and waked up in distressing suffocations. During the summer 22 DROPSY WITH URINE these symptoms were much alleviated; but in the winter 1805, the chest again became affected; and there was very considerable anasarca of the lower extremities. At that time I found his pulse eighty, quick, regular; appetite good, alvine discharges natural, urine of a light colour, clear, without sediment, not at all coagulating by heat or nitrous acid, furnishing an unusually large precipitate on the addition of acetate of lead, and in quantity exceeding the healthy standard. He often made between one and two quarts in the night. The tincture of squills was tried in this instance, with- out any good effect. The powder of digitalis was then given, by the advice of another practitioner. He took but two doses, of one grain each. His pulse immedi- ately became irregular, which it had never been before, and his stomach very languid. About a week after, he died suddenly. CASE VI. J. N., aetat. 60, subject when young to psoroph- thalmia and scaly eruptions of the skin, and since that period to irregular attacks of gout, was likewise ex- tremely fanciful and hypochondriacal, and had the mis- fortune of having all his complaints attributed to this last cause. Many of them appeared to me, however, to be much more deeply seated. These were, a pulse stronger in the right arm than in the left; dyspnoea and palpitations on motion; a tendency to deliquia on slight occasions; orthopnoea after the first sleep, with great agitation of mind and sense of suffocation returning se- veral tir^ps through the night, and attended with such a faintness as induced his friends to be constantly urging him to the use of cordials; a permanent uneasiness in the region of the heart, which was increased by lying on the right side; and a short cough, with some irrita- tion about the larynx, which did not, however, prevent him from taking a full inspiration. To these were add- NOT COAGULABLE.—CASES. 23 ed, severe complaints of the stomach, acidity, heart- burn, oppression after food, irregular appetite, and an inclination for pastry and fruit, over which he had no kind of command. A bilious diarrhoea was frequently the consequence of such imprudence. There was a very considerable degree of anasarca. His urine was pale and copious, and often deposited red gravel immediately on being discharged. It did not in the least coagulate by heat or nitrous acid, nor did it furnish any saccharine extract. But it was once observed that, on keeping long, it gave out, instead of the putrid foetor, rather a mouldy and acetous smell; which Vauquelin and Fourcroy assert to be as common a form of decomposition in urine as the putrescent. It was obvious that the akaline diuretics were the only ones likely to be of service. But these he never could be brought to use to any extent, not even die soda water. He consulted many physicians, and took squills, digi- talis, mercury, without advantage; afterwards he gra- dually became more suffocated and dropsical, and died in that state; having been attacked, in consequence of indigestion, several weeks before his death, by a verti- go and fulness of the head, which terminated in a per- manent weakness of the right arm. CASE VII. A. W., aetat. 58, had been subject for more than two years to frequent returns of pain in the right side, at- tended by cough and dyspnoea. These symptoms had latterly become fixed, with considerable anasarca, and a copious pale urine, not coagulable. She derived not the least benefit from fox-glove, calomel, squills, or strong purges, and soon died. 24 DROPSY WITH URINE The urine above described as pale, crude, and appa- rently diluted, is not very common in dropsical com- plaints. No coagulation is produced by heat or nitrous acid. In two instances, however, where I made the experi- ment, the addition of the oxymuriate of mercury detect- ed the preserice of a small quantity of albumen. In the same instances the infusion of galls caused a very partial coagulation, less, certainly, than is observ- ed in many other dropsies; but what proportion it bears in extent to a similar effect in other disorders, and in some circumstances of apparent health, I am unable to say. It is a subject entitled to further inquiry. The copious flaky precipitate, thrown down by the acetate of lead, consists of saline matter, and, probably in no small degree, of animal mucilage, of which it is a delicate test. This state seems to be often connected with great and irretrievable injury of the internal organs; but by- no means uniformly so: on the contrary, the first ex- ample of it here related is likewise one of the least complicated cases in the whole volume; and apparent- ly originated in that mere feebleness, both of the sur- faces concerned and of the constitution, to which all dropsies have been referred by some authors. I request the particular attention of the reader to it. The changes of the urine were carefully observed, because, at the time of its occurrence, I supposed that the watery accu- mulations following scarlatina were always accompanied by a serous state of that discharge. It will be of im- portance to bear in mind this evidence to the contrary; although I am by no means prepared to say, in what proportion similar examples occur. The inefficacy of digitalis, in the same instance, is well worthy of notice, but will be discussed with great- er propriety in a more advanced stage of the inquiry. It has not succeeded better in the other cases; of course its use cannot be indifferent. Diuretics, indeed. NOT COAGULABLE.—REMARKS. 25 generally speaking, promise more in a scanty and load- ed urine, than in the diluted state of it here mentioned. The carbonate of potash, joined with a mild bitter, is the most likely to be successful. Where the viscera are untainted, much is to be hop- ed for from brisk and stimulating purges, such as scam- mony and jalap, &c, but from which calomel is ex- cluded, and a very speedy use of the most active tonics immediately after the evacuation of the water, or even before, and mixed with the evacuants. The well-known electuary of Dovar is a formula of this kind, and probably owes its character in a great measure to the addition of the chalybeate. A general laxity and sallowness of complexion particularly call for this remedy. It appears, also, than an habitually large quantity of pale urine, not relieving the disorder, but forming a part of it, is a very bad sign, since it precludes the use of many diuretics, is more especially hostile to digitalis, and indicates a completely broken state of health. Some authors have alluded to it under the name of diabetes insipidus. The most probable correctives of this symptom are the alkalis and magnesia, (for the urine has a great tend- ency to acescency in such a state); and at the same time the weakness of the whole habit requires a free use of fermented liquors, and a liberal diet. The leucophlegmatia, connected with chlorosis, be- longs more to this place than to any other. The urine is pale, and gives no coagulum; but it contains some- times a white sediment. There is no pretence for saying, that any viscus is in these instances unsound in its organization; and they therefore form another example of oedematous swell- ings of the asthenic kind, in which the urinary discharge is not serous. And if the general health be improved by chalybeates, the oedema spontaneously disappears. (4) ( 26 ) CHAPTER III. CASES OF ASCITES AND HYDROCEPHALUS, IN WHICH THE URINE WAS RATHER SCANTY, BUT IN OTHER RESPECTS APPEARED TO DIFFER LITTLE, OR NOT AT ALL, FROM THE HEALTHY STATE.--DISSEC- TION.—REMARKS. Those accumulations which take place in the small- er and less vital cavities, as, for example, the hydrocele, do not probably for a long period affect the urine; but sometimes even when the parts concerned are more ex- tensive or essential to life, still that secretion does not appear to be materially changed, except, perhaps, in quantity. Of this the following cases of ascites and hydrocephalus are a sufficient proof:— CASE I. Mary Ellet, aetat. 20, Devon and Exeter Hospital, 1798.—Ascites; anasarca of the lower extremities, up- per part of the body much emaciated; pulse soft and feeble; loss of appetite; menstruation obstructed; but, at the expected periods, a slight leucorrhaeal discharge. The urine was rather scanty, clear, of a natural co- lour, deposited a slight branny sediment, and did not at all coagulate either by heat or nitrous acid. About six months before, a spontaneous diarrhoea had come on, attended by irregular wandering pains of the abdomen, and had been speedily followed by as- cites. The anasarca made its appearance very soon after; and during the whole of this period she had been obstructed. DROPSY WITH URINE, &C. 27 Laxatives, as indeed might reasonably have been foreseen, occasioned great disturbance of the system with no relief. She benefited more by the tincture of squills, till an over-dose produced vomiting and diarrhoea, and she could never bear a repetition of that medicine. The bitter infusion with akaline salt was then directed for her with great advantage; and under the use of 00611113' Chalybeate Mixture she entirely recovered. CASE II. Mary Gibbons, aetat. 40, was admitted into the hos- pital, 1799, on account of a confirmed syphilis, and whilst under an active mercurial course, principally by friction, was seized with a violent diarrhoea attended by discharges of blood, to which succeeded an ascites and anasarca of the lower extremities with great weakness and loss of appetite. The urine gave no coagulum by heat or nitrous acid. It was of a natural colour, rather scanty, and de- posited an inconsiderable branny sediment. By the use of the Peruvian bark with diuretic salt, it flowed in great quantity; the swellings were carried off, and she was enabled to return to her mercurial course with advantage. CASE III. N. G., astat. 2, a poor scrophulous infant, was trou- bled with a purulent discharge from the meatus au- ditorius externus, to relieve which her mother gave her two grains of calomel for many successive nights; being the remainder of some powders that had been of service to another child. They purged her greatly, and at length affected her gums. The breath was observed to be very foetid, and she slavered much, although no 28 DROPSY WITH URINE- longer about her teeth. In a few days she became heavy, unwilling to sit up, and vomited at intervals. About a week after I visited her, and finding the pulse slow and intermittent, great pain in the head, a fixed pupil, convulsions, strabismus, and a general feebleness that forbad evacuations, I could entertain little or no hope. Her urine, with difficulty preserved, was of a natural colour, clear, and deposited a slight branny sediment. It did not in the least coagulate by the application of heat or nitrous acid. Its quantity was considered to be rather diminished. She died two days after. The pa- rents consented to the examination of the head. We found the dura mater adhering rather firmly to the cranium, the veins of the pia mater unusually tur- gid, and that membrane itself rather inflamed; the la- teral ventricles of the brain distended with a clear fluid to the amount of more than three ounces, which be- came slightly clouded on the application of heat; the neighbouring parts very soft, and covered with red points; and some water in the other ventricles, as well as in the basis of the skull. The purulent discharge be- fore mentioned arose from the meatus externus only, and no injury extended to the internal parts of the or- gan of hearing, or to the bones connected with it. These two cases of ascites followed a diarrhoea; and the accumulations in the abdomen were probably the immediate effect of that loss of tone in its membranes which such a discharge seems calculated to produce. It is observable, likewise, that the anasarca was of the lower extremities only. The principal indication here was of course to im- prove the strength; and any attempts to carry off the NOT COAGULABLE.—REMARKS. 29 accumulations would have been advisable, only as they coincided with this. The second of these cases, as well as that of hydro- cephalus, are examples of the bad effects of mercury; and, I believe, the event and appearances recorded in the latter are a much more common result of large doses of calomel, in infantile complaints and scrophu- lous habits, than is generally suspected. The extreme youth of the patients, and the discharge being often involuntary, make it difficult to ascertain the qualities of the urine in hydrocephalus. On these accounts, I am uncertain whether even its quantity is usually much lessened. Mercurial purges are known to relieve the early symptoms of that disease, originating probably in foul- ness of the bowels; but in the present instance such a plan would obviously have been misapplied. Is it possible to think that any other would have succeeded? The debility so often produced in children by the rash and indiscriminate employment of purges and mer- curials, and which in them is so apt to fall upon the brain, renders this question not an unimportant one. ,30 DROPSY WITH URINE CHAPTER IV. OF DROPSY, IN WHICH THE URINE, NOT COAGULA- BLE BY HEAT, IS SCANTY AND HIGH-COLOURED, BECOMES EXTREMELY TURBID ON COOLING, AND DEPOSITS A COPIOUS SEDIMENT, MORE OR LESS LATERITIOUS. The dropsy, considered to be indicative of diseased viscera, is characterized by an urine scanty and high- coloured, loaded with a red sediment, and depositing nothing on the application of heat. It includes a great variety of instances of ascites, hydrothorax, and hydrops pericardii, united with ana- sarca, some examples of which are here subjoined. SECTION I. Cases with Dissections, CASE I. A. S., aetat. 40, ascites, very slight anasarca, jaun- dice, pain of the right side, cough, frequent return of bilious vomiting and diarrhoea; urine scanty, high-co- loured, containing a red sediment, not at all coagulating on the application even of boiling heat. She had been attacked with inflammatory symptoms some weeks before, to which the dropsy had gradually succeeded. Calomel and opium at night, with tincture of squill two or three times daily, soon relieved her complaints. Even after this relief, however, chalybeates could not NOT COAGULABLE.—CASES. 31 be borne; but she derived advantage from the bitter alkaline infusion. CASE II. M. C, aetat. 15, ascites, anasarca, pain of the right side, fasces scarcely tinged with bile, urine hig;h-colour- ed, scanty, foul, depositing a branny and lateritious sedi- ment, not at all coagulable by heat. I found that jalap and crystals of tartar rendered no service; but some mercurial ointment rubbed on the abdomen, and the vinegar of squill in proper doses, ra- pidly carried off the swellings. She then took a chalybeate electuary and was entirely cured. CASE III. H. B., a woman of very intemperate habits, lay op- pressed with an ascites, swellings of the legs, and some sense of suffocation. The urine was very dark-coloured, foul, lateritious, and not at all coagulable by heat. What placed her in more immediate danger, was a vio- lent bilious vomiting, with constipation. Calomel removed this obstruction, the swellings re- mained, but were soon after carried off by the use of tincture of squill, and she completely recovered. CASE IV. R. B., aetat. 60, very robust and bulky, who had never entirely recovered from the effects of the influenza 1803, began about two years since more decidedly to emaciate and lose strength; and when he consulted me again about ten months ago, he was labouring under the most extensive ascites 1 ever witnessed; and his bo- dy was reduced to a mere skeleton. He informed me that he had lost more than lOOlbs. weight in six months. 32 DROPSY WITH URINE He was completely jaundiced; his urine very turbid, loaded with the pink-coloured sediment and with bile, but not at all altered by heat; his bowels irritable; and he suffered much from pain in the right side. There could be no doubt that his complaint originat- ed in a scirrhus of the liver; and as little expectation that any benefit could be derived from medicine. How- ever, the bringing on a slight salivation, which we found very difficult, certainly lessened the abdomen several inches ; but that process debilitated him, and he could not persist in it. He was afterwards tapped several times, and died quite exhausted. CASE V. W. R., aetat. 40, returned from Holland, 1799, la- bouring under a quotidian ague. This was afterwards stopped by Peruvian bark; but dropsical swellings of the legs still remained, with ascites, pain and stitches at the margin of the ribs on the left side, frequent cough, shortness of breathing, urine very scanty, foul, high-co- loured, and loaded with a branny and lateritious sedi- ment. On being exposed to heat it gave no coagulum. Some blue ointment rubbed on the abdomen, one grain of calomel every night, and suitable doses of vine- gar of squill, completely carried off these symptoms, after slightly affecting the gums. CASE VI. An officer in the army, who had served at the battle of Vimeira, returned to this country not long after, suf- fering from a tertian ague and considerable anasarca, with fulness in the region of the spleen. The urine was scanty, high-coloured, and contained much lateritious sediment. It gave no coagulum on the application of heat. NOT COAGULABLE.—CASES. 33 The ague, which had been in vain treated with bark, disappeared when the gums were made sore by mer- curial friction; and the swellings were soon removed by the use of the bitter alkaline infusion. CASE VII. J. R., returned from Walcheren with an irregular ague, to stop which vain attempts had been made by large doses of cinchona, as well as the mineral solution. He had a cough, pain of the left side, enlargement of the spleen felt externally, lower extremities very cede- matous, urine high-coloured, depositing much lateritious sediment, not coagulating by heat. Calomel and mercurial ointment, continued till his gums were sore, greatly debilitated him, without sus- pending the paroxysm ; and I found with regret that the urine under their use began to coagulate by heat. Of the further progress of this case I am not inform- ed, as he was removed to quarters at some distance; but I understand that he at length recovered. CASE VIII. In the effects of mercury on the system, this case is analogous to the preceding. R. S., aetat. 50, sallow, emaciated, affected with pain of the right side, soreness and fulness of the epigastric region, cough, sanious sputa, swelled legs; urine high- coloured, very turbid, lateritious, and not giving the least coagulum. Both digitalis and squills were tried without much good effect. By mild mercurials he seemed at first benefited; but after the continued use of this mineral, and a soreness of the gums partly produced by friction, he immediately became bloated, and affected with mark- ed signs of internal as well as diffused dropsy. The (5) 34 DROPSY WITH URINE urine now again examined gave a coagulum under the boiling heat; and I cannot help fearing that mercury had some share in thus changing the type of the disease. CASE IX. Anne Molony, Devon and Exeter Hospital, 1797, aetat. 40 ; anasarca, ascites, joined with much distention of the abdomen from flatulency; pain at the margin of the ribs on the right side; tongue rather foul; bowels costive; pulse regular; urine scanty, foul, containing a copious branny sediment, with some lateritious, not coagulable by heat. She was likewise much troubled with varicose veins of the legs, from which a peculiar kind of uneasiness and vapour were often propagated as high as the sto- mach. She had suffered from dropsical symptoms for nearly twelve months; and the ascites had been much more considerable than it was at the time of her admission. The tincture of squill in the dose of fifty drops, with one grain of calomel every night, gave relief very speed- ily ; she likewise derived great benefit from bandages on the legs, and was soon discharged from the hospital cured. CASE X. A. D., aetat. 48, who, like the subject of the preced- ing case, was much distressed by varicose veins, and a peculiar uneasiness propagated from them to the sto- mach, was attacked in the winter of 1798 with increased tumour and erysipelas of the legs, anasarca, cough, shortness of breathing, inability of lying on the left side, which Avas likewise painful, urine scanty, foul, deposit- ing a branny and some lateritious sediment, not coagu- lable. NOT COAGULABLE.—CASES. 33 These symptoms had continued for two months be- fore I was consulted. She was entirely relieved by the same plan as had been successful in the preceding in- stance, with the addition of a blister to the side. CASE XI. G. R., aetat. 40, formerly a very stout and healthy man, had been affected, eight months before I was call- ed to him, with obscure symptoms, of which an over- flow of bile and pain of the right side were considered the most predominant. To these gradually succeeded emaciation, anasarca, irregular and intermittent pulse, palpitations, cough, copious expectoration of frothy bloody sputa, great dyspnoea, such complete orthopnoea as obliged him to pass whole nights in his chair, dread- ful suffocations and deliquia after his first sleep, con- siderable difficulty of deglutition, a croopy sound in breathing, much aggravated by the least exertion, a very anxious countenance and great agitation of mind, at length spasms of the muscles of the face, and a near approach to the risus sardonicus. I need not add, that death soon followed. Through the whole of his disorder there was a cos- tive body, and a sense of fulness at the pit of the stomach, partially relieved by strong purging. His urine was very scanty, and contained a branny and pink-coloured sediment, but did not in the least coagulate by heat. The dissection, which we were permitted to make, showed how much the causes of this malady were be- yond the reach of any human skill, or even of reason- able conjecture. On opening the body we found considerable adhe- sions of the lungs to the pleura on the right side, some of them elongated, others firm and close; no water on cither side of the chest; in the cavity of the pericardi- 36 DROPSY WITH URINE um about two ounces of fluid, coagulating on the appli- cation of heat almost as strongly as the serum of the blood; that portion of the membrane which was reflect- ed over the heart, dull, thickened, and marked with several spots of lymph. The lungs were apparently sound when examined externally, but on removing them we discovered be- hind the trachea, at its birfurcation, a scirrhous mass of the size of a large man's fist. It extended from that spot a considerable way into the substance of the right lung, principally surrounding the bronchial tube. In two or three parts of it were more defined round soft masses, resembling lymphatic glands beginning to suppurate. The lower part of the trachea, but particularly the right branch was inflamed and covered internally with a thin red lymph. But there was no appearance of any ulceration of the inner membrane. The larynx and upper part of the trachea natural. In the abdomen we found a few adhesions of the liver to the diaphragm on the right side; and on the surface of that gland two or three small thickened spots, hardly amounting to a diseased structure; every other part natural. CASE XII. H. L., aetat. 60, ascites; anasarca; cough with frothy crude expectoration, and pain of the left side; some difficulty of lying down in bed; pulse nearly natural; urine high-coloured, scanty, very foul, with a lateritious sediment, and not coagulable by heat. These symp- toms had been forming for six months. The tincture of squill carried off all appearance of dropsy; but some cough and pain of the side still re- mained. NOT COAGULABLE.—CASES. 37 CASE XIII. S. B., eetat. 60, pain of the left side, reaching from the axilla to the hip; cough, with expectoration of a ropy mucus; some orthopnoea; difficulty of lying on the right side; palpitations; disturbed sleep; hurried dreams; purple lips; loaded and distressed counte- nance ; pulse 80, regular; urine very scanty, depositing a branny and lateritious sediment, not coagulable. Notwithstanding the absence of anasarca, there seems to be no reason to doubt that this was a case of hydro- thorax. A blister was applied, and the vinegar of squill giv- , en every eight hours. The urine shortly became clear; and all her com- plaints on the chest disappeared. CASE XIV. J. Penny, aetat. 62, Devon and Exeter Hospital, 1800. Great and universal anasarca; dyspnoea; cough; orthopnoea; suffocations after the first sleep; pain of the left side, and difficulty of lying on it; urine scanty, high-coloured, foul, with a lateritious sediment, but not coagulable. A blister, and four grains of the powder of squill, repeated at the interval of six hours, completely remov- ed his symptoms, and he was discharged cured. CASE XV. L. Q., aetat. 60, greatly debilitated in her nerves, and of a sallow complexion, after having suffered from se- veral attacks that were called bastard peripneumony, fell into a state of chronic cough and dyspnoea, great difficulty of walking up stairs, and fits of orthopnoea, 38 DROPSY WITH URINE with a tendency to deliquium about three o'clock in the morning. There was no oedema of any part of the body; pulse 90, regular; urine not high-coloured, but scanty, de- positing a white sediment, with some lateritious, and not coagulating by heat. Twenty-five drops of the vinegar of squill, three times daily, rendered service, but very imperfectly, till one grain of calomel was added every night. The urine then flowed, and the dyspnoea entirely disappeared. She has since been obliged occasionally to have re- course to the same medicines, and has certainly gained much ground. More than two years have now elapsed since I first prescribed for her. CASE XVI. E. N., aetat. 48, when she consulted me, laboured under the following symptoms: a weak and intermit- tent pulse; palpitations; face bloated and purple, with much anxiety of countenance, dyspnoea, orthopnoea, hurried dreams; legs very oedematous and painful; urine scanty, foul, loaded with a pink-coloured sedi- ment, not coagulating. These symptoms could not be mistaken; they were carried off very rapidly by tincture of squills, with the addition of one grain of calomel at night. She quitted my neighbourhood soon, and died about twelve months afterwards. CASE XVII. J. L., who had been thought in the spring of 1807 to labour under an inflammation both of the lungs and liver, and had been properly treated in consequence on a strictly antiphlogistic plan, had remaining about him, during the summer, some cough, dyspnoea, and stric- NOT COAGULABLE.—CASES. 39 ture on the chest. In the autumn a swelling of the legs came on, and such severe symptoms, as could leave no doubt of the existence of hydrothorax ; great dyspnoea, a total inability of lying down in bed, and after his first sleep even in his chair, the most horrible spasms, pulse 100, weak, but regular, urine scanty, high-coloured, foul, loaded with a pink-coloured sediment, not coa- gulating by heat. He had tried digitalis with bad effect. I ventured in this urgent state to encourage the hope of relief by the tincture of squill, accompanied by a mild mercurial course. He bore the increase of the dose to sixty drops; and then, at the moment at which his gums be- came sore, a copious diuresis took place. He was soon able to lie horizontally in bed, and to walk up and down stairs. Between a fortnight and three weeks after the discon- tinuance of medicine, he complained one night of some little dyspnoea, and the next day, whilst walking across the room, dropt down and expired instantly. CASE XVIII. J. E., of a remarkably stout and robust chest and very active, aetat. 55, was affected when I was called to him in January 1803, with the following symptoms: an irre- gular and intermittent pulse, a fluttering at the pit of the stomach, a harsh cough and mucous expectoration, great dyspnoea on motion, orthopnoea increasing after the first sleep to an agony, both of body and mind, which I ne- ver saw equalled in any other instance, extremities great- ly swelled, purple and loaded countenance, the urine scanty, high-coloured, depositing a branny and pink- coloured sediment, not coagulable by heat. .• About nine months before, he had been attacked by the influenza at that time epidemic, and then had suf- fered severely from pain of the right side and cough. 40 DROPSY WITH URINE Through the summer, this last symptom had continu- ed with dyspnoea, and a little tendency to dropsy, all which increased in the beginning of the winter, previ- ously to my being consulted. The tincture of squill, in the dose of thirty-five drops, repeated every eight hours, acted so speedily, that in a few days his urine became pale, limpid, and copious. The oedema was carried off, and the breathing quite re- lieved. The pulse likewise became more regular. Through the ensuing summer he went on well; but the next winter his symptoms several times returned, and were as often checked by the same remedy. When they were once more obstinate than usual, a little calomel was added, and the salivary glands and the kidneys became affected at the same time. The digitalis was tried without any good effect. At length after a period of more than two years, whilst apparently free from any dropsical symptoms, he died suddenly. He had spent the early part of his life in the East In- dies, where hehad suffered much from the complaints peculiar to that climate. Since his return to England, however, he had become very strong, and capable of great exertions in field sports. It is, therefore, less material to add, that more than twenty years before, he had received a wound by a musket shot in the thorax, near the left shoulder. He immediately expectorated large quantities of blood, became emphysematous, and for many months was thought consumptive. After a lapse of several years the ball showed itself under the skin of the loins, and there continued during life. CASE XIX. L. G., aetat. 70, of a gouty habit, had laboured for several months under the following obscure symptoms; a sense of bloating and fluttering at the pit of the sto- NOT COAGULABLE.—CASES. 41 mach, with costive bowels, dyspnoea and faintness on motion, particularly on going up stairs, yet rather lessen- ed than aggravated after dinner, not the least degree of or- thopnoea or nightly suffocation, pulse from 120 to 130 in the minute, irregular and intermittent, which state of the circulation had continued ever since he had been attacked by the influenza three years before. There was very slight oedema of the legs. The urine was likewise worthy of notice, which, al- though not considered to be scanty, was made frequent- ly, in small quantities at a time, and was very turbid and excessively overloaded with a lateritious sediment. It did not coagulate on the application of heat. All these circumstances, notwithstanding the quanti- ty of the urine, convinced me that an internal dropsy existed. The effect of the remedy prescribed was a still more convincing proof of this; for, in consequence of the exhibition of squills, much pale urine was void- ed, and immediate relief obtained. The same advantage was several times afterwards derived from it, the moment the water became much loaded. Two winters since, in addition to his other complaints, he had loss of appetite, nausea aggravated by the medi- cine, bilious tinge of the skin and eyes, and a feeling very distressing to himself of fluctuation of water at the lower part of the sternum. Small doses of digitalis somewhat relieved him ; but he relapsed, and soon after bore squills, united with opium, and was greatly bene- fited. The horizontal posture preferred by this patient, and the sense of fluctuation perceived by himself, always convinced me that he laboured under a hydrops peri- cardii. The complaints on his chest have now for more than two years entirely left him, having been succeeded by gout in the extremities, and a severe fit of the gravel. (6) 12 DROPSY WITH URINE CASE XX. R. L., astat. 60, sallow, but not jaundiced, had suf- fered for many months from gradually increasing drop- sical symptoms, with a cough, ropy expectoration, great dyspnoea, some orthopnoea, and suffocations after the first sleep, pulse regular, the alvine discharges often nearly devoid of bile, urine scanty, foul, with a lateri- tious sediment, not coagulating by heat. He had tried in London a variety of remedies under very able prac- titioners, without the least good effect, particularly digi- talis and strong purges. I directed for him the vinegar of squills; and he had not taken it above a fortnight, before he was completely relieved both from his anasarca and the affection of his breath. His own irregular habits, and cold several times, brought him into the same state again, and he was as often restored by the same means. A little calomel likewise rendered him service; but he could not be per- suaded to go through a course of it. Tonics, either bark or steel, had a tendency in every stage of his complaint to aggravate the symptoms. After three years he died with jaundice and decided marks of a diseased liver. CASE XXI. Elizabeth Drawer, aetat. 60, Devon and Exeter Hos- pital, March 1810. Universal anasarca; legs affected with a considerable erysipelas and deep sloughing sores ; ulcers on the sacrum and hips; pulse 110, weak, irre- gular, intermittent; dyspnoea; nightly suffocations; loose bowels; urine brown, scanty, foul, containing a branny sediment, with some lateritious. It did not in the least coagulate by heat. NOT COAGULABLE.—-CASES. 43 These symptoms had been forming two months, and she attributed them to cold. The tincture of squill in- creased the quantity of urine, rendering it likewise pale and perfectly without sediment. The legs were con- sequently somewhat reduced, and the breath very ma- terially relieved; but the ulcerations, aggravated by her unwieldly habit, spread to a great extent, and soon put a period to her life. On examining the body the next day, we found a small quantity of turbid fluid in the abdomen; the liver much harder and somewhat smaller than natural, and the lower edge slightly curled and bent forwards. Its substance, when divided, exhibited no very peculiar structure, but an unusual degree of firmness and so- lidity. This Dr. Baillie considers the first step to- wards the tuberculated liver, more commonly called scirrhous; the other viscera of the abdomen sound. In the thorax the lungs were sound, but adhering in several places to the pleura; about a pint and a half of pale fluid in each of its cavities, and somewhat more than the natural quantity in the pericardium. The fluid taken from the cellular membrane by in- cision was a very diluted serum, hardly changing co- lour on being raised to boiling heat, and on evapora- tion throwing off a few films. The thoracic and peri- cardial fluids were less diluted, becoming opaque at about 160°. The changes discovered on dissection, in this in- stance, are certainly neither far advanced nor unusual; but they are, perhaps, on those very accounts the more instructive, and point out to us in what an early stage of a scirrhus of the liver, hydrothorax, as well as ana- sarca, may take place. 4* DROPSY WITH URINE SECTION II. General Remarks on the preceding Cases, and par- ticularly on the Dropsy that attends the intermit- tent and Walcheren Eevei^s. From the preceding statement it is evident, that in a considerable proportion of dropsies, the urine, although apparently loaded with animal matter, does not contain albumen in such a form as to be detected by the test of heat. It will be found, even before much anasarca occurs, scanty, very high-coloured, made frequently and in small quantities. It grows extremely turbid on cooling, and deposits a copious sediment which is late- ritious and branny in various proportions, the former usually predominating and largely crystallized. A sediment of this sort terminates the paroxysms of in- termittents and of gout, but is here rather symptomatic than critical, although it often appears in larger quanti- ty, and of a brighter pink-colour than is customary in either. To prevent the necessity of repetition, I have reserv- ed it to this place to state, that on frequent trials a large extract has remained after evaporation, and a copious precipitate being thrown down by the infusion of galls, but none by nitrous acid. The oxymuriate of mercury like vise has sometimes produced a coagulum much resembling the effect of heat in some slighter cases of dropsy, where the urine is coagulable by that test. It ap-eared to me to be, in a great measure at least, al- bumen, as I h;.ve likewise stated it to be in the cases alluded to, page 24. If so, the precipitate caused by infusion of galls is not wholly gelatinous.* * See Dr. Bostock on the Analysis of Animal Fluids, Edin- burgh Medical and Surgical Journal, vol. 1st, p. 238, &c, and NOT COAGULABLE.--REMARKS. 45 This urine, when recent, reddens vegetable blues, but speedily putrefies. By a few experiments made with the other common re-agents, pure ammonia, the muriate of barytes, and acetate of lead, it likewise ap- pears to contain rather a large proportion of the saline matters which usually enter into the composition of this secretion, as indeed might be expected from its scanti- ness and want of dilution. The precipitate caused by the last was sometimes very large, and I suppose in these, as in many other instances, is greatly increased by the mucilage of the urine.* It may be proper to add, that when the urine clears, and recovery is taking place, it is equally devoid of coagulum, probably with much less tendency to it than during the violence of the disease. The reader has, I trust, gone before me in observing, that the examples above selected furnish a consider- able variety, not only in the extent and seat of the wa- tery accumulations, but also in the severity of the vis- ceral obstruction and in the possibility of cure. I do not see amongst them one instance of anasarca, unconnected with some injury of the breast or abdomen or some dropsy of those parts; and I believe that such an anasarca rarely, if ever, does assume the form de- scribed in this chapter. The same assertion may be made of the hydrocephalus, and particularly of that sudden metastasis to the brain, which often occurs in original dropsies. In cases I. II. III. IV. the principal symptom is an ascites, wThich with great appearance of justice is to be attributed to obstructions of the abdomen, particularly the liver, and which gentle courses of mercury with diuretics, as squills or the carbonate of potash joined the same author on the Gelatine of the Blood, Medico-Chirur- gical Transactions, vol. 1st, p. 72, &c. * See the work last quoted, p. 73 and 74. 46 DROPSY WITH URINE with some bitter infusion, not uncommonly relieve. The carbonate is to be preferred to the subcarbonate, as being more palatable, but I am not aware that its diuretic effects are superior. The three following, V. VI. VII., are examples of dropsy attending intermittent fever; and in two of them there was an evident enlargement of the left hypochon- drium, in which the spleen seems to have been princi- pally concerned; more probably, by an accumulation of blood in its substance, than by a scirrhus, or in the first stages any active inflammation. When such a case occurs, it is not always easy to say to what extent the mischief may have spread, and whether the texture of the affected parts has been much injured. The prognostic must of course be doubtful. If no entire disorganization has taken place, great benefit is sometimes derived from a course of mercury cautiously conducted. The bitter alkaline infusion is likewise a very excellent remedy; and under this plan I have seen the visceral obstruction and watery swell- ings, and even the ague, disappear at the same time. In the more aggravated circumstances of this dis- order, particularly after the Walcheren remittent, mer- cury often fails; and if given in any other way than as a purge, has been thought injurious. Its bad effects partly, perhaps, depend on a greater tendency to suppu- ration in such cases, from which even the lungs are not excluded, as I have more than once witnessed on dis- section. But it seems likewise probable that the drop- sy which supervenes on the Walcheren fever, especial- ly after the dysentery and in exhausted subjects, is it- self differently modified from that which attends the common ague; in short, that there combines itself with the disease a truly hydropic diathesis, as shown by the quantity of albumen in the urine, a state of health this which mercurial courses often aggravate and even pro- duce. NOT COAGULABLE.—REMARKS. 47 An altered texture of the blood, the consequence of the Walcheren remittent and of calomel exhibited for its cure, has been mentioned by Dr. Wright in his work on that complaint, and considered by him to be the cause of many of those dropsies which ensued. He has even on this principle founded an arrangement of them, to which I refer the reader, as being not wholly dissimilar to mine, although he has not availed himself of the same signs.* The phenomena occurring in case VII. first led me to suspect the danger of converting the symptomatic swellings to a worse type by the too liberal use of mer- cury. That which immediately follows, namely, VIII., adds great probability to this opinion; and I believe it will be found to be fully proved in the succeeding pages of this volume. SECTION III. On the Hydrothorax, its symptoms, causes, and cure by squills, calomel, fyc. In the last nine of the remaining cases, namely, from XII. to XXL, the most marked and distressing cir- cumstance of the disorder was the pressure of water in the thorax or pericardium, united very commonly with an anasarca extensively diffused, and still more with unsoundness of the viscera; but the favourable termi- nation of case XIX. proves that it is not always so united. The utmost extent of a lateritious sediment was in this instance dependent on an effusion, in which the membranes appear to have been the parts affected, the glands probably being sound. Generally, a loaded high-coloured urine is amongst the first symptoms. A slight oedema soon begins to * See Wright on the Walcheren Remittent, p. 149 to 179. 48 HYDROTHORAX WITH URINE show itself, with a harsh cough, attended by ropy ex- pectoration, dyspnoea particularly increased on moving up stairs, and often such a sense of stricture or pain on one side of the chest, as rather encourages the opinion of some inflammatory action; and this appears to mc more particularly probable, when I recollect that several elderly persons, whom I visited, fell into the hydrothorax after the influenza of 1803 ; and the first attacks are usually in the winter season. More decided signs of obstruction to the circulation at length show themselves; a purple, loaded, very anxious counte- nance, an irregular pulse, palpitations of the heart, a fluttering at the pit of the stomach, nightly orthopnoea with hurried dreams and all its aggravated sufferings. Costiveness and flatulency are observed to a con- siderable degree, and not so much a loss of appetite as an oppression after food. The faeces are in many in- stances but partially tinged with bile; and frequently a true ascites is added to the other accumulations. Sal- lowness is not an unusual sign, and occasionally some degree of jaundice; but it is to be noticed that the pa- tient is not commonly cachetic, or of a bloated pale complexion, to which appearance the faciei pallor of Dr. Cullen, that forms part of his definition of hydro- thorax, seems particularly to allude.* If he directs himself properly, abstains from intemperate diet, and has a medical attendant, who will not force an unsound system by bark and chalybeates, he usually passes the ensuing summer in a tolerable state of health, and is disposed to flatter himself with the idea of a complete recovery. But he is shortly undeceived. The next return of cold weather, or the slightest irregularities even in the mean time, bring back all his complaints, but particularly that loaded state of the urine, which I have known to give the first warning of a relapse. At * Cullen's Synopsis, vol. 2, p. 278. NOT COAGULABLE.--SYMPTOMS. 49 length medicine begins to lose its effect. After the ter- mination of each attack, he is found to be more and more emaciated, and in a few years dies either sudden- ly or oppressed by an increasing suffocation, and pro- bably during the prevalence of an east wind. Every such patient soon learns by experience to consider that as his greatest enemy. Rarely after being repeatedly relieved he seems to overcome his complaint. The series of symptoms, above detailed, must be al- lowed to carry with it a strong presumption of visceral disease. Undoubtedly many of the appearances can only be explained on the supposition of a fluid collect- ed in some cavity of the chest, or the cellular mem- brane of the lungs; and the sudden relief of the breath- ings by diuretics strongly confirms this opinion. But the increasing emaciation, the sallowness, the pulse never made uniform, the visceral countenance, &c. in- struct us to consider these extravasations generally as mere symptoms, although prominent ones, and the cause to be more deeply rooted in great glandular un- soundness. The liver is more frequently accused than any other gland. Its size, its importance in the animal economy, the effect which a free mode of living is well known to have on it, the partial secretion of bile, and other symptoms unnecessary to be repeated, seem to prove that this accusation is often just. It is likewise rendered probable by several of these cases, particular- ly XX. and XXL, that some hepatic obstructions pro- duce, even in their early stages, a disposition to hydro- thorax, which is very much under the influence of> medicine, till the original malady completely exhausts the patient. Such accumulations are naturally to be expected by us, when we recollect the situation of the unsound part so near to the lungs, the immediate con- nection which it has with the large blood vessels, the sympathy, in short, which is well known to subsist even in common inflammations between the organs (7) 50 HYDROTHORAX WITH URINE above and those below the diaphragm. The bulk like- wise and hardness of so large a scirrhus, acting almost like an extraneous body or dead weight attached to that muscle, will give great impediment to its movements; and all the bad consequences of an obstructed respira- tion and circulation through the lungs must necessarily ensue. Amongst these, a tendency to inflammation in full habits is frequently not the least; and the vessels will partially attempt to unload themselves by an in- creased exhalation. I have observed, however, in such cases, (and the dissection in case XXI. particularly confirms this ob- servation,) that the hydrothorax sometimes comes on earlier, and is more severe than the ascites. It does not so readily appear why this should ever take place; all arguments drawn from the situation and structure of the parts would lead us to expect the contrary; nor would the fact itself be of much practical importance, except as the presence of water in the chest, under certain circumstances, may lead to a suspicion of scir- rhus of the liver, before it is unequivocally detected by its peculiar signs. The pink-coloured sediment, so often mentioned, is considered by Mr. Cruickshank in some measure to characterize a scirrhous liver. Beyond any doubt it does not so universally. In case XL this sediment was present; and yet the injury was found to be seat- ed in the lymphatics at the root of the lungs; Neither does its absence afford any positive conclusions on the other side. In the succeeding part of this volume a dissection will be related, in which that gland was a scirrhous mass, whilst the urine was remarkably pale and loaded with albumen, and totally devoid of sedi- ment of any kind ;* so uncertain are what we call pa- thognomic signs; and so much safer is it to determine * Chap. VII. Case V. NOT COAGULABLE.—CURE. 51 from all the appearances collected together, than from any single symptom, however important. In the early stage of the disorder, medical treatment does a great deal, principally by means of diuretics; and squill is by far the most powerful of them. This drug gives out its virtues so perfectly to different men- strua, as to make the form of its exhibition in that re- spect a matter of indifference. But a solution of it is much more accurately and easily dosed than the pow- der, and probably admits of a more ready absorption. A minute attention to its dose is likewise of great con- sequence. It never operates so favourably, as when it is given in the fullest quantity which the patient can bear without sickness. Indeed, that excellent practical writer, Van Swieten, as well as Dr. Cullen, considered some degree of nausea as proper for securing its diure- tic effect. But few persons can be brought to submit to this for several days in succession; and it appears to be an unnecessary piece of severity, particularly as a risk must thus sometimes be incurred of producing full vomiting, which greatly prevents its future use as a diuretic. It is therefore proper to begin with a dose of the vinegar or tincture of squill, so small as not to in- cur any reasonable chance of sickness, and to increase the quantity gradually, till either the desired effect takes place, or some degree of nausea. Just under this point it should be continued, till it operates favourably, which will often be in a few days. In this manner it may be exhibited three times daily, and commencing with thir- ty drops the quantity may be increased to forty or fifty. The mistura ammoniaci and spiritis aetheris nitrici seem to assist its operation. With the foregoing cautions, the squill will be found to produce very great effects. The urine becomes pale and copious under its use; proportional relief is obtain- ed in the breathing and in the diffused swellings; and it seldom either purges or palls the appetite, as it is 52 HYDROTHORAX WITH URINE « justly accused of doing under other circumstances. Frequent repetition only, and the increasing strength of the original malady, impair its action; and if we look for any great effect from it in removing the visceral ob- structions, we shall undoubtedly be disappointed. In recommending this article, I am glad not to intro- duce any novelty. The materia medica is already load- ed with powerful instruments, which rather want pre- cision in their direction than any increase to their num- ber. The squill is one of these. Its effects on the system are always powerful, frequently beneficial. But it is too indiscriminately employed, and often rather with a fortunate conjecture, than under any precise laws. The appearances, in short, that should regulate its ex- hibition, are certainly not even yet, after the experi- ence of so many ages, understood as they ought to be. Why else have we to lament, I will not say, its occa- sional want of success, (for that must always be expect- ed,) but the injury which it sometimes does to the di- gestive organs, and the rapidity with which the system sinks under its use ? No medicine ever aggravated the complaint for which it was directed, but by some mis- take in the prescriber. The rules for its employment have been misapplied, or, such are the manifold imper- fections of our art, have never been agreed upon even by the most skilful practitioners. It apologizes for all errors, to attribute these bad effects to an idiosyncracy, and to state them not to be discoverable but by experi- ment in each individual. I should hope that in the in- stance alluded to they are rather the result of the form which the disease assumes, and which is capable of be- ing denoted by its external signs. The colchicum is probably suited to the same occa- sions as the squill. But I have not had much experi- ence of it. In removing glandular obstructions, the preparations of mercury are considered to hold a principal rank. Its NOT COAGULABLE.—CURE. 5\i assistance as a diuretic is undoubtedly not inconsidera- ble. For when the squill does not act entirely as could be wished, the addition of a grain or two of the submu- riate of mercury, every night, is frequently followed by a great flow of urine, at the same time that the salivary glands are affected. As to any further aid from it, our expectations ought to be restrained by the recollection of many discouraging circumstances connected with the advanced age and free habits of the sufferers, and of the extensive havoc we often meet with on dissection. There are obstructions in the liver, even attended by ascites, which courses of mercury remove; but on the scirrhous or tuberculated state of that gland, a frequent cause of dropsy in this country, I have seldom seen it make any impression. It would be somewhat in its favour to add', that it is universally safe. I dare not as- sert this; since I have seen in such instances the mer- curial habit superadded by continual salivation, and thus the disorder become more complicated and more speedily fatal. Squills having answered so well as a diuretic in the circumstances before described, my experience of the digitalis is very limited in them, and does not entitle me to say any thing decided respecting it. These patients bear purging badly; and the operation seldom carries off much water. Tonics in any stage uniformly do harm, and repro- duce the swellings. 54 DROPSY WITH COAGULABLE URINE. CHAPTER V. OF DROPSIES, IN WHICH THE URINE IS COAGULABLE BY HEAT. The presence of serum in the urine, as discovered by the application of heat, is not entirely confined to dropsies. It certainly cannot be considered as a com- mon occurrence in other diseases, much less in health; but sometimes, where without any effusions the emacia- tion has been greater than could be accounted for by the obvious symptoms, I have suspected that this pro- cess was taking place, and in two instances have detect- ed it, though in a very slight degree. In one of these we found on dissection an extensive scirrhus of the stomach near the pylorus; in the other there had been a large haemorrhage from the nose, succeeded by the most extreme dejection of spirits and loss of strength. I have likewise some suspicions that the excessive use of the alkalies and magnesia disposes the serum of the blood to pass off by the kidneys. This symptom is, however, rarely found to exist, perhaps never, in any consider- able degree, but as a sign of some dropsy either form- ing or already formed. These are the anasarca, hydro- thorax, ascites, and hydrocephalus, with their various combinations. Many cases indeed are very imperfectly described by either of these terms singly, and are ra- ther a general dropsy, involving the cellular mem- brane extensively, and one or more of the large cavities likewise. For these there is no appropriate title in our books of nosology; but as the anasarca is their most obvious and early symptom, and the existence of the in- ternal accumulation is often more or less doubtful, I DROPSY WITH COAGULABLE URINE. 55 have arranged them with the former. The anasarca, strictly speaking, and for any long period, is compara- tively rare. The continuance of this disease is generally followed by a depravation of the whole habit, and by that sallow transparency of complexion which cannot fail to strike even an inexperienced observer. There are many ca- ses, in which these alarming signs give their character to the eedematous swellings, from their very commence- ment, and in which the patients have been pronounced to be in a cachexy, even before the dropsy has been completely formed. This state, although called a spe- cies of anasarca, has appeared to me to be entitled to a separate consideration in the present inquiry. It is very apt to terminate in universal effusions, and often in old subjects in an hydrothorax. Petechia are sometimes superadded to it; and it is then not easily distinguisha- ble, if indeed it be at all different, from the land-scurvv. 5(5 ANASARCA, &C AFTER CHAPTER VI. OF THE ANASARCA AND GENERAL DROPSY, IN WHICH THE URINE IS COAGULABLE BY HEAT. The dropsy diffused through the cellular membrane, and in its progress usually involving the large cavities likewise, is a very common form of the disease. Its exciting causes are sometimes sufficiently remarkable, and where they can be readily ascertained, constitute a natural and useful distinction, of which I have availed myself in arranging the cases contained in this chapter. One of these causes is scarlatina, which operates to a great extent in certain seasons; another is courses of mercury imprudently conducted, and perhaps aided by cold ; a third the drinking of cold water, when heated; and I have reserved a fourth section for those cases, in which the exciting cause was not very obvious nor pre- cise, but appeared connected with different circumstan- ces of fatigue, cold, the use of strong liquors, visceral disease, or the injudicious employment of tonics. In the histories themselves the general character of the urine is given, and the extent of its coagulation by heat. The occasional experiments, which I have tried with other chemical tests, are, to prevent the necessity of repetition, placed together. I lament, undoubtedly, that they are so few and so limited, because the dis- charge of albumen by this unusual channel might pro- bably be much illustrated, by ascertaining whether any saline matters were present, that particularly favoured its solution. The complicated nature of that fluid, at all times, but especially in disease, seems to surround the subject with difficulties. SCARLATINA.—CASES. 57 SECTION 1. Cases of Anasarca, fyc. after Scarlatina, with a Dissection.—Remarks. CASE I. E. Hammet, aetat. 42, Hospital, June, 1798, had been confined by scarlatina five months since, and three weeks afterwards had become dropsical. At the time of her admission she had an ascites, very universal ana- sarca, great feebleness and frequency of pulse, with general weakness and a bad appetite. The urine was nearly natural in colour and quantity. On being subjected to heat, the whole fluid was render- ed uniformly opaque at 160°, and soon deposited a considerable coagulum. Squills, the bitter alkaline infusion, crystals of tartar, and many other diuretics and purgatives, were exhibit- ed without effect. Her apparent loss of tone induced me to try bark and steel, both with and without evacu- ants; but they aggravated the symptoms. At length scarifications of the legs were employed, and there was much discharge from the wounds. This fluid gave no precipitate even at boiling heat, and very little by the addition of nitrous acid. The oedema was not perma- nently lessened by these means; but in two or three weeks a severe erysipelas of the lower extremities fol- lowed, and gangrenous spots, with a total failure of strength. In this dangerous state it was necessary to give bark and port wine very largely. These not only succeeded in stopping the erysipelas, but encouraged such a flow of urine and discharge from the legs, as speedily unloaded her. The urine in this increased quantity contained a less proportion of serum; and (8) 58 ANASARCA, &C. AFTER greater heat was required for its precipitation. Dis- continuing the bark too soon, she became again some- what oedematous, the urine altering in the same propor- tion ; and it was only by returning to a long and regular course of that medicine, that she perfectly recovered. CASE II. R. D., aetat. 10, just recovered from an attack of scarlatina, so slight, that he had been hardly kept one day from school, complained of pain on the outside of the right leg, somewhat above the ancle. The part was very hot, difficult to be moved, slightly swelled as if from rheumatism, and did not retain the impression of the finger. This seemed to be the complaint, which his friends noticed most. I observed besides a quick and feverish pulse, with a bloated abdomen, pale purple lips, languor and shortness of breathing. The night be- fore, he had been awakened by some spasm on his chest, and cough. His urine on examination proved to be scanty, and very serous. A few mild purges reduced his fever, and brought him into a state in which he bore the cinchona well. The urine then cleared, and he recovered. CASE III. M. J., aetat 10, anasarca; ascites; palpitations of the heart, dyspnoea, excessive languor; urine pale, not scanty, nor depositing any sediment, but greatly loaded with serum. These symptoms had succeeded a mild scarlatina about ten days before. Bark had produced a tightness of the chest; and under the use of calomel, squill, and other diuretics, there was a rapid increase of all the bad signs. Particularly, the exhibition of two grains of calomel, every night, had been followed by great de- bility and frequent retching. SCARLATINA.--CASES. 59 I directed two drachms of the infusum digitalis every day, which restored her speedily. CASE IV. J. E., aetat. 12, had recovered from scarlatina about three weeks, when he became suddenly dropsical. There was an ascites and very universal anasarca, the scrotum particularly being enormously distended. I found his urine so overloaded, as to resemble serum of the blood three or four times diluted with water. It was high-coloured, and contained a bloody sediment. Two drachms of the infusion of digitalis, every eight hours, soon removed his swellings, whilst the urine im- mediately became more diluted, and in a short time quite natural. Let me add once for all, that in the in- stances of cure by digitalis, this improvement of the urinary discharge is simultaneous with a relief of the other symptoms, is certainly not subsequent to them, but always amongst the earliest good signs. This child, however, continued feeble, and although the dropsy did not return, yet on again applying the test of heat to the urine, whilst he was continuing that remedy, it became quite opaque at boiling heat. The Peruvian bark soon corrected this appearance; and he regained strength rapidly. CASE V. E. W., aetat. 3, sister of the child, whose recovery is related under the article hydrocephalus, lay ill of scarlatina at the same time, and when I visited him, was quite anasarcous. The urine was turbid even when made, speedily de- posited a dark bloody sediment, and was overloaded with serum. The sediment did not in this and the other instances 60 ANASARCA, &.C. AFTER disappear by a slight heat, as it would have done if it had been of the branny kind, but gave a brown tinge to the coagulum. The infusion of digitalis carried off these symptoms; and she required some Peruvian bark for the re-esta- blishment of her appetite and strength. CASE VI. F. M., aetat. 7, about three weeks after a slight at- tack of scarlatina, began to swell, and had been purged by medicines, of which calomel formed a principal in- gredient, in consequence of which his symptoms in- creased. I found him with the legs slightly swelled, abdomen considerably; and he could not lie down in bed. His urine was very scanty, foul when made, and soon de- posited something that appeared to be lymph, and likewise a bloody mucus. Much under boiling heat, it grew very opaque, and exhaled a most foetid odour. Small doses of digitalis rendered him service; and he then took Peruvian bark with great advantage. CASE VII. E. C, aetat. 8, in the fifth week after a mild scarla- tina became dropsical. During the exhibition of mer- curial purges, the swellings of the extremities had been reduced. But a very considerable ascites remained, with a bloated pale complexion, stiffness of the knees, great feebleness, a quick pulse, and much pain between the eye-brows. Her urine was scanty, foul, quite dis- coloured with blood, and greatly loaded with albumen. I considered this child as on the verge of an hydro- cephalus ; but most of her bad symptoms disappeared in a few days ui der the use of the fox-glove; the as- cites continued longer, and was not finally removed till she took the Peruvian bark. SCARLATINA.—CASES. 61 CASE VIII. L. D., aetat. 8, became generally bloated and swell- ed, in the abdomen particularly, about ten days after the disappearance of the scarlatinous eruption. I found his urine rather scanty and pale, very slight- ly changed by boiling heat, and giving some coagulum on the application of the nitrous acid. Qn standing, it deposited a loose bloody sediment. This child had taken no medicine at any period of the disease. Very small doses of digitalis every way unloaded him, but during its continuance, greater symptoms of feebleness came on without swelling; and the urine again precipitated something by heat. The cinchona in substance restored him speedily. CASE IX. J. N., aetat. 16, passed through a very mild attack of scarlatina, and about a month after, as if from a recent cold, became slightly anasarcous in the extremities, and affected with some shortness of breathing. His medical attendant very judiciously gave him the fox-glove, which much relieved him. At this period, however, I was consulted, and finding that the urine was very slightly discoloured by heat, and as little by nitrous acid, (which is often the case after that remedy has done its office,) and that his pulse was quick and feeble, I ordered the cinchona, in great hopes that all stricture of the chest was removed. The contrary prov- ed to be the fact; and I was obliged to have recourse to small doses of tincture of digitalis, under which plan he soon recovered. 62 ANASARCA, &C. AFTER CASE X. Sarah Ellicot, aetat. 30, was brought into the Devon and Exeter Hospital, 1800, in a state of great distress, labouring under universal anasarca, and an erysipelatous inflammation of the lower extremities, with much dis- charge, and deep sloughs on the hips and sacrum. The urine coagulated, although not to the extent sometimes observed; and it flowed freely, as I have often noticed it to do, whenever much serum is dis- charged from the legs. She had the remains of a florid sanguine tempera- ment, and had been in good health till about two months before, when a fever with great redness of the face and extremities attacked her; soon after which she had become dropsical, and affected likewise with stric- ture of the chest, cough, and pain under the left breast. All her present symptoms demanded the cinchona, which she took in very large doses, and with great ad- vantage. She was quite inundated with the discharges from the legs and the increased flow of urine. The erysipelas disappeared, and, shortly after, all vestiges of dropsy. But the sloughs above mentioned had pene- trated deeper than we hoped; the bones became carious, and about two months after she died exhausted, the anasarca never having returned. It was not uninteresting for me to ascertain by dis- section the state of the internal parts, and particularly the kidneys; not, indeed, that I suspected any thing more than a disordered secretion from that gland; but that it is always satisfactory to leave nothing to conjec- ture on subjects where ocular demonstration is to be obtained. The kidneys were rather soft and flaccid, and more loaded with fat than could have been supposed after so long an illness, but in other respects quite natural. SCARLATINA.--CASES. 63 There was no morbid appearance in any other viscera of the abdomen. The pleura of the left lung bore marks of inflamma- tion, more severe than the common adhesive ; for small flakes and granula of coagulated lymph covered it in several parts, principally in a spot answering to the seat of the pain during life; and that membrane was sepa- rated from the body of the lung for about the size of a shilling, by a very small deposition of pus. Opposite the same spot the pleura costalis was inflamed. In other respects the substance of the thoracic viscera was sound, and there was no unusual quantity of water in the cavities. The bloody sediment observed in the urine, in no less than five of these ten cases, is well worthy of notice, as indicating how nearly the other remarkable character of it is allied to a true haemorrhage. It is not quite peculiar to the scarlatinous dropsy, nor to the ear- ly age at which that fever usually occurs; as will be seen in the succeeding pages. I have thought it to be hastened and encouraged by the use of mercury. That this sediment does actually derive its colour from the presence of red blood, is evinced by its appearance, which can hardly deceive, by its being so speedily de- posited, and by its remaining undissolved when heat is again applied. It has not been wholly overlooked by authors. Von Rosenstein states, that the urine is mixed with blood in some patients, when the body swells after scar- latina.* Burserius describes it as turbida et fusca, et * See Von Rosenstein on the Diseases of Children. Sfiarr- man's Translation, p. 166. 64 ANASARCA, &C. AFTER quandoque omnino suppressa ; and adds in a note, that it has been found to resemble, in colour, water in which flesh had been washed.* The dissection in case X. possesses some value. Practitioners have usually thought themselves justified in supposing the serous membranes to be relaxed only, and discharging too much fluid from their numerous exhalants. We here find the pleura to be inflamed, and even partially suppurated. Burserius notices the presence of internal inflamma- tion, particularly peripneumony, in the scarlatinous oede- ma, and adds, that this opinion of its nature has been confirmed by dissection, and by the great advantages derived from blood-letting. He draws, however, a distinction between the oedema calidum and frigidum, which appears to me not perfectly correct. The for- mer of these, known by an increased temperature, florid colour, and hardness of the parts affected, he considers to be an inflammatory state, and curable by antiphlogis- tics; whilst the latter, a pale and cold oedema, is usually without fever, and to be treated like a common anasar- ca, f I have not made experiments on the blood of persons so attacked, because I have found them curable by milder means; but if there is any analogy between this and other dropsies, the cold and soft oedema is by no means inconsistent with great inflammation of the habit. Digitalis is its sovereign remedy. Dr. Withering has made this assertion without reserve respecting the scarlatinous anasarca-! Applied to that form of the disease which we are now considering, it is strictly cor- rect. I know of no instance where digitalis has failed, when properly exhibited; and I add, without fear of con- tradiction, that it is equal to almost every emergency, * Burserius' Institutes, vol. ii. p. 80. t Burserius' Institutes, vol. ii. p. 81. \ Withering's Account of the Fox-glove, p. 25. SCARLATINA.--REMARKS. 65 short of that destruction of parts, which admits of no cure. But I must again request the reader to bear in his mind the exception to the general character of such cases, contained in the beginning of the second chapter, and the failure of digitalis in that instance.* SECTION II. Of the Anasarca, fyc.,from Mercury, with Dissections and Remarks. CASE I. L. G., aetat, 25, 1806, had been, when he consulted me, just undergoing a mercurial course of two months' continuance for a venereal complaint; during which he was become universally and rather suddenly anasarcous. The urine was scanty, high-coloured, and deposited a branny and lateritious sediment. It was much loaded with serum. He besides complained of cough and pain in his left side. Some blood was on this account taken from the arm, and found watery, but inflamed. Crystals of tartar were then prescribed in large doses, and the legs directed to be scarified. But with unusual severity the surgeon made several scarifications of four inches in length on each leg. I expected nothing bet- ter than a sphacelus. By fomentations, however, the inflammation was restrained; and the discharge was so excessive as to pass through the patient's bed repeated- ly upon the floor every day. To support this, he soon required a very cordial treatment, both bark and port wine, and under that plan was quite restored. * Page 19, (9) 66 ANASARCA, &C. FROM CASE IL H. G., aetat. 12, was suspected by her parents to have worms, and took by their direction some doses of an empirical medicine, containing calomel. Her gums were not observed to be affected; neither was she much purged; but very soon after, and without any other assignable cause, she became almost suddenly oedema- tous in every part of her body ; an ascites speedily fol- lowed ; and the pain in her left side, and dyspnoea on motion, made me suspect the thorax likewise. I found her urine to be very pale, speedily putrefying, and loaded with a white sediment and flakes, part of which, from its being insoluble by heat, I considered to be lymph. The clear fluid did not much alter before boiling heat; but then became thick and ropy, and on the slightest evaporation was converted into a mass nearly gelatinous in appearance. I tried digitalis with considerable confidence in this instance; and the immediate result showed that I had fixed rightly. The urine in a few days was increased in quantity, and its coagulum much lessened. The swellings began to diminish; but being removed into the country, she took larger doses of the tincture of di- gitalis than were directed, and died suddenly, the ana- sarca and ascites having previously almost disappeared. CASE III. L. N., aetat. 50, 1804, had been labouring for more than three years under constitutional symptoms of the lues venerea, and had used repeated courses of mercury for many months together, from which his general health suffered extremely. I considered the venereal taint to be eradicated, and that his symptoms were attri- butable to mercury, a great dejection of mind, a sallow MERCURIAL COURSES.—CASES. 67 countenance, perpetual diarrhoea, pains in the joints, restless nights, no sleep being obtained but by large doses of opium, a rapid pulse, considerable anasarca, and urine loaded with serum. The anasarca had been very gradual in its appearance. Sarsaparilla and meze- reon he tried largely without effect. Under the use of one drachm of nitrous acid daily, for two months, he gained strength, and lost his pains; but the swellings and loaded urine still continued. He bore no tonics, and seemed to be still less a subject for evacuations. As he lived at a distance of more than ten miles from me, I saw him but seldom. In my absence the attend- ant apothecary drew a few ounces of blood from his arm, on account of a violent pain at the pit of the sto- mach, from which he had long suffered in some degree, with greater severity only a few hours. To my surprise, when I visited him the next day, I found the blood completely inflamed. The serum ex- actly resembled runnet whey in colour and appearance, and the small coagulum which swam in the midst was covered with a thin, white, extremely firm crust, cupped to little more than the size of a half crown. The serum coagulated strongly by heat. Whoever had been wit- ness to this state of the blood, must have been convinc- ed that it was not the process of a day. I was, how- ever, fearful, considering all the circumstances, of eva- cuating him further, and he soon afterwards died. CASE IV. Robert Mock, aetat. 50, a sailor, was admitted into the Hospital, 1809, partly on account of a severe slough- ing ulcer of the left leg, the tibia of which was enlarged. His constitutional symptoms likewise were very formi- dable ; a general sallowness, great dejection of spirits, and loss of muscular strength, a slight but tense oedema of the lower extremities, a very chorded pulse, a moist 68 ANASARCA, &C. FROM clean tongue, thirst, total loss of appetite, and frequent vomiting, particularly of aperient medicines. Ho had neither cough nor orthopnoea. The urinary discharge amounted to about three quarts in twenty-four hours, the principal part being made in the night. It was very pale and clear, deposited no sediment, retained lor man) days its quality of reddening infusion of litmus, and continued long free from any apparent putreiaction. It became opaque at 160° of heat, and soon deposited large and firm flakes. From four ounces of clear urine placed in a phial before the fire for a few minutes, were obtained forty grains of a solid coagulum, which was in the proportion of two ounces to the quantity of urine discharged daily. It lost by a very moderate desiccation only one-fourth part of its weight. He was very uniform in his statement, that the ulcer had originated, more than twenty years before, in the sting of an insect in North America. For its cure he had been admitted into many hospitals in this country without effect; and had undergone several salivations, partly for syphilitic complaints, of which he had been the repeated victim. One very long course of mercury he had suffered about twelve months before, and during it some degree of anasarca had come on, which for many months affected only the sound leg, afterwards both. Lately he had been taking Peruvian bark with an aggravation of his symptoms. The ulcer was soon reduced to nearly an healing state, by the use of the fermenting cataplasm; but with no relief to his constitution. The oedema in a few days partly quitted the limbs before affected, and spread to the covering of the abdomen and thorax and to the arms; or it was rather a pale tense tumour, hardly retaining the impression of the finger, and in some slight degree sore to the touch. Aperient medicines were rendered inadmissible by an extreme irritability of the stomach, and a most pain- MERCURIAL COURSES.—CASES. 69 ful prolapsus. Of the tincture of foxglove not more than two or three drops could be borne without vomit- ing. Blood drawn to the amount of sixteen ounces was very much inflamed, and cupped, and not watery; the serum of a whey colour. He bore the operation well, and the pulse was somewhat reduced. For a day or two after the urine gave very little precipitate by heat, but it gradually resumed its former character. From the cold weather of January he suffered extremely, not being able to obtain the least sensation of warmth. A dry cough likewise took place with some stricture upon the chest, and excruciating pain darting from the sternum to the back quite through the region of the heart. A tendency to deliquium was likewise observed on raising himself in bed; but he could lie down ho^ rizontally. The pulse was about eighty, strong and hard, but by no means interrupted. It was impossible not to conclude that the membranes surrounding the heart were inflamed. Besides the use of blisters, a large venae-section was instantly directed; and he lost nearly thirty ounces of blood, before there was the least reduction of the hardness of the pulse. At the end of that operation it became nearly natural, and the pain wholly subsided. The blood, though only trickling from the orifice, on account of the difficulty which the oedema of the arm presented, was in the highest degree inflamed and cupped. The relief, however, was only temporary; and his bodily weakness, as well as the ana- sarca, certainly increased. Several returns of pain and stricture, though in less degree, rendered bleeding again necessary. He lost in about a month somewhat more than an hundred ounces of blood, always in a very inflamed state, and always with present relief, although not so direct a diminution of the quantity of serum in the urine. The recurrence of his bad symptoms, and a greater softness of the oedema said to indicate digitalis, induced me again to have recourse to it. He now bore 70 ANASARCA, &C. FROM it in doses of twenty drops every eight hours; but it had no beneficial effect upon him, notwithstanding that it produced a great retardation of the pulse, and the feelings peculiar to its poisonous action. Some diar- rhoea ensued, which remained with him to his death. His urine became gradually less serous, and more pu- trescent. He grew feebler, at last tympanitic, and had sloughs on his hips and sacrum. In this way he ter- minated a most miserable existence. On opening the body we found, on the right side of the thorax, twelve ounces of serum, in which were some floating membranes; the pleura in several parts inflamed, and covered with exudations of lymph; the left side nearly in the same state, the fluid about ten ounces: the lungs sound, but rather overloaded with blood in the posterior part, and at their roots; the peri- cardium, both the investing membrane and its duplica- tive, thickened and inflamed, and in many places quite woolly, with flakes of lymph adhering to it, particularly about the origin of the great artery; in the cavity three ounces of a turbid whitish fluid; the heart very large, pale and firm, and three or four ossified spots in the inner membrane of the aorta. In the abdomen, the stomach was greatly distended with air; the omentum rather thickened; the peritoneal coverings of the spleen and liver dull and slightly in- flamed, particularly that of the former, which was like- wise connected by adhesions to the surrounding parts; the latter of these glands rather firmer than ordinary; the kidneys likewise unusually firm; in the left, one very small hydatid, in the right two; more than an ounce of fluid in each lateral ventricle of the brain. The cellular membrane of the trunk and extremities was every where loaded with a coagulated semi-trans- parent effusion, which gave an unusual resistance to the knife. This was particularly the case in the parieties of the abdomen, and in the loins, and certainly explain- MERCURIAL COURSES.—REMARKS. 7j ed the tension and soreness to the touch not common in anasarca. The fluid which drained off from the in- cisions was very glutinous, and on exposure to air for some time formed into an apparently gelatinous sub- stance, which, on being heated, separated into a solid lymph and thin fluid. The serum of the pericardium coagulated strongly by heat; that from the thorax and abdomen in a less degree, and the water of the ven- tricles of the brain was the most diluted, though still coagulating to an unusual extent. In the two former of these cases the attack was ra- ther sudden and probably aided by cold or some other cause of inflammation. The latter are specimens of a true mercurial habit, slowly forming, distinguished in their advanced stage by a most unconquerable buffiness of the blood, and an unusual colour even of the serum. They perhaps belong rather to the article cachexy; but I preferred placing them in this section on account of the identity of the exciting cause, and for the purpose of better illustrating the action of this mineral. No one can contemplate these remarkable characters of the blood, the dry cough and pains in the side, the thicken- ed membranes and turbid fluid discovered on dissec- tion, and particularly the spontaneous coagulation of the fluid taken from the cellular membrane, without form- ing conclusions favourable to the doctrine of an inflam- mation induced by mercurial courses, and of the great risk of that inflammation fixing internally. It is like- wise a circumstance of some importance, that the urina- ry discharge so often alluded to, which carries with it the suspicion of debility, may be united with an exces- sive arterial action in no ordinary degree, and is some- times relieved by the same means. There are, how- 72 ANASARCA, &C. FROM ever, exceptions to this coagulable state of the urine,* which are probably to be attributed to the mercury passing off rapidly by the bowels, and thus leaving the constitution weakened rather than inflamed. The five following cases are added, not as examples of a complete mercurial dropsy, but to show of what nature those slighter swellings of the extremities are, which often follow the use of mercury in certain con- stitutions : but I willingly avail myself of an opportuni- ty of recording the fifth in particular, and the annexed dissection, as containing the history of a malady not yet sufficiently noticed by physicians. CASE I. A young woman from Jamaica had been undergoing in that island repeated salivations for the yellow fever, and its subsequent obstructions. Her health had been completely shaken by these causes. She remained af- fected with darting pains through her right side, a great deal of dyspnoea on motion, puffy, cedematous, irregu- larly shifting swellings of the ancles, knees, and other joints, and an urine giving a coagulum under the boil- ing heat. I had many reasons, connected with the history of her complaint, for attributing these circumstances to mercury; and they certainly indicated a state quite un- fit for such an exhibition of that mineral, as the pains of the liver seemed to require. * Pages 20 and 21. MERCURIAL COURSES.—CASES. 73 CASE II. R. L., aetat. 30, persisted in the use of mercurial friction, for pains of the joints undoubtedly aggravated by mercury. One of his legs became oedematous, and the urine slightly coagulated by heat. He readily gave up his former plan, and by change of air and sarsaparilla was restored. CASE III. R. M., aetat. 50, burst an internal abscess, that had been connected with pain in the region of the spleen. The pus discharged itself upwards and downwards; and suspicious sputa with cough remained. Mercuri- als were ordered by the attending practitioner; but his gums became shortly affected, and his legs at the same time oedematous. . The urine examined at that period was found some- what impregnated with serum. The sputa likewise assumed a form more decidedly purulent. On the discontinuance of the mercury, the urine gra- dually improved. CASE IV. G. H., aetat. 30, was recommended to the coast, of Devonshire on account of a cough and spitting of blood. Severe bilious symptoms came on during his residence there, with jaundice, an apparent induration of the right side, and a very remarkable dyspnoea. Two grains of calomel were exhibited every night with great advantage, in respect to these symptoms, and particularly his respiration. But at the end of a week (10) 74 ANASARCA, &C. FROM his legs swelled, and the urine on examination was found partially to coagulate. CASE V. G. Hatswell, aetat. 35, Hospital, 1811, of a scrophu- lous habit, and blind in his right eye in consequence of that taint, was put under a mercurial course on account of a diarrhoea, the circumstances of which I shall pre- sently describe. His gums were with difficulty affect- ed ; he grew weak ; and his legs began to swell. The urine exumined at this time became opaque considera- bly under the boiling heat, which had been particularly ascertained not to be the fact previous to the exhibition of mercury ; and after the discontinuance of that mineral for a fortnight or three weeks, some oedema still remain- ing, this appearance gradually lessened, although it never entirely ceased. The diarrhoea, for which such a course had been pre- scribed, was of a remarkable kind, consisting of discharg- es which nearly resembled yeast in colour, fluidity, and effervescence. They were likewise extremely copious, and followed by the most excessive sinking. He suf- fered altogether more from flatulency, dyspepsia, and dejection of spirits, than from any precise pain ; some- times, however, he complained of stitches in his left side, to which lit- had been subject in consequence of a strain and haemoptoe four years before ; and when ques- tioned would acknowledge an obscure uneasiness and fulness towards the lower part of the abdomen, on the right side. This I apprehend increased latterly. He had been ill several months, and continued to emaciate imd grow feebler, till he was reduced to a mere skeleton. Cough and purulent expectoration were amongst his last symptoms. The suspicion of a liver disease, which most of us perhaps are too willing to entertain, induced me to put MERCURIAL COURSES.--CASES. 75 him under the influence of mercury. In a saline form, this mineral greatly disagreed with him. A small quan- tity of pilulae hydrargyn, guarded by large doses of opium, with some difficulty affected his gums; and certainly at the same time the discharges became more solid, and coloured with green bile. But he had not firmness enough for such a course ; the diarrhoea return- ed ; and he again lost ground rapidly. Astringents greatly bloated and oppressed him. Nothing but tincture of opium at all palliated his com- plaints ; and under the use of it, his diarrhoea subsided for three weeks before his death. Two months pre- ceding this event, he had become an out-patient; and I therefore cannot speak precisely with regard to several of his latter symptoms, particularly the presence of blood or pus in his discharges. The examination of the body baffled all our conjec- tures. The liver was natural both in size and struc- ture, and the gall-bladder full of a yellow healthy bile. But on tracing the intestines, we found the caecum and its appendix, with some of the neighbouring parts, in- volved in a mass of scrophulous adhesions, which, when taken out and dissected at leisure, presented the follow- ing appearances. The disease began about two inches above the termination of the ileum. Its inner mem- brane was, to the extent of a crown-piece, covered with spots of lymph; and there were two or three small ul- cers. The whole of the inner membrane of the caecum was completely destroyed by ulceration, and its other coats much thickened; the beginning of the colon in the same state, for five or six inches further nearly healthy, and then again for a short space thickened and ulcerated, in a spot where by a sort of unusual course of the intestine it had doubled down upon the caecum, and was involved in the same mass of adhesions. The remaining part of the great intestines appeared to be sound ; but we did not make any minute examination 76 ANASARCA, &C. FROM of it; the glands of the mesocolon were enlarged; the kidneys remarkably loaded with blood as if injected; the lungs were full o£ tubercles partially suppurated. I apprehend a slight degree of this disease to be not unusual. I have seen four cases of it to an extraordi- nary extent, where the discharges by stool greatly re- sembled yeast in their appearance, and in one instance were nearly raised by their effervescence over the sides of the vessel. All the patients had this in common, that they died extremely emaciated, and after a most tedious lingering. Their depression of spirits was excessive; their sinking after these discbarges dreadful, with a sensation as if the whole body were coming out; frequently they expected not to survive them. In all, there was much flatulency, and in some a croaking noise of air, apparently seated in the ascending arch of the colon, and sometimes producing such a projection there, as almost to give suspicion of a ventral hernia. Pain they did not suffer in proportion to their other symptoms. One of them had been subject to haemor- rhoids, and prolapsus ani. Mercury, even by friction, could not be brought to affect the gums of any but the subject of the present case, and there without any ad- vantage ; and the debilitating effects of the saline pre- parations of that mineral were very great. Writers describe this remarkable complaint imperfect- ly ; and when they notice the occurrence of yeasty discharges, they generally seem to refer them to an ob- struction of the liver exclusively. But many circum- stances, particularly the preceding dissection, prove the large intestines to be much engaged in this disorder. And although it is possible that vitiated secretions from the upper part of the alimentary canal, and food imperfectly converted, may be the primary cause of such excoriations of tlfe lower bowels, as acrid bile is in the dysentery of the Bast yet it is no small point, to be satisfied, that the liver is not organically unsound, that DRINKING COLD WATER. 77 mercury is injurious, that deobstruents are not called for. 1 consider opiates as the most likely to render benefit, with small doses of ipecacuanha, and probably a course of the Bath waters. The coeliaca passio of Aretaeus resembles it in many points.* SECTION III. Of the Anasarca, fyc. from drinking cold Water, when heated and fatigued. CASE I. R. E., aetat. 50, 1801, in the evening after return- ing from work, having been much exposed to heat, and drank cold water in that state, was attacked with febrile symptoms, attended by pain of his left side, and inabi- lity of lying on it. In two or three days he became universally anasarcous. I was consulted for him three weeks afterwards, and found that his urine was both scanty, and much over- loaded with serum. There was a very strong and full pulse, a total loss of appetite, and a rotten taste in the mouth, with a dry costive habit. He had been taking purges of jalap and cream of tartar occasionally, with some advantage. I continued the cream of tartar principally in large doses; and the urine flowing with much freedom, he soon recovered complete health, under the use of Peruvian bark. CASE II. William Rowe, a stout and large#tian, aetat. 35, Hos- pital, 1809; very extensive anasarca ; bloated and sal- * Aretaeus de morbus diuturnis, lib. 2d, chap. 7th. 78 ANASARCA, &C. FROM low countenance; puise 90, quick, chorded, redoubling; urine coagulating at a low heat, when recent, reddening infusion of litmus, but soon putrefying; there was no ascites, nor, as iar as we could judge from the total ab- sence of cough and orthopnoea, any probability of hy- drothorax. He attributed the attack to drinking a large quantity of cold water when heated, and fatigued by labour in the harvest, more than twelve months before. He was the same evening seized with rigors, but no local pain, and soon became universally anasarcous. Squills had little or no effect on the swellings. His pulse continued very chorded ; a d he complained of a throbbing in different parts, particularly his head with a kind of confusion of thought. These symptoms made me think venae-section, however unusual in dropsy, ad- visable. The blood drawn was watery, but covered with a remarkably thick and firm buff; and he was much re- lieved by the loss of about ten ounces. I then directed daily large doses of crystals of tartar, under which plan the inflammatory symptoms soon left him ; the swellings still further subsided ; and he began to feel a vertigo, and a numbness of his limbs, aggravat- ed by purging. The urine in this state was still coa- gulable, although by a greater heat and less firmly. By large doses of bark this appearance was removed in a fortnight or three weeks; and he entirely recovered, a painful ulcer in his leg of some weeks' continuance healing at the same time. It is probable that this drain had acted very beneficially in preventing some determina- tion to the internal parts. Case II. is an example of a very severe and long- continued inflammation of the blood, not connected with any corresponding affection of the internal parts. Can COLD, INTEMPERANCE, &C.—CASES. 79 we suppose it possible, that such a disposition as this should be merely general ? Or, is the cellular mem- brane in these instances the seat of an obscure inflam- matory process, in which the exhalant arteries are too active, and secrete a fluid every way unfit for its purpo- ses? SECTION IV. Cases of Anasarca, fyc. from Cold, Intemperance, £r. Remarks. CASE I. W. L., aetat. 60, a very robust man, had noticed, about a fortnight before I was called to him, a swelling of one leg without any precise constitutional complaint. In that state he attended the funeral of a neighbour, was much exposed to cold and rain, and, as I was informed, drank freely of some strong liquors. An universal ana- sarca succeeded in a very few days. I observed considerable suppressed cough, pain at the pit of the stomach, and some orthopnoea, with many marks of an inflamed chest, particularly great protrusion of the abdomen in breathing, and a proportional diffi- culty of elevating the ribs; pulse 90, quick, hard. The anasarcous swellings were by far the greatest I ever wit- nessed. The urine was very scanty and foul, with a red sediment; and on being heated it thickened into a white and opaque mass which soon became nearly solid. He had been scarified in the legs and scrotum, before I visited him. The wounds were now inflaming with great pain; and an erysipelas extended from them al- most over the whole body. These complicated com- plaints proved fatal to him in a few days. I never saw a dropsy run so rapid a course, nor stronger signs of pleuritic inflammation joined to it. The state of the SO ANASARCA, &C. FROM scarified parts, which were becoming rapidly gangren- ous, deterred me, perhaps not with sufficient reason, from adopting those active measures which could alone at any time have saved his life. CASE II. H. R., aetat. 70, 1806, a washer-woman, robust and of a ruddy complexion, had an universal anasarca, some cough, soreness of the chest and dyspnoea, with a quick and hard pulse; urine pale and apparently thin, be- coming quite opaque at 160°, depositing no sediment, remaining for a long time free from putrefaction, and for more than a week reddening litmus paper. The quantity made was between one and two quarts daily ; and the coagulum, obtained from one quart placed be- fore the fire for a few minutes, amounted to ten drachms, which lost by moderate desiccation nearly half its weight. She had been attacked about a month before with a swelling of one leg, in the groin of which there was an enlarged lymphatic gland. A legitimate dropsy speed- ily followed, all which she attributed to cold, and the fatiguing posture necessary in her employment. I directed blisters to the chest, and some purgatives, consisting of jalap and crystals of tartar. The anasarca was by these means relieved, but nothing more. Even elaterium, which to all appearance totally emptied her, left the urine unaltered. Squill rather irritated than un- loaded. Crystals of tartar in large dilution somewhat kept down the phlogistic habit, but at length brought on a debilitating diarrhoea. Tonics of all kinds, even when the swellings were most reduced, gave speedy marks of aggravating every symptom. She was scarified with some relief. The fluid dis- charged by this operation did not at all coagulate by heat, very little by nitrous acid, and left hardly any ex- COLD, INTEMPERANCE, &C.--CASES. 81 tract on evaporation. The urine became for a few days entirely devoid of serum. Salivation was readily excited by mercurial frictions; the debilitating effects of this mineral soon followed, and the effusions increased. Digitalis gave so much relief, that I have to lament it was not exhibited sooner. It produced a softness of her pulse, and diminished the swellings; but some un- conquerable obstruction to the circulation still remained; she continued to suffer severely from palpitations, night- ly spasms, a pain in the region of the heart, and an in- ability of lying on the left side, though she could bear well the horizontal posture; and the urine but partially cleared. The length of the complaint afforded us an ample opportunity of trying most of the popular and celebrated remedies, tincture of cantharides, blue vitriol, the alka- line salts with bitters, expressed juice of artichoke, broom-tea, &c.: the three first of these with bad effect, the others with none. A sudden attack of convulsions, with violent head- ach, blindness, dilated pupil, and some degree of stra- bismus, which lasted several days, convinced me that fluid was accumulated on the brain; and she was twice relieved from this state, as rapidly as she had fallen in- to it. An ascites at length came on; and for the few last months of her life she was tapped almost every week, in the whole fourteen times; a fluid being at the first, as well as at every subsequent operation, drawn off, re- sembling in appearance soapy water, not coagulating at all by boiling heat, very little by nitrous acid, but a good deal by the acetate of lead. Flakes of lymph often obstructed the canula. As the disorder advanced, she became bloated, and lost her colour and appetite; the urine was less loaded, 82 ANASARCA, &C. FROM and more putrescent; and she died in a state of the most complete emaciation. This patient's illness continued for more than two years; and during the whole of that period, with the few exceptions before mentioned, she had discharged daily by the kidneys a considerable portion of the coa- gulable part of the blood. Such a loss, even if artifi- cially produced, no one, I imagine, could bear for many months together, without its proper signs, a bloated and cachectic habit. I consider the pericardium to have been the membrane most affected, from the seat of the pain and her frequently preferring the horizontal pos- ture; but some unlucky circumstance prevented my putting the truth of this conjecture to the test by dis- section. CASE III. R. B., aetat. 40, very intemperate in the use of fer- mented liquors, and liable to severe fatigues at night, in the winter of 1809 became universally anasarcous; and his chest was affected very soon after. He attri- buted the attack to cold. He was treated by drastic purgatives and squills without the least good effect, but on the contrary an aggravation of all its symptoms. There was a very general anasarca; a suppressed cough; expectoration of bloody frothy sputa ; pain un- der the right breast; difficulty of lying on that side; great dyspnoea; orthopnoea; frightful dreams; pulse 100, very obscure. The urine became turbid when cold, and deposited a copious, branny, and lateritious sediment. It coagulated at a very low heat, and in an unusual degree. I directed venae-section twice with considerable re- lief; and the blood, though rather watery, appeared to be in a highly inflamed state, as buffy as is ever seen in a pleurisy. In addition to these, the application of COLD, INTEMPERANCE, &C.—CASES. 83 a blister, and the use of half an ounce of infusum digi- talis three times a day, with what mild laxatives the state of the bowels demanded, speedily recovered him; and the urine became natural. His pulse was for a day or two alarmingly retarded. In a few months, from some irregularity, be had a slight relapse, and was again relieved by small doses of the foxglove in tincture, persisted in during some time. Under this plan his health seemed pretty well re-esta- blished. But his habits of life led him into excess; and two winters after, during the prevalence of very cold weather, he was again seized with signs of inflamma- tion upon his chest, and what I was alarmed at more than any thing else, dark sanious pleuritic sputa in the quantity of nearly one pint a day. His urine was every way loaded as before. This last symptom, as well as the dyspnoea, was relieved by digitalis; but the bloody sputum gradually changed into true foetid pus, and in six weeks he died tabid. CASE IV. E. J., aetat. 20, three months since, after unfmipl exposure to cold, became anasarcous, and complained of pain in her left side, with cough. She had been treated in vain with a variety of the common remedies, purges, squills, crystals of tartar, &c. I found the urine serous and rather tinged with blood, skin bloated and pale, legs swelled, pulse 90, hard, ab- domen flatulent; and she had a certain degree of dul- ness of apprehension, joined with deafness and tinnitus aurium. In the early part of her .disorder, leeches had been applied to the head, on account of some pain there which was never well defined. Soon after she had been put under my care, she was attacked suddenly, and without any apparent cause, by a most violent vomiting and diarrhoea, with head-ach of 84 ANASARCA, &C. FROM the most excruciating kind, a sensation as if the scalp were lifted by an internal force, some indistinctness of vision, intolerance of light, &c. She continued many days in the most excessive agony, the pupils neither fixed nor at all dilated, and the understanding suffering now and then only a momentary eclipse. Some blood was drawn from the arm, and observed to be consider- ably inflamed; and a blister was applied, but without any relief. About twenty-four hours before death, she fell into an apoplectic stupor. On examining the head, we found the veins of the pia mater turgid ; in each of the lateral ventricles about half an ounce of blood loosely and recently coagulated, with some serum ; the third and fourth ventricles filled With a similar substance ; and the brain itself in the im- mediate neighbourhood of these last considerably in- jured in its texture. The haemorrhage was traced to the basilary artery, which nearly at its bifurcation was dilat- ed into an aneurismal sac of the size of a horse-bean, and appeared to have opened into the cavities of the brain at the communication between the third and fourth vepjiicles. A considerable quantity of pretty firmly cpalgllated b?ood was found under the membrane co- vering the tuberculum annulare and medulla oblonga- ta ; and this extravasation extended further down in the course of the medulla spinalis, than we could readily follow by dissection. The blood, though firmly coa- gulated, did not assume the form of successive layers, as is usual in aneurismal extravasations of any long continuance. The artery was entirely sound and natu- ral in every other part of its course. The lungs were sound. There were adhesions on both sides of the thorax, rather recent on the left; the fluid in the pericardium nearly natural. A few lymphy spots were observed on the heart. The abdomen was free from any appearances of dis* ease. COLD, INTEMPERANCE, &C.—CASES. 85 The cellular membrane of the whole body, and of the lower extremities particularly, besides containing a quantity of serous fluid, was loaded with a coagulated semi-transparent substance, similar to that described in page 70. The very remarkable aneurism, which was the cause of death in this instance, was undoubtedly not the cause of the dropsy ; nor can we reasonably consider it to have produced the inflammation of the blood; the anasarca itself therefore was of the inflammatory kind; and in this dissection we have an opportunity, not often present- ed, of observing the effects of that disease, arrested, as it were, in the middle of its course. CASE V. M. B., aetat. 17, 1809, when she consulted me, had a considerable degree both of anasarca and ascites, a chorded pulse, dyspnoea, pain of the left side, with dif- ficulty of lying on it, cough, urine scanty, lateritious, and greatly loaded with serum. I ventured to draw some blood, which was found buffy; and the operation gave great relief. These symptoms had come on about six weeks be- fore, on her recovery from a febrile attack, called typhus, but which had probably left some congestion; as on her beginning to take, by the advice of her officious neigh- bours, large doses of bark in substance for the improve- ment of her general health, the symptoms above related had rapidly made their appearance. The apothecary added, that squills had rather aggravated her com- plaints. On scarifying the legs, much fluid was discharged from them, which gave hardly any signs of albumen by the common tests. The urine, at the same time, be- came copious and perfectly watery; so true is the re- mark of that excellent writer Van Swieten, that discharg- 86 ANASARCA, &C. FROM es from the legs often make a favourable change in the urine.* But the effect seldom continues long; it soon ceased in this instance, and the danger of sloughs is certainly so great as to preclude their very general use. Digitalis speedily and entirely relieved her. CASE VI. R. B., aetat. 35, accustomed to a sea-faring life, in which he had lately exposed himself much to rough weather, and been very intemperate, became, in the course of ten days, universally anasarcous, and felt some pain in his side, with cough and dyspnoea; the bowels costive, with tension of the abdomen; the urine scanty, depositing a red sediment, and coagulating by heat. Half an ounce of infusion of digitalis, twice a day, shortly recovered him. ' CASE VII. C. D., aetat. 40, was very extensively anasarcous, and somewhat oppressed in her breathing; bowels cos- tive ; urine natural in appearance, coagulating in some degree by heat. She attributed the attack, which was rather sudden, to checked perspiration. She speedily recovered by the use of digitalis. CASE VIII. R. F., aetat. 40, very intemperate, and long subject to a pain of the right side, in the winter of 1809, after the most excessive use of strong liquors, and some ex- posure to cold, became rapidly anasarcous, and affected with cough and slight haemoptoe. Bowels costive; urine coagulating. * Van Swieten Commentaria, 4to. torn. iv. p. 255. GOLD, INTEMPERANCE, &C.—CASES. 87 Digitalis in very moderate doses soon carried off his bad symptoms. The next winter he had a similar at- tack, relieved by the same means; but he does not re- gain any robustness of health. CASE IX. E. D., aetat. 30, a corpulent woman, of a phlegmatic temperament, had swelled legs during her pregnancy. After her confinement, her symptoms increased rapidly to a true anasarca; and she had much cough. I found the urine to coagulate. Digitalis entirely unloaded her; and she then took the Peruvian bark with great advantage. These cases speak for themselves; and it is, I trust, unnecessary to recall to the reader's recollection those signs of inflammatory disposition, which occur in many of them; the cough, pain, and stricture of the chest in some, the hard pulse in others, the occasional inability of lying on the affected side, the buffiness of the blood, wherever it was drawn. It is difficult to suppose, that the watery effusions are distinct from that character of inflammation, which we find so prevalent. The princi- pal danger arises undoubtedly from the latter, and from its great tendency to fix internally. If it can be checked before the inflamed surfaces are much altered, there is hope: if this alteration has gone to any extent, there is none, 88 CACHEXY. CHAPTER VI1 OF THE CACHEXY, WITH CASES AND A DISSECTION. The term, Cachexy, has not always been employed in the same sense by medical writers. Amongst the older physicians it was used to denote that remarkable state approaching to actual dropsy, in which the oede- matous swellings are slight, but the depravation of the whole habit very considerable. Linnaeus has most ac- curately and elegantly defined it by the words, pallor corporis ozdematosus cum debilitate et moerore; and Boerhaave has entered very minutely into its history. We have, on the other hand, the great authorities of Cullen and Sauvages, who express by this term not one disease, but a whole class of diseases, including emaciation, swellings, and defoedations of the skin. Dr. Cullen, in particular, asserts, that what the ancients call- ed cachexy, is the true dropsical habit, always the commencement of an universal dropsy, and therefore not requiring any separate consideration. It is certain- ly a dropsical habit, and disposed to terminate in the ex- quisite form of that disease, particularly if any attempt is made to remove it by inflaming and tonic remedies. But sometimes these patients, when the urine is greatly increased in quantity, as in the cases mentioned by Dr. Latham* and by Mr. Watts of Glasgow,f continue rather emaciated than truly xlropsical; and Boerhaave has well stated amongst the confirmed symptoms of cachexy, marcor vel leucophlegmatia et hydrops.% * Latham on Diabetes, p. 139. f Watts on Diabetes, case iii. p. 74. \ Boerhaave's Aphorisms, 1170. CACHEXY. 89 Van Swieten adds in his commentary, that if the urine is increased in quantity, the body wastes; if lessened, it swells. The latter is undoubtedly by far the most frequent occurrence. Altogether it differs so much from the common anasarca in its early symptoms, and often in its progress, that without any desire to restore obsolete terms, I think it necessary to give to the facts themselves a distinct consideration. The cachexy is usually marked from the very first by some disorder of the abdomen. The patient is dispirited, has no appetite, and digests nothing. There is likewise, even before the swellings make any pro- gress, a bloated, almost transparent, complexion, the truest proof of the body not being nourished. Where proper food is not abstracted, this deficiency can only have for its cause, either the imperfect conversion of food into chyle, or frequent losses of blood. Dr. Dar- win describes the extreme of the former of these causes, when he asserts, that occasionally, the liver failing in its office of secretion, the body ceases to be nourished, and the complexion resembles the transparency of a full- grown silk-worm, with a yellow tint not greater than is natural to serum. He thinks these patients die from inanition and want of chyle, and even proposes transfu- sion of blood.* A similar transparency of colour, though with more sallowness, has been compared by Mr. John Bell to modelled wax, and observed by him to originate in small repeated discharges, as, for exam- ple, the menorrhagia, the haemorrhoidal flux, the bleed- ing from stumps after amputation, and even the leucor- rhcea. He adds, that this complexion never quits the patient entirely, although he may recover from the dis- order. In the present instance, both these causes seem to unite; the food is imperfectly assimilated, and the * Darwin's Zoonomia, vol. i. sect. xxx. 1. 4.; and vol. ii 1, 2. 6. (12) 90 CACHEXY. coagulable part of the blood, generally, at least, if not in every instance, passes off by the urine. At what period of the disease this discharge takes place, and what share it has in producing the other symptoms, is worthy of serious inquiry. I have seen it when the legs only just begin to swell; and lately in two cases of ca- chexy threatening an entire dropsy, it was to my sur- prise wholly wanting. CASE I. W. E., aetat. 70, of a gouty habit, and very intem- perate mode of living, had been declining in health for nearly twelve months. His skin was remarkably pale and transparent, the pulse nearly 100, low and intermitting, appetite very bad, bowels irregular, faeces pale, urine almost colour- less. He did not lie easily on the left side, and complained of a stricture about the lower part of the chest and hy- pochondria, with some wheezing, and expectoration of a few dark sanious sputa. Suspecting a diseased liver, I ordered very mild mercurials, but without any good effect. He died not long after; a decided anasarca having at length come on, and the urine then examined being found serous. At what period this symptom began, it is now impossible to say. CASE II. W. N., aetat. 50, of intemperate habits; great feeble- ness and dejection of mind; complexion very pale and transparent; dyspnoea; short cough; stricture of the chest and hypochondria; loss of appetite; nausea; loose- ness of the bowels; faeces hardly coloured with bile; legs slighdy swelled; urine pale, scanty, when cold uni- CACHEXY. 91 formly turbid, and as white as if chalk had been mixed with it. It became clear on the application oi heat, and then soon coagulated. After the use of a dose or two of calomel, it had been observed once or twice to de- posit a bloody sediment. These symptoms had been forming about six months, and he soon became more entirely dropsical. Digitalis tried, however cautiously, debilitated him; squill acted not much better. Many mild diuretics were exhibited without effect. He pursued the same intemperate habits, and died not many months after. CASE III. E. B., aetat. 60; complexion pale and transparent; ancles swelled; pulse 80, weak and regular; shortness of breathing; cough; indigestion ; irregular appetite, and occasional vomiting of a fluid that in smell and taste she described as resembling Harrowgate water; faeces but little coloured; urine pale, natural in quantity, much loaded with serum. These symptoms were of three months' duration; she had long suffered from the species of indigestion above described, and a fulness of the right side, for which she had been treated by several courses of mercury; but particularly the very free and continued use of crude quicksilver, advised by the late Dr. Warren. She soon became anasarcous, and was unable to lie down in bed. The oedema, as is common in scorbutic persons, fre- quently attacked and quitted a part almost instantane- ously. She could now hardly be prevailed on to try any re- medies, and shortly afterwards died. CASE IV. Mary Bancroft, aetat. 58, Hospital, 1809. Her ap- pearance was marked by great dejection and anxiety, 92 CACHEXY. and a very sallow bloated skin. I observed that the conjunctival was not discoloured. There was consider- able dyspnoea on motion; the pulse 80, strong and quick ; slight swelling of the ancles; a general fulness of the abdomen ; and many signs of a loaded stomach, with foetid eructations and a bilious diarrhoea. Her urine was moderate in quantity, rather high-coloured, and coagulated by heat to a great degree. Milder laxatives failing, I was tempted by the severe bilious symptoms to give a few doses of calomel, which somewhat relieved the bowels, but certainly debilitated much. A slight salivation followed, with increased dyspnoea and pain upon the chest; the urine became more loaded than usual, and then for the first time, as far as was observed, deposited a bloody mucous sedi- ment. These circumstances induced me to draw off •some blood which was highly inflamed. The operation gave great relief, and was afterwards repeated to the fourth time with similar advantage. The tincture of digitalis was then directed in the quantity of seven or eight drops three times a day. It required as much laudanum to prevent its affecting the stomach and bowels, besides the frequent use of solid opium, and in that form was continued for more than two months, with a daily amendment of all her symp- toms, and particularly of the state of the urine. At the end of that period she was reported cured. About four months after, on exposure to cold, she was attacked with an inflammatory pain under the left breast, darting most acutely through the region of the heart to the blade-bone. It yielded to very large venae- section and gentle purges. The urine was not again loaded. A lapse of more than three years has now con- firmed her cure; and she is regaining a state of health and complexion much beyond what it was possible to calculate upon. What share of her recovery is to be attributed to thr CACHEXY. 93 opium, it is not easy to say. Dr. Mead cured by it one case of dropsy, which he supposed connected with pre- ternatural heat and inflammation of the abdominal vis- cera, and quotes Dr. Willis's authority for some simi- lar facts.* Dr. Heberden likewise speaks favourably of this remedy.f CASE V. R. B., aetat. 45 ; sallow and bloated skin ; pulse 100, hard and redoubling; loss of voice ; dyspnoea; inability of lying on the left side; stricture about the hypochon- dria ; abdomen swelled, but giving no decided sense of fluctuation ; frequent dark bilious discharges; oedema of the legs; eyes not tinged with bile ; urine of the colour and appearance of rennet whey, copious at night, pre- cipitating at 160°. Six months before, she had been attacked with in- flammatory pain of the right side, a large expectoration of bloody sanious sputa, called hepatic, and great dis- order of the bowels. These symptoms had continued, though with less severity, ever since. Soon after I visited her, there came on, from no ap- parent cause, a violent vomiting and constipation, at- tended by great oppression of the head. General con- vulsions succeeded, with a permanent stupor and fixed but not dilated pupil. The bowels at length yielded, and much black bile was discharged, but in vain. Dur- ing this struggle, which lasted four days, the oedema totally disappeared, the urine increasing in quantity and passing off involuntarily. Blood drawn on the third day was watery, but much cupped. Not more than two hours before her death, the pulse remained still quick and hard. * Mead's Monita et Precepta Medica, cap. 8th. t Heberden's Commentaries, page 224. 94 CACHEXY. We found, on opening the head, inflammation of the pia mater; the vessels overloaded with blood; and about a tabie spoonful of water in each of the lateral ventricles. In the thorax, the lungs were every where free from adhesions, and bore no marks of any inflammation ex- tending from the liver; but in the lower part of the right lung, there were many small coagula of extrava- sated blood, apparently seated in the cellular membrane, from which source probably the sanious sputa above mentioned originated. About four ounces of bloody serum were found on each side of the chest, and a small quantity of pale fluid in the pericardium. In the abdomen there was but little water; the liver hard, with a thick curled edge, its membrane being rather white and greatly thickened, and the surface ir- regular with tubercles. A considerable portion of its substance was divided into hard brown tubercular masses; but this process was least marked in the cen- tral parts, and seemed to have begun superficially. The other viscera of the abdomen were sound; I speak particularly of the kidneys. The absence of the bilious tinge in the eyes, and of the high colour of the urine, thought necessary signs of a scirrhous liver, is entitled to some notice; and I must request the reader particularly to attend to the state of the right lung, which I think demonstrates the origin of some of those spittings of blood connected with hepatic obstructions, without our having recourse to the sup- position of an adhesion of parts, and an inflammation of the diaphragm itself. The speedy termination of this case appears to have depended on a sudden dropsical metastasis to the brain, of which vomiting is a common sign. CACHEXY. 95 The transparency of complexion above described is sometimes connected with a remarkable paleness or loss of colour, as in the three first cases. In these very little bile appeared to reach the intestines, and none certainly was absorbed. Dr. Darwin thinks that a torpor or palsy of the liver exists in such persons, and adds, that he has in vain attempted to stimulate them by calomel and steel. We cannot be surprised at this want of suc- cess, when we recollect that mercury, which corrects an inflamed or active liver, frequently adds to a feebleness of that gland; and patients fall into such a state, who have often undergone courses of mercury for its sup- posed or real obstructions. As to chalybeates, I have found them to be rapidly and uniformly injurious. In cases IV. and V. there was a considerable sallow- ness, as well as transparency of skin, probably from ex- cess of bile, since there certainly was an overflow of it into the intestines. The presence of a bloody sediment in cases II. and IV., connected apparently with the use of mercury, is likewise entitled to some attention. ( 96 ) CHAPTER VIII. CASES RESEMBLING LAND-SCURVY. CASE I. W. S., aetat. 40, 1800, of very temperate habits, was attacked about six weeks before I visited him, with febrile symptoms, attended by incessant vomiting of bile and constipation. He complained particularly of a pain and trembling in the region of the stomach, great- ly increased by fermented liquors. After a few days this sensation was transferred from the stomach to the extremities, which became stiff and swelled, particularly at the ancles and knees. At the same time he was co- vered with petechias ; and an affection of the wrists and shoulders took place, not wholly unlike that proceeding from the colic of lead. In this state he consulted me. I found his pulse 90, and rather hard, complexion sallow and very bloated, a pale purple colour of the lip, dejection, dyspnoea, and such a loss of strength that he could hardly walk about. Round the ancles a slight impression of the finger was left on pressure; but his joints generally, and particular- ly the bendings of the knees, were rather tense than oedematous. There was some disposition to haemor- rhage from the nose. The urine was amber-coloured, moderate in quantity, and coagulable by heat. It was once or twice slightly tinged with blood. It did not change the colour of infusion of litmus CASES RESEMBLING LAND-SCURVY. 97 added to it within an hour after it was made,* and speedily putrefied. His quitting the neighbourhood at this time prevent- ed my attending to the case further. My short expe- rience of it showed me that he bore purging badly, and tonics still worse. I have since learnt that he became emaciated rather than dropsical, and died about twelve months after. CASE II. W. R., aetat. 50, of a very unhealthy habit, became suddenly feverish, and vomited bile, with great pain of the stomach and constipation; about a week after, pete- chias appeared with some little relief, and as the termi- nation of a febrile paroxysm. This patient had, when young, been affected with sea-scurvy. For nearly two years he had declined in health and spirits, and suffered much from violent ver- tigo. Twelve months since, he had consulted me on account of what I then thought a threatening dropsy of the chest. Without examining the urine, I had direct- ed calomel and squills, with one or two doses of which, as he informed me, he grew better. I saw him again about a month after the petechias had appeared, and found an irregular, intermittent pulse, palpitations, dysp- noea, languor, loss of appetite, bilious vomiting and purg- ing, sallow, bloated complexion, conjunctiva yellow, the slightest possible oedema of the ancles, urine loaded with serum, but not high coloured; which made me suspect that the yellowness of the eye was produced rather by an altered texture of the blood, than by bile. The bark and vitriolic acid brought on a stricture of * I omitted to mention, that a similar experiment was tried in the case related in the Introduction, page 11, with the same result. (13) 98 CASES RESEMBLING LAND-SCURVY. the chest; neither did a free use of lemons and oranges, or of the anti-scorbutic herbs, do any thing for him. He became dropsical, with signs of internal effusion, and died suddenly. Blood drawn in the advanced stage of this complaint, for the relief of his breathing, was found to be very buffy. CASE III. W. H., aetat. 60; pale complexion; anxiety; weak pulse; shortness of breathing; legs oedematous, and covered with small pulpy tumours, which, after inflam- ing, dispersed without bursting; a few petechias ; urine scanty, made frequently and in small quantities, parti- cularly at night; by heat, a little below boiling, it be- came very slightly clouded, and deposited an inconsi- derable coagulum by nitrous acid. These complaints were of some weeks' duration. The squill purged and nauseated him much, without any apparent advantage ; but under the use of decoction of bark and diuretic salt he improved rapidly, and soon recovered his former health. CASE IV. W. R., aetat. 35, June, 1803, had been long in the habit of great excesses in diet, and a very free use of spirits. He had been subject to discharges of blood, considered hasmorrhoidal, to pains of the head, epistaxis, haemoptoe, occasionally a nightly asthma, and what are called hypochondriac symptoms. He had the influenza in 1803, and did not well reco- ver from it. His cough remained; and his legs began to swell. I perceived in him a considerable distress in breathing, and a sallowness of complexion, with a re- markable purple tinge of the lips. The urine was pale CASES RESEMBLING LAND-SCURVY. 99 and coagulable. His dropsy increased. The legs at length began to discharge freely, and his breathing was so much relieved, that I ventured on the Peruvian bark. He thus became totally unloaded, and was thought to be recovering. But some inaccuracy of diet, of which he was frequently guilty, brought on a diarrhoea. To this, after it had continued not more than two days, suc- ceeded a bloody salivation, and an eruption of petechias. A sphacelus appeared on the ulcerated spots on his legs, and he was shortly carried off. I could not learn that he had taken any mercurials which might possibly ac- count for the salivation. If the cachexy approaches to the land-scurvy by a similarity of symptoms, these four cases are brought still nearer to it by the addition of a petechial eruption. Two of them in particular can be hardly said to differ at all from the purpura minutely described by Dr. Wil- lan.* It is important to recollect that this disease is not characterized by sponginess and bleeding of the gums, as an essential symptom; that it originates in causes materially different from those which produce the sea- scurvy, and is apparently of a more inflammatory na- ture. In the. two cases above alluded to, it was hardly possible to overlook the acuteness of the attack, the signs of inflammation in the upper part of the abdomen, and that remarkable metastasis to the surface of the bo- dy and the extremities. In some of these respects, they greatly resembled the case mentioned in the intro- duction to this work, as occurring at St. Bartholomew's Hospital, and in which nothing but the diabetic dis- * Willan on Cutaneous Diseases, vol. i. p. 467. 100 CASES RESEMBLING LAND-SCURVY. charge of urine appears to have prevented dropsy.* Venae-section would, I beiieve, have been their appro- priate remedy; in the early stage, probably a successful one; nor does the presence of petechias furnish any in- superable obstacle to such an operation. Sydenham considered purple spots as the height of inflammation in fevers. Dr. Darwinf met with several examples of petechias, vibices, swelled legs, and pulmonary haemor- rhage, which he calls scorbutic, attended by an inflamed blood; and Dr. Parry has inserted in the 5th volume of the Edinburgh Medical and Surgical Journal two in- stances of a similar nature. Such authorities stand in need of no addition, except in ascertaining the frequen- cy of the occurrence. An opinion of the great affinity between scurvy and dropsy has long prevailed; to which Sydenham alludes when he quotes the saying, ubi scorbutus desinit ibi incipit hydrops.% He considered it as the part of an erroneous doctrine then in fashion, by which almost all chronic diseases were at times pronounced scorbutic, and asserts the maxim to be true only in a more limited sense, that where the dropsy appears the preconceived notion with regard to a scurvy falls to the ground. But it seems to me not unaptly to delineate several of these cases, which are connected with dropsy by a resem- blance in the urine, and by a general similarity of symp- toms with the scurvy. Experience can alone show how far the coagulable state of this discharge extends in scorbutic cases. An assertion of Hoffman would lead us to believe that it is very common. He remarks, that in confirmed scurvy the urine is so loaded, that one pint of that fluid sometimes contains from three to four * Introduction, p. 11. t Darwin's Zoonomia, vol. i. sect, xxvii. 2. \ Sydenham. Opera, p. 276. sect. vi. cap. v. de Rheumat. CASES RESEMBLING LAND-SCURVY. 101 ounces of solid extractive matter, as ascertained by evaporation.* In chronic petechias this symptom is certainly not always present. In some mild cases, in one very se- vere case distinguished by sponginess of the gums and haemorrhages, in two where the legs were even swelled, no traces of it could be discovered. * Hoffmanni Opera, torn. i. p. 379 102 HYDROTHORAX WITH CHAPTER IX. CASES OF HYDROTHORAX, IN WHICH THE URINE WAS COAGULABLE BY HEAT ; WITH A DISSECTION, &C. CASE I. M. B., aetat. 40. Her legs were very slightly swell- ed ; but the state of the urine, independent of other cir- cumstances, would have instantly convinced me that these swellings were truly dropsical. It coagulated by heat much below the boiling. Her other symptoms were great debility and languor, with a sallow com- plexion, purple lips, abdomen greatly distended, and tympanitic, pulse 120, weak, regular, inability of lying on either side, some orthopnoea, great dyspnoea, and harsh ineffectual cough with much pain. She had been brought to bed about ten weeks before. During her pregnancy, she had suffered greatly from cough and pain of the right side. These increased much soon after her confinement, which she attributed partly to the cold lo- tions used at that period, for the purpose of stopping a severe uterine haemorrhage. She was in so weak a state, that evacuations by purg- ing could not be attempted. The foxglove affected her violently in the smallest doses ; and the preparations of squills seemed to increase her cough and difficulty of breathing. As she became oppressed with water, I thought it advisable to scarify the legs, which certainly was not done without temporary advantage; and whilst the discharge from them continued, the urine was more natural. She died soon after. COAGULABLE URINE.—CASES. 103 On examining the body, we found that the tympany observed during life was confined almost entirely to the stomach, which was excessively distended. There was some whey-coloured fluid in "the abdomen; the liver rather large, firm, and pale, but not otherwise diseased ; the kidneys remarkably small, and sound, if we except two or three hydatids, of the size of a garden pea, in the cortical part. The right side of the thorax was completely over- loaded with turbid water; the lung compressed to the size of a man's fist, and a very small quantity of pus, about half a tea-spoon full, deposited under the pleura pulmonalis, nearly as in the case described in page 95 ; the pleura costalis universally much inflamed, and co- vered with so thick a layer of lymph, as quite to ob- literate its surface; on the left side, the lung sound, and its membrane free from any great mark of inflammation, whilst the pleura costalis on that side likewise was coat- ed with.lymph, and there was a great deal of serum in the cavity; pericardium containing rather an unusual quantity of fluid; heart natural. CASE II. J. R., aetat. 60, of a gouty habit; pulse 80, strong, full, intermittent; palpitations; loaded countenance; cough; wheezing; dyspnoea much increased on motion; total inability of lying down in bed, till about two or three o'clock in the morning, when a little sleep is ob- tained, the suffocation in the beginning of the night being very dreadful; legs oedematous; hands slightly puffed; urine scanty, made frequently and with pain, and containing a branny sediment. Before it reached the boiling heat, it became slightly clouded, and de- posited a few flakes. Some years since he had been attacked by a palsy of the left side; the dyspnoea had been observed about six 104 HYDROTHORAX WITH months; and the cough and nightly suffocation rather more than three. Two drachms of infusum digitalis were ordered three times daily. Its diuretic effect followed rather unex- pectedly in four or five doses, and was attended by a great relief of his symptoms. His life was undoubtedly prolonged some years by the cautious repetition of this medicine; and he at length died from complaints of a very complicated nature. CASE III. L. B., aetat. 30, was labouring under the most ex- cessive dyspnoea, and orthopnoea, with an eager anxious countenance, very quick pulse, no sort of oedema, the urine pale, and coagulating at a low heat; complexion not sallow. He had suffered for several springs a pain in the right side, relieved by gout in the extremities; but in the preceding month of March this pain never quitted the region of the liver, and was attended by a conges- tion of the abdomen, which had caused the exhibition of many mercurial laxatives. At present the fasces were rather thin, and totally devoid of bile. The dysp- noea had come on and increased very suddenly, being altogether not much more than of a week's duration. The state of the urine, combined with other circum- stances, made me attribute it to one of those rapid effu- sions on the chest which sometimes occur, although his complexion had none of that sallow paleness so com- mon in this disease; and I despaired of his recovery. He took the digitalis with some relief for a few hours, but died two days after. CASE IV. J. R., aetat. 60, lame in the right leg in consequence of a scrophulous caries, was now labouring under de- COAGULABLE URINE.—CASES. 105 cided marks of hydrothorax, for which he had been tak- ing squills and calomel. I found him in a salivation, suffering from the most excessive dyspnoea, the pulse hard, blood much cupped, urine pale and greatly loaded with serum. Nothing could be done for him, and he died shortlv after. CASE V. W. H., aetat. 48, pale and bloated, with a remark- able purpleness of the lips, but no oedema of the ex- tremities ; pulse 80, quick, irregular; fulness in the re- gion of the stomach; flatulency ; costiveness; great dyspnoea on motion; a harsh and dry cough; urine con- taining a red sediment, and coagulating by heat some- what under the boiling. He had been falling gradually into this state for near- ly twelve months, and had been lately taking squill with some aggravation of his symptoms. Fifteen drops of tincture of digitalis every eight hours gave considerable relief, and enabled him both to lie down in bed, and to walk up hill with ease. For these two last winters he has been obliged to return very cau- tiously to the same remedy, and always with advantage. CASE VI. R. C, astat. 50, who had passed many years in the West Indies, and suffered from the disorders of that climate, consulted me by letter, from some distance, January 1808. He described himself as sallow, and rather bloated, but without any true oedema even of the ancles; as having an irregular and intermittent pulse, a short cough, and considerable dyspnoea after any exer- tion ; awaking also from his first sleep in severe suffo- cations, and being unable to lie down for the remainder (14) 106 HYDROTHORAX WITH of the night. The bowels were stated to be costive, and the urine high-coloured and foul. He added, that he had tried calomel and squill by the advice of a neighbouring practitioner without advantage, and squill alone in full doses, with a great increase of debility and loss of appetite. I declined prescribing for him till the state of the urine, with regard to heat, was ascertained, and was soon after informed by the attending practitioner, that on experiment it grew milky long before it boiled, when placed in a spoon over the candle. From this circum- stance, more than any other, I recommended the digi- talis, and with sufficient confidence to make him eager- ly enter upon its use. He took only two drachms of the infusion, twice a day, for a week. His symptoms were wholly carried off by it; but his pulse fell to 40; and for a day or two there was some alarm about him. A few weeks after he had strength enough to throw out gout. Every winter since he has had a slight attack, though very careful about cold; and he takes at those times, by my advice, no more than ten drops of the saturated tincture of digitalis twice a day, which uniformly re- lieves him. A larger quantity than this affects the pulse unpleasantly. As he is a man of observation, I can trust to his report when he informs me, that on the at- tack, his urine is not only turbid, but grows milky by heat, and so continues till he takes digitalis, when it uniformly clears every way. CASE VII. W. L., aetat. 30, subject in his youth to scrophulous disease and a caries of the bones, had for many years past been resident in London. For the last twelve months he had suffered under symptoms considered at first asthmatic, but afterwards assuming the complete COAGULABLE URINE.--CASES. 107 character of hydrothorax; for which he was originally treated on the tonic plan with* an increase of the dysp- noea ; soon after, by another physician with a salivation, that greatly debilitated him; and from a third, with rather better effect, he took digitalis mixed with purga- tives. He was at length recommended to try his na- tive air. When I was consulted for him in Exeter, I found him very weak and emaciated, with an irregular pulse never less than 120 in the minute, anasarca, cough, sputa slightly tinged with blood, pain of the right side of the thorax, and spasms extending down the whole of that arm. Mixed with these, there was a great deal of load in the abdomen, and other symptoms resembling the spasmodic asthma. The urine was generally pale and not otherwise remarkable; but when the dyspnoea was most severe, it grew foul and lateritious, and slight- ly coagulated under the boiling heat. This is one of the few instances which I have met with where such a character was temporary; perhaps it may occur in asthmatic cases more than in any other. Purgatives partially unloaded and relieved him; digi- talis rendered very little, if any, service; and he died suffocated. I learnt that the smallest dose of mercury had always injured him; and squill had usually augmented the dyspnoea to a most distressing degree. There was some obscurity in this case, which could have been cleared up by dissection only. The evidence of water in the chest was considerable; but there seem- ed still greater reason to believe that the viscera them- selves were unsound. CASE VIII. J. T., aetat. 30, January, 1812, was recommended from London to this neighbourhood for the sake of the 108 HYDROTHORAX WITH climate. I found his expectoration beyond any doubt purulent, his legs swelled, abdomen somewhat bloated, breath short with complete orthopnoea, urine scanty and high-coloured, depositing much sediment, and coagulat- ing in some degree by heat. In other respects there was a certain firmness of habit, which made me think him capable of bearing squills. He was not cachectic in his colour, was desirous of food, and appeared to digest it. I directed for him forty-five drops of the vinegar of squill every six hours. In the course of two days he was enabled to lie horizontally in bed; the swellings disappeared, and his urine entirely cleared in colour, se- diment, and coagulum. I consider it possible that, with such stamina, the ul- cer of the lungs may yet heal. CASE IX. R. N., aetat. 60, subject to irregular gout and dys- pepsia. I found his pulse quick, skin hot, considerable dyspnoea on motion, and even on speaking, great or- thopnoea, nightly suffocations, an inability of lying on either side, a very anxious countenance, legs oedema- tous and spotted with a few petechias, the urine rather copious, pale, crude, without any sediment, but coagu- lating at a low heat. There were likewise much indi- gestion and vomiting. These symptoms had been gradually forming for many months. They indicated unequivocally an exu- dation into some cavity of the thorax ; and a remarkable load about the heart, with a sense of fluctuation there often complained of by himself, convinced me that the pericardium was the membrane most affected. ^ Squiils had been tried without any advantage. The digitalis was then directed. It was exhibited in the quantity of half an ounce of the infusion daily, and cer- COAGULABLE URINE.—CASES. 109 fciinly showed very considerable power over the disease, by palliating the most urgent symptoms, and rendering the urine in every respect more natural. He was ena- bled to throw out a slight gout. As however the complaint was by no means carried off, the remedy was continued in smaller quantities. During the use of no more than two drachms of the in- fusion daily, a pain came on over one of his eyes. He complained of great disturbance of his brain, which he himself referred to the draughts; and within twenty-four hours this symptom was followed by a watery exhaust- ing diarrhoea and low delirium. General convulsions speedily ensued, in which there was complete insensi- bility and foaming at the mouth, with an almost total cessation of the action of the heart. From this state he was recovered by an opiate injection. Similar paroxysms returned two or three times dur- ing the next three weeks. In the intervals he became forgetful, delirious, and felt much pain in the head. The anasarca totally disappeared, discovering the most excessive emaciation ; his posture in bed became nearly natural, but his urine still coagulated; and in one of these convulsions he expired. Case I. is an example of hydrothorax connected with a very inflamed state of the membranes, and also of the lung. The deposit of pus under the pleura pulmonalis exactly resembled that mentioned in the article scarlati- na.* We see how perfectly impossible recovery was in the advanced stage, and how very different a system from that of diuretics was proper at any period. Per- haps there was a time when a paracentesis might have rendered service. '" Page 62. 110 HYDROTHORAX WITH In many instances it is probable that the internal membranes continue for a long period but little defaced, and still capable of some absorption; in consequence of which, relief is obtained by small doses of medicine for many years together ; but the parts seldom recover their proper tone, and are disordered by every irregularity, but particularly intemperance and cold. Dissections are wanting to explain their exact state. The prevalence of this disease in the gouty habit, and the relief which gout driven to the extremities gives, persuade me that the slow and insidious process here suspected is often of that nature. I likewise observe, that relief is more common, when there is a sediment, even of a pink colour, in the urine, than when there is none. It indicates indeed fever, but some strength of constitution to throw it off. There is a cough to which old gouty habits are liable in the winter-season, with milder symptoms than those described in the preceding part of this chapter, and yet sufficiently severe to excite great alarm and distress. The following is an example of it. E. L., aetat. 63, of a florid complexion, liable to year- ly fits of gout, and whose nephew "forms the subject of one of the preceding cases, in the winter of 1807 did not throw out this disorder to the extremities, but had a violent harsh cough, with nightly resdessness and fe- ver, swelled legs, and some degree of dyspnoea. Squills relieved him. The next year he fell into the same state, and that remedy entirely failed. On examining the urine, which his complexion and general appearance had not hitherto induced me to suspect, I found it to coagulate by heat, and to be rather high-coloured, though without sediment. Change of air and the return of warm weather for that time relieved him. He ceased to reside in this county, and died the next winter. COAGULABLE URINE.—REMARKS. HI I have known digitalis greatly disagree with these coughs; but whether from inaccuracy of dose, or the entire impropriety of the remedy, I cannot yet deter- mine. J . The reader may perhaps be of opinion, that case III. is of this kind, rather an example of gouty suffocation than hydrothorax. 112 > ASCITES WITH CHAPTER X. CASES OF ASCITES, IN WHICH THE URINE WAS CO- AGULABLE BY HEAT ; WITH A DISSECTION, AND REMARKS. CASE I. R. H., aetat. 60, pale and bloated; ascites; no ana- sarca ; urine slightly opaque under the boiling heat. A pain of the right side, with dyspepsia, and his very intemperate habits induced suspicions of a diseased liver; but he sunk rapidly under a mercurial course. CASE II. L. M., aetat. 13, suffered from a severe peritonitis, at the same time that I was attending, in consultation with Dr. Parr, her mother who died of the puerperal form of that disease. The daughter survived; but her abdo- men became distended and fluctuating. The urine, clear and without sediment, grew milky under the boil- ing heat. There was not the least anasarca. The navel soon after burst; and there were discharged from two to three quarts of sero-purulent fluid, with a complete subsidence of the swelling. She changed the air and gained strength; and I learnt that, after the fluid had collected and discharged a third time, the orifice quite healed, and she perfectly recovered. CASE III. R. Forward, aetat. 32, very intemperate in the use of fermented liquors, was infected with syphilis some COAGULABLE URINE.—CASES. 113 years since by her husband, and had undergone repeat- ed irregular salivations with partial relief. She was ad- mitted into the hospital as an in-patient, for the remains of that complaint, but soon afterwards, at her own de- sire, went into the country, where for more than six months she kept herself under a constant course of mercurial friction, both whilst pregnant and after her delivery. She was re-admitted under my care, 1810, on account of the debility which this course had occa- sioned. There was a very considerable ascites, Math some slight swelling of the lower extremities, a total loss of appetite, glossy red tongue, irritable bowels, and a low pulse. The urine, far from being scanty, was made in the quantity of two quarts every night, and about one quart in the day. It was pale, without the least sedi- ment, and coagulated by heat. Sarsaparilla passed through the bowels rapidly. By- rne exhibition of two or three small doses of digitalis, the ascites was somewhat relieved, but only to give way to tympany; and such debility and diarrhoea en- sued, as made it necessary to support her by wine and cordials. From this situation she rallied, could not bear the smallest dose of digitalis, and fell at length in- to a completely typhoid state, with brown crust of the tongue, repeated aphthae, sordes about the teeth, refu- sal of all food, and a gradual reduction of the swellings. The bark at all periods produced an increased and pain- ful tension. She died after lingering in this state more than six weeks. On examining the body, we found that the puffy node on the forehead concealed a caries which reached to the frontal sinus. In the body of the tibia likewise was a large abscess. On the right side of the abdomen a considerable vis- ceral hardness was felt externally. It was produced by the remarkable shape and enlargement of the right lobe 114 ASCITES WITH of the liver. The whole of that gland was unusually weighty and solid, with membranous thready marks on its surface, when cut, firmly resisting the knife, and of a texture resembling the incipient scirrhus. Its edges were blunt, rounded, and thick; and its size unusually great. A natural variety perhaps contributed to this bulk; for whilst the right lobe projected downwards in a thick large mass, the left was subdivided into several lobules, so as to expose almost the whole of the gall- bladder. The concave surface of the liver was some- what connected to the neighbouring parts by mem- branous adhesions, as was likewise the spleen. The gall-bladder was filled with a dark green bile. The other viscera were sound, except the kidneys, which were remarkably solid and hard, and their structure somewhat confused. I considered it approaching to scirrhus. In the cavity of the abdomen there was about a pint of serum, which coagulated by heat more firmly than usual. The heart was very small; the lungs sound, adhering to the pleura in some places, and their cavities containing no fluid. The purulent fluid discharged from the cavity of the abdomen in case II. is worthy of particular notice, es- pecially as there was not the least appearance of any other dropsical accumulation which might be thought to supply, by absorption, the serum present in the urine. I request the reader to connect case III. with diose related chapter VI. section II. under the article, mercu- ry. The hardness and enlargement of the liver pro- bably originated in the excessive use of spirituous liquors; but it is at least worthy of remark, that the freest and most continued exhibition of mercurv afford- COAGULABLE URINE.—REMARKS. 115 ed no relief; how far it aggravated the complaint is a more doubtful question. There is something likewise very uncommon in the state of the kidneys here described.* I am not aware that such a hardness approaching to scirrhus has ever been attributed to the use of mercury ; yet in another case, where mercury had been employed to a great ex- tent, the kidneys were observed to be unusually firm.f * See Baillie's Morbid Anatomy, p. 181. (article, Kidney Scirrhous.) t Page 70. 116 HYDROCEPHALUS WITH CHAPTER XI. CASES OF HYDROCEPHALUS, IN WHICH THE URINE WA3 COAGULABLE BY HEAT, OR CONTAINED A BLOOD\ SEDIMENT ; WITH A DISSECTION, &C. The following cases of hydrocephalus internus might perhaps with equal or more propriety have been ar- ranged under the several heads of scarlatinous and mer- curial dropsy ; but the accumulation to which they re- late is of so much importance, that I prefer placing them in a separate article. CASE I. J. W., aetat. 10, excruciating pain in the forehead, attended by the most incessant screams; squinting of the left eye; pupil fixed, but not dilated ; frequent and violent convulsions of the whole body ; pulse 60, ir- regular in strength and number, and often intermitting; urine foul, dark-coloured, depositing, as soon as it was made, a sediment slightly tinged with blood, and giving a large coagulum at a very low heat. No part of the body was oedematous. The bowels had been regularly opened. I entertained no doubt, that this was a case of incipi- ent hydrocephalus; and indeed, whoever candidly reads the whole of this statement, must be of the same opi- nion, unless he has commenced his studies on these subjects with determining, that water in the head is never cured. This child had suffered about a month before from scarlatina, the symptoms of which had not been very COAGULABLE URINE.—CASES. 117 severe; a fortnight afterwards he had become anasar- cous, and appeared to be relieved by a few purgatives, united with squills; the anasarca, however, had left him in a sudden manner, and from that time he had com- plained of pains in his head, which rendered him heavy and ill-disposed to move. On the morning of that evening on which I saw him, he had waked after a disturbed night, totally blind and with the symptoms before detailed. Not willing to wait for the slow operation of leeches, I requested that the temporal artery might be opened, which was done with great adroitness, ten ounces of blood being drawn off very rapidly. The head was somewhat relieved by this operation. His bowels were then unloaded by a colocynth injection, and a dose of jalap, to which was added a quarter of a grain of digita- lis. A large cap-blister was likewise applied, covering the whole scalp, and three drachms of infusion of digi- talis given every eight hours. Under this plan the con- vulsion speedily ceased; correct vision returned; and the urine became natural. A few days after, whilst this remedy was still con- tinued, some pain of the head returned, with great con- fusion of thought, and the urine was again observed to be tinged with blood. It likewise precipitated by heat, but not till it began to boil; and the coagulum was so / loose, that I was very confident, from former observa- tion of this fact,* tonics were demanded. He according- ly took the cinchona in substance, and speedily recover- ed. Three years have now confirmed his cure. CASE II. J. E., aetat. 7, of a scrophulous habit, and whose fa- ther had died phthisical some years before, was affected, * Pages 59 and 60. 118 HYDROCEPHALUS WITH June, 1804, with common febrile symptoms attended by vomiting and costiveness. For the purpose of open- ing the bowels, repeated doses of calomel were given at very short intervals, and the object fully obtained in the discharge of black liquid stools, such as are not only brought off by mercury but often entirely caused by it. To produce this result, two scruples of calomel had been given in forty-eight hours. I was consulted on account of a very sudden pros- tration of strength, that followed. It was attended with a soreness of the gums, some effort at salivation check- ed by an exhausting diarrhoea in which the stools were devoid of bile, a pulse irregular in number, strabismus, and low delirium. These increased in a few days to stupor, hemiplegia, convulsions, &c. which shortly ter- minated the scene. The urine was likewise observed to be very foul and greatly loaded with a most offensive bloody sediment, no blister having been at that time applied. On examining the head, we found the veins of the pia mater turgid, that membrane inflamed, the lateral ventricles distended and containing nearly three ounces of watery fluid, which was more turbid than usual and coagulated both by heat and acids in a degree not com- mon. The surface of the ventricles appeared dull and clouded, the neighbouring brain very soft and covered with red points. I,more particularly noticed the condition of the sur- face of the ventricles, because it is undoubtedly mem- branous,.and proved indeed by anatomical demonstra- tion to be a direct continuation of the arachnoid coat. In respect to their covering, therefore, they resemble other perfect cavities, and we may reasonably suppose them to be liable to the same processes both of health and disease; amongst the latter of which an inflamma- tory dropsical effusion is perhaps the principal. COAGULABLE URINE.--REMARKS. 119 Case I. we must acknowledge to have been, in its termination at least, very unusual; but I hope, that the treatment so successful in it may be advantageously followed. Dropsical metastasis, particularly from the chest to the head and the contrary, have been often mentioned jby practical authors ; this is an example of metastasis from the extremities to the head, and favours an opinion, that such accumulations are rather of an active than a passive kind. Case II., which I beg the reader to compare with case III., page £7, is, I fear, one only amongst many instances, in which calomel, pushed to an improper ex- tent in very young persons, has been productive of the most fatal results. A general opinion prevails, that their constitutions resist mercury in a remarkable degree. Its entrance into the system they certainly do resist, more than we could expect; but they are greatly over- come by salivations; and the possible occurrence of such accidents may well set us constantly on our guard. These few cases furnish no decided inference with regard to die state of the urine in hydrocephalus gene- rally. An hydropic habit is probably attended by its proper constitutional signs, on whatever part it falls; but when scrophula or other causes locally affect the brain and produce an effusion, we are by no means entitled to expect the same changes in the blood and the secretions, as are observed in original dropsies. But experiment should in future supersede all conjec- tures on this subject. 120 RECAPITULATION. CHAPTER XII. RECAPITULATION. From the foregoing cases it is evident, that the urine of dropsy assumes very different, and even opposite, ap- pearances ; and that though it often errs, as indeed we might expect it always would, by an excess of colour, sediment, and extractive matter; yet that sometimes it verges towards the opposite extreme, is apparently lit- tle animalized and crude, does not seem to possess the appropriate characters of urine, and is, I suppose, parti- cularly deficient in what the chemists have lately called urea. I consider the former of these to indicate a strength of constitution, but an internal obstruction, and to require both active diuretics and deobstruents ;* the latter to denote a feeble and impoverished habit, either simply, or combined with great disease and with an en- tirely broken state of health, f In the midst of these extremes it need not surprise us that, if the constitution is not greatly shocked, or the extravasation be small, this secretion should occa- sionally differ but little from the healthy state.! In addition to those characters which are discoverable by mere inspection, there is another infinitely more important, its property of coagulation by heat.§ This property is not connected exclusively with any particu- lar situation of the accumulated fluid, nor with the af- fection of any particular organ. It very generally, al- though not uniformly, attends what may be called ori- * Chapter IV. | Chapter II. * Chapter III § Chapter V RECAPITULATION. 121 ginal dropsy, and frequently is superadded to great vis- ceral unsoundness; and there cannot be a more fruitful source of error in practice, than to consider it as an evidence of mere debility, a term so incorrectly applied to several different species of disordered action. In short, it occurs under a great variety of circumstances, and where, from a resemblance of other symptoms, it has been most expected, is sometimes absent. The laws that regulate its appearance, what it denotes, and what it requires, have been hitherto almost equally un- noticed. But is it possible, that such facts can be indifferent? or will any one flatter himseif that he understands an individual dropsical cast, whilst he overlooks this im- portant feature of it? The neglect, which it has received from practitioners in general, makes me almost mistrust myself, when I estimate it so highly; and I should be unwilling to strain any consideration in medicine, as is too often done, beyond its reasonable and proper value. But it really does appear to me, that a more correct ap- plication of diuretic remedies is one only amongst the many advantages which may be derived from this dis- tinction ; and that it will hereafter be found capable of explaining many doubts, of reconciling many apparent anomalies, and of affording an insight hitherto rather de- sired than expected into the state of the blood and the secretions. I shall therefore dedicate the remaining pages to a more complete investigation of its nature, founded in a great measure on the preceding cases, partly on others which it is unnecessary to detail. Of the encysted dropsies I have designedly omitted to speak; because, as the very term implies, consisting of accumulations not diffused through the natural ca- vities, but confined -to cysts usually either hydatids or an enlarged viscus, they admit neither of the same ex- planation nor the same relief diat is applied to the dis- orders of serous membranes. (16) 122 RECAPITULATION. The ovarian dropsy, the most common of these, can be viewed only in the light of an enlarged viscus; and I have not found the urine to be distinguished by any very remarkable qualities. ( 123 ) CHAPTER XIII. OBSERVATIONS ON DROPSIES WITH COAGULABLE URINE, DERIVED FROM THE PRECEDING CASES, &C. In treating of dropsies distinguished by a coagulable state of the urine, it appears to me desirable to bring first into view those facts, which relate to the nature and degree of that coagulation, and whatever else there may be remarkable in the urinary discharge. In the succeeding sections of this chapter, the symp- toms of the disease are described, both where the drop- sy is universal, and where it is confined to a single ca- vity. As the effects however of water pressing on any particular organ must be nearly the same, whatever be its constitutional cause, little novelty can be expected in this detail. Nor indeed could I flatter myself that the history of the general symptoms would be agreeable to nature, if it did not in most important respects coin- cide with the descriptions of dropsy given by preceding writers. I have found it however necessary so far to deviate from the common arrangement, as to include in my description some cases of Cachexy distinguished rather by emaciation than swelling. The character of the urine has proved these to be of a truly dropsical na- ture ; and nothing but an increased quantity of that dis- charge, however bad its quality, has prevented the ap- pearance of anasarca. In some of them the increase is so great as to constitute a diabetes; and I have thought these entitled to particular notice in the last section of this chapter, under the name of Diabetes Serosus. The remaining chapters are occupied with the causes and treatment of the disease. 124 OF DROPSIES WITH SECTION I General Appearances of the Urine. The coagulation which takes place in dropsical urine is vei) various in its extent. Sometimes this fluid be- comes opaque and milky at 160° or less, and soon breaks into small coagula, or even forms further into a mass nearly solid.* In other instances it undergoes no al- teration till it almost arrives at the boiling heat, becomes then slightly opaque but not milky, and gives a precipi- tate both small in quantity and loose in its texture. More rarely, although the change is inconsiderable be- fore it boils, the least evaporation converts it into a tre- mulous mass.f The exact state of dilution, in which the serum is present, is not very easy to be determined. Undiluted serum coagulates in a mass, into the composition of which it is evident that much water enters; whilst the coagulated part of this secretion is more separated from its water, more opaque, and resembling lymph or curd; and I have not been able by any artificial dilution of serum to produce exactly the same appearances of coa- gulation. In one case, and that not apparently the most severe, I obtained from four ounces forty grains of a firm white coagulum, which lost by moderate desicca- tion one-fourth part of its weight, and was in the propor- tion of two ounces to the quantity of urine discharged daily.J In another, there remained on the strainer se- venty-five grains from four ounces, in the proportion of ten drachms daily, which was softer and was reduced * Page 79 ; and Rollo on Diabetes, p. 447 and 448. t Page 66. \ Page 68. COAGULABLE URINE. 125 by moderate desiccation to nearly one-half of its* weight. In its least degree it barely tinges the boiling fluid.f The nitrous acid produces a similar effect; and per- haps may sometimes succeed, where the application of heat fails. But the latter of these shows both the extent and mode of coagulation with much nicer precision: and besides the superior facility with which it is em- ployed, it has the great advantage of leaving the fluid free for further experiment. The oxymuriate of mercury, which detects very mi- nute quantities of albumen, is a test not particularly useful here; since it acts on the urine in many other ca- ses of dropsy,J and in some inflammatory disorders ; nor is it yet ascertained, to what extent this coagulum con- sists of albumen. Infusion of galls produces a large precipitate; the fluid strained after coagulation by heat, is of course less affected by this test, and has been found to leave but a small extract on evaporation. This kind of urine is not unfrequently tinged with red blood,§ and occasionally deposits pieces of lymph, and a bloody and very offensive sediment which does not re-dissolve by heat. || In other respects it varies much, and in nothing more than in quantity, being sometimes very copious, so as almost to assume the character of diabetes,^ more fre- quently scanty. It is rarely high-coloured, when made, but often deposits a branny and lateritious sediment, or even a white one, as if chalk had been mixed with it,** rarely of a bright pink colour; it likewise putrefies soon, * Page 80. t Pages 103, 107, 112. | Page 44. § Pages 83, 91, 96. || Pages 59 to 61, 92. If Introduction, page 11; pages 68 and 113; and Watts on Diabetes, page 74. ** Page 91. 126 OF DROPSIES WITH and at least within an hour after it has been made, has been found to have no effect on vegetable blues.* In some cases, on the other hand, it appears remarka- bly devoid of those sensible properties which common- ly distinguish urine, and is probably deficient in urea. In this state it is perfectly clear and aqueous, apparently unanimalized, and what has been called crude; shows an excess of acid by reddening infusion of litmus, which property it long retains, and continues for a much long- er period free from any evident decomposition.f It at length putrefies. The quantity of animal matter which it contains would lead us always to expect a very rapid putrefaction ; and there must be something extraordina- ry in its other combinations, which enables it in any in- stance so long to resist that process. It would be of great practical importance to pursue this inquiry further, and likewise to determine on the other hand by accurate experiments, whether the serous urine, at the time of its being made, is ever without an excess of acid; and still further, whether it is in any degree actually alka- line. I have occasionally tried some other common re- agents, such as the acetate of lead, pure ammonia, mu- riate of barytes, &c. but without any very important or satisfactory results. This discharge has seldom been observed without some signs of dropsy, although they may be as yet ap- parently slight, amounting to nothing more than an oedema of one leg,J or a generally bloated habit. § At what precise stage of the disease it begins, whether gradually or at once, and whether it ever precedes the dropsical symptoms, would be a task of some labour to ascertain; certainly, when it has once formed, it conti- nues with a very considerable regularity, most severe perhaps before there is much anasarca, and gradually * Page 97, and note in that page. f Pages 68 and 80. \ Introduction, page 11. § Pages 96 and 97. COAGULABLE URINE. 127 rather declining towards the fatal termination; though even this uniformity of its continuance I do not consi- der to be a constant law.* With the first appearances of amendment, the urine becomes more diluted. This favourable change parti- cularly follows scarificationsf and tapping ; but it then generally lasts only a few days. The blood, in most instances in which it has been drawn, has been found buffy, often much cupped,! and remarkable even as it escapes from the vein, watery and of a dull colour very opposite to florid. The quan- tity and firmness of the albumen in the urine bear usu- ally a direct proportion to the appearances of inflamma- tion. Some portion of it, however, is consistent with a condition very opposite to the inflammatory, and even where Peruvian bark has effected a cure.& With re- gard to the absence of inflammation, much may be de- termined by the looseness of the coagulum, and the high degree of heat required for its precipitation. Thus distinguished, I have known it re-appear with signs of great feebleness in the constitution, where digitalis has been continued too long, and after all the accumula- tions have beenjj removed. Similar effects have speed- ily followed the use of mercury given improperly, and during the existence of an internal ulcer. If * Page 107. f page 85. t Pages 65, 67, 69, 78, 82, 84* 85, 92, 93, 98. Watts on Diabetes, page 83. § Page 78. || Page 59. f Pages 72, 73, • « 128 OF DROPSIES WITH SECTION II. Symptoms of Anasarca and general Dropsy, includ- ing Cachexy, tyc. The diffused and general dropsy here described sometimes come on very suddenly and in habits pre- viously sound; often their approach is more gradual, being apparently the result of what is called, a broken state of health. The dropsy which takes place after scarlatina is of the former kind; and if it be considered of much im- portance to trace the discharge from its commencement, will afford us the most favourable means of doing so. It is likewise observed, particularly in those cases where the intensity of inflammation has fallen rather on the skin than the throat, after a mild disease, hardly ever in consequence of the severer form of it, the angina maligna; and 1 have thought, that a discreet use of the cold affusion has prevented its occurrence. From a very obvious difference in the character of the swellings, it has been divided into the hot and cold oedema. The former comes on from a week to ten days after the disappearance of the eruption, and is attend- ed by a fresh accession of fever, with great restlessness and irritation. The joints speedily become painful and swelled, particularly the knees, ancles, and wrists, and in a form greatly resembling the acute rheumatism, or rather gout; I have even noticed an extravasation of fluid in the large bursa above the knee; and the pains to dart in the course of the muscles. In a few days more the swellings gradually subside, or change into a true oedema. COAGULABLE urine. 129 Not unusually the anasarca shows itself without much pain or inflammation, and the face and extremities be. come suddenly bloated. This takes place with a less exact limitation as to time than the former, even as late as a month after the decline of the efflorescence, and when the patient has been apparently recovering his strength. I speak with greater precision to the coagu- lable state of the urine in the latter case, than in the former. A dropsy of the large cavities very commonly ensues; in this way the abdomen is often affected; but the tho- rax is more disposed to show signs of inflammation. As however the viscera are for the most part sound, it is commonly the fault of the practitioner if any fatal mischief takes place. From this probability of recove- ry I must except the hydrocephalus, in which the parts concerned are of so tender a structure, as seldom to bear much pressure without irreparable injury to their organization. The urine in this attack is often singular,even in its appearance, being turbid when made, of a very offensive smell, and resembling water in which flesh had been washed, as has been already remarked by Burserius. On standing it becomes clear, and deposits a bloody sediment. I have suspected that this state sometimes followed the very free use of calomel, a practice much too indiscriminately resorted to in the febrile complaints of children; but I cannot deny that it has appeared, where not only no mercury, but no medicine of any other kind, had" been exhibited during the whole illness.* It should, however, give an immediate alarm. It is the effect of an aggravated hydropic habit, and requires the utmost activity as well as caution on the part of the practitioner. In young and scrophulous subjects, this tendency to * Page 61. (17^ 130 OF DROPSIES WITH effusion, is apt to be speedily translated to the brain; and sometimes with a most terrible violence. A pain between the brows and heaviness of a few days' dura- tion are succeeded by symptoms of hydrocephalus that cannot be misinterpreted; a pulse preternaturally slow and irregular; convulsions; inability to bear the upright posture; frequent exclamations of, Oh! my head! the most incessant screams, as if the skin were pinched; blindness ; strabismus ; dilated pupil; and in the very- last stage again, a great rapidity of circulation, with paralysis on one side of the body, whilst the other is convulsed. The emaciation, in such instances, is observed to be singularly rapid; what is commonly the effect of an atrophy of many months, taking place in a few days. A slow and interrupted pulse is likewise amongst the most distinctive symptoms of incipient pressure on the origin of the nerves; and hardly ever, I believe, origi- nates in children from any other cause. Its presence is nearly conclusive. The anasarca* generally disappears in a very delu- sive manner at the beginning of this attack on the brain, as if connected with the translation of some inflammatory process; for that a mere feebleness and loss of tone should suddenly be transferred to a distant part, carries with it no air of probability. A similar metastasis has been observed from the chest to the head. Both in adults and children, convulsions often give the first warning of this sudden change of the seat of the disor- derf, whilst in the primary and original hydrocephalus many other decided symptoms precede this. The dropsy from drinking cold water is likewise acute, and speedily follows the application of the excit- ing cause. The same suddenness of attack is some- times observable, where the cause is less obvious, but * Page 117. t Page 81. COAGULABLE URINE. 131 usually in the opinion of the patient connected with the external application of cold. Obscure chilliness is suc- ceeded by heat and increased action, such as the phleg- matic constitutions most liable to these complaints are capable of raising, and particularly by a pain in the side. But the attention is soon diverted from these to the ana- sarcous swellings, which come on to a greater extent, and with more rapidity than are observed in any other instances. I have known a single fortnight completely sufficient for this effect; and the vulgar have attributed it to witchcraft. An oedema is now and then propagat- ed over the whole body from one of the lower extre- mities, which for a few days had been observed to be rather painful and tense.* The scarlatina likewise furnishes examples of this kind ;f and Dr. Monro men- tions a similar fact in consequence of a sprain of the wrist.:}: The mechanical pressure of these diffused swellings will of course affect the breathing to a considerable de- gree ; but the harsh cough, discoloured sputa, stitches in some part of the thorax, and inability of lying on one side, show that the cause of this dyspnoea is often more deeply seated. The abdomen likewise becomes bloat- ed, with thirst, costiveness, and some difficulty of pro- curing discharges. The pulse is generally hard or ob- structed, and rising on blood-letting; the blood inflam- ed. This disease, if treated with indiscriminate remedies, proceeds to a fatal termination. The patient falls gra- dually into a cachectic state, and loses his appetite and digestion. Water accumulates in most of the great ca- vities ; least frequently, perhaps, when the patient is of mature age, in the ventricles of the brain, but very sud- denly ; and the absorption from that part has been * Pages 80 and 81. f Page 58. | Monro on Dropsy, page 10. Note. 132 OF DROPSIES WITH known to be as sudden as the deposition.* In the tho- rax, it is most common, most distressing, and product- ive or the greatest anxiety of mind. In some instances a sudden death happens from this cause; in others a more lingering one, connected with sloughing ulcers of the lower extremities. In the last stage, the dropsy often disappears; the abdomen becomes flaccid; and a superficial observer might think some great relief were at hand. But the urine is never natural; a tympany succeeds to the as- cites ; the strength and nervous influence daily fail; the brain appears affected; and the scene is not closed, till after the most complete emaciation has taken place. Nor do I know any sign more delusive, than a subsi- dence of the swellings, and an increased quantity of urine, if the character of it be not improved. The natural cure is effected, either by a copious flow of diluted urine, which, if not strictly speaking sponta- neous, is at least unexpected, and originates in circum- stances of diet thought trifling, or by excessive discharg- es from the legs. A diarrhoea and sweating very rare- ly supply the place of these. It is not to be supposed that the sudden and univer- sal anasarca, here described as particularly following scarlatina and the extraordinary action of cold, is the most common form of the disease. Often the exciting cause, particularly if connected with intemperance, ope- raies less immediately and by repeated impressions; in consequence of which the accumulations are more gra- dual and apparently milder in their symptoms, but with much greater difficulty carried off; "their prevalent cha- racter, however, appears to be the same, and will cer- tainly be best illustrated by contemplating attentively the more marked and unmixed cases. A purulent expectorationf is not very unusual, either * Page 81. f Pages 82. 108. COAGULABLE URINE. 133 as the result of that same distemper of the constitution which produces the dropsy, and in such instances has affetted more than one order of parts, or as preceding it, and predisposing to it, and materially altering its nature. Sometimes the principal severity of the disorder falls, from the very first, on the viscera of the abdomen. The patient has been sallow, and not positively well for some weeks ; and at length, in consequence of some occasion- al cause, not always correotly ascertained, but referred generally to cold and inaccuracy of diet, is attacked by symptoms more decidedly febrile or rather inflammato- ry ; rigors, heat, great thirst, pain in the region of the stomach, vomiting, by which green bile and occasion- ally blood is thrown up, a loaded yellow tongue, ten- sion of the hypochondria and costiveness, to which suc- ceed bilious and even bloody discharges. The pain, which has been described as attended by a remarkable fluttering, has been known to be suddenly translated to the extremities, with a sort of scorbutic puffiness of the knees, ancles, and wrists, and a weakness of the latter resembling the paralysis from lead.* Petechias like- wise have made their appearance with some temporary relief, f The patient speedily becomes so feeble and short-breathed, that he can hardly walk about. The dejection of spirits is excessive, and the sallow, bloated, appearance of the skin truly remarkable; but the body rather emaciates, than swells greatly; and it is late, be- fore any decided signs show themselves of accumula- tions in the thorax and abdomen. A natural or increas- ed quantity of urine usually retards these. Haemor- rhages and foul ulcers are also very apt to occur. Un- der such aggravated circumstances, the blood has been found inflamed; and Dr. Darwin's authority, already quoted, is very strong in proving a similar fact.J Al- * Page 96. t Pages 96, 97. $ Darwin's Zoonomia, vol. i. xxvii. 2. 134 OF DROPSIES WITH together these symptoms have such a resemblance to the land-scurvy, that I really know no sign by which they can be distinguished; and I believe that many of the cases, published under that title, are in fact no other than the disease here described. The above acute attack of cachexy, if I may use that term, is however comparatively rare. More fre- quently these signs of an utter depravation of the habit come on in a gradual manner, and with no very sudden exacerbation. They have been in a great measure al- ready enumerated: thirst; habitual fever; loathing of food, with a rotten taste in the mouth; costive but very feeble bowels; dyspnoea on the slightest movement of the body, and even on speaking ; palpitations; a short cough; swellings of the ancles: emaciation of the rest of the body ; a paleness and transparency of complexion, with a pearly colour of the conjunctiva, from which the red vessels disappear, and a death-like paleness of the lips; or a considerable sallowness of skin, with an over- flow of bile; urine made rather frequently, particularly at night, and apparently crude, but now and then de- positing a bloody sediment. Dropsy generally ensues, unless prevented by diabetes; and the prognosis is un- favourable. Under such circumstances of impaired digestion and colour, our suspicions are reasonably directed to the viscera of the abdomen. There is not always, however, any decided proof of the exact nature of the injury; and in some instances it seems doubtful, whether the structure of these parts is affected, or only their secre- tions. That failure of the biliary secretion which is indicated by a complexion perfectly pale as well as transparent, is a very bad form of the disease. Greater sallowness of colour and an overflow of bile are the evi- dence of more activity, and permit the use of remedies. Linnaeus has sketched the outlines of this cachectic state with the hand of a master, when in defining it he COAGULABLE URINE. 135 has used the words, "pallor corporis cedematosus cum debilitate et mcerore." These terms appear to me so descriptive, that I have already quoted them in the for- mer part of this volume, chap, vii., and to that and the succeeding chapter I beg leave to refer the reader for further observations on this subject, and on the purpu- ra, or land-scurvy. As the complaint advances, what are called bilious and rotten sputa are often expectorated. The appear- ance of these, joined to a peculiarly offensive smell of the breath, has been thought particularly to indicate a scirrhus of the liver; but the surface from which they originate has been much mistaken, when it has been supposed that some morbid communication exists be- tween the liver and lungs by adhesion, which furnishes a passage from the former into the bronchia. The dis- section recorded in page 94 is a sufficient proof, that such sputa may be connected with a scirrhus of that gland, and yet the diaphragm remain sound. Such a communication, indeed, and a true bilious spitting, I believe to be, in this country at least, a very rare occur- rence ; and I am confident, that the facility with which purulent spittings attended by bilious symptoms, are called hepatic, is the source of infinite mischief by ap- pearing to justify, what can rarely be justified in inter- nal ulcers, a mercurial course. The anasarca during courses of mercury, when sud- den and connected with cold, has nothing in it very un- tractable; but if it rises gradually, and from the repeat- ed introduction of that poison into the system, it is a tru- ly formidable disease. The natural and animal functions suffer a remarkable depression, whilst, on the contrary, the movement of the heart and arteries is carried on with a degree of tension peculiar to that state. The blood is not only unusually cupped; but the buff has been known to form, where it has only trickled down the arm; and the occasional whiteness bath of that crust 136 OF DROPSIES WI14I and of the serum are deserving of much notice. When this distemper has proceeded to a great extent, it is hardly cured. The common symptomatic swellings are sometimes converted into this by mercury given for the relief of the obstructions; and then nothing favourable is to be expected. The mercurial hectic in syphilis, which puts, or ought to put, an instant stop to the use of that mineral, I have known once or twice to be distinguished by a serous state of the urine, even though there has been no absolute anasarca. How far this sign prevails generally, it is very important to inquire; since we frequently want all the evidence which the nature of the subject will admit, with regard to the propriety of continuing a mercurial course. SECTION III. Of the Hydrothorax, or Dropsy of the Cavities of the Thorax and Pericardium. The hydrothorax, as has been already observed, is not an unusual termination of diffused dropsies. Some- times the chest is attacked in the first place. This occurs in old and weak subjects, and is attend- ed generally by signs of broken health, particularly a pale sallow complexion. The anasarca increases gra- dually ; and in the early stage I have known it to be ab- solutely wanting. There is usually a short cough, and something so far febrile about such patients, that they are hurt by whatever has a tendency to excite inflamma- tion. Often, upon recollection, they are able to trace their symptoms, or at least the sudden increase of them, to some imprudent exposure in bad weather; and they are particularly sensible to the effects both of cold and i COAGTTI.\BLE URINE. 137 of close rooms. The urine gives a loose and slight co- agulum, and is often loaded with a red sediment. In these cases particularly, gout thrown to the extremities is wont to give a great and unexpected relief. There is another form of hydrothorax, which may occur at a less advanced age, and is a true example of dropsical inflammation. Serum and lymph are thrown out instead of pus. There is even a partial suppuration of the lungs. That organ becomes at length compress- ed and greatly diminished in bulk; and life is extinguish- ed by this mechanical violence. Who, that has witness- ed a dissection under such circumstances, but must ac- knowledge, how much our art might have done in pre- venting this accumulation, how little in removing it ?* This variety is, I believe, sometimes accompanied by a pain or numbness and oedema of the arm on the affected side ;f in the former, both arms are thought oc- casionally to sympathize. The principal signs of water in the cavities of the thorax or pericardium are, a more than ordinary dysp- noea particularly marked on going up hill, an irregular or intermittent pulse, a difficulty of lying down in bed, frightful dreams, as of drowning or falling down a pre- cipice, from which the patient awakes agitated to the most distressing suffocations with palpitations of the heart, and a sense of fluctuation observed by the patient himself. These signs are not in strict propriety, pathognomic. All of them, excepting the last, occasionally attend other disorders; all, but the first, may be absent in this. And yet there are combinations of them, the evidence of which it is hardly possible to resist. To prove the uncertainty of these signs, singly con- sidered, it is only necessary to state that the pulse is * Chapter IX. case I. see also page 63. t Page 107. (18) 138 OF DROPSIES WITH rendered irregular by organic injuries of the heart, and it is sometimes perfectly regular in the most decided hydrothorax.* Again, the orthopnoea is often an asthmatic symptom; and I have known persons prefer the horizontal posture in bed, in whom dissection, or other conclusive evi- dence, proved that an hydrothorax existed.f Similar assertions may be made of the hurried dreams and nightly suffocations, f Of the fluctuation observed by the practitioner I have no experience. That complained of now and then by the patient, is seated, as far as I have been able to learn, at the lower part of the sternum on the left side. It may be supposed to be exaggerated by his fears; yet more than one very calm person has assured me of its reality.§ Hypochondriacs and dyspeptics have some- times complained of a similar feeling; and the opinion of its being connected with the presence of water has taken firm possesion of them. When combined, how- ever, with other evidence, and in persons of sober judg- ment, it is of great weight. I believe it belongs more to the dropsy of the pericardium, than of the cavities of the thorax; as indeed its situation implies. And if there are any other circumstances which should direct our at- tention particularly to the former of these, they are, a re- markable sense of faintness, combining itself with the dyspnoea produced by exercise|| and change of posi- tion ;H and in bed, even when difficulty of breathing is present, the preference of a posture different from the erect, as of the completely horizontal,** or a considera- * Cases and Dissections, pages 69 and 102. f Case and Dissection, page 67; Case, page 40. \ Case and Dissection, pages 35 and 67; Case, page 40. § Cases, pages 40 and 107. || Page 40. 11 Page 69 ** Case, page 40; Case and Dissection, page 67; and Ma- clean on Hydrothorax, pages 68 and 69. COAGULABLE URINE. 139 ble inclination forwards, the face nearly resting on the knees.* The distressing dreams and nightly suffocations I consider to be very rarely indeed absent, where the wa- ter presses on the lungs. A remarkable dyspnoea is present in all, not only in- creased on going up stairs, but attended by an embar- rassed gait, a loaded countenance, an habitual slowness and pause in speaking, a peculiar look of distress, not easy to describe, and from which the features rarely re- turn to their proper harmony, even though the patient obtain relief. On the whole, so remote from entire certainty are these signs, that in one in whom all, except the sense of fluctuation, were combined, with some others indeed superadded, a pulse every way irregular, palpitations, cough, dyspnoea, inability of remaining in the bed for a single instant, suffocations and deliquia after sleeping even in his chair, and an anxious, embarrassed counte- nance, the whole injury was found, on dissection, to be seated in the body of die lung, and the lymphatic glands at its root.f We can hardly expect that the signs of diseased or- ganization, which in fact are nothing but impeded func- tions, should be as various as the disorganizations them- selves; still less that, complicated as these injuries often are and modified by the sensibility of the subject, the symptoms peculiar to each, even if there be any such, should always be able to develope themselves. A pro- bability short of certainty must regulate our decision. If to many of the signs above described be added a * In a patient at St. Bartholomew's Hospital, who could bear no other posture in bed than the leaning forwards and resting on his knees, I found after death the pericardium containing half a pint of clear serum, the membranes not apparently in- flamed, lungs sound, and no water in the cavities of the thorax. t Case, page 35. 140 OF DROPSIES WITH dropsical habit with a serous condition of the urine, the existence of an hydrothorax will be in the highest de- gree probable; if the patient has been before relieved by diuretics, it can no longer admit of doubt. Are a dyspnoea and orthopnoea of a few days' dura- tion, and a highly serous condition of the urine, without any sort of dropsy besides to account for it, sufficient evidence of a dropsy existing in the chest ?* Anasarca of the lungs does not appear to be very common. Dr. Baillie never met with a satisfactory case of it on dissection ;| which argues that its frequen- cy in the living body is over-rated, or that it is not a fatal disorder. At least its symptoms, as distinguished from hydrothorax, are not sufficiently understood. SECTION IV. Of the Ascites, or Dropsy of the Belly, and of the Tympany. The ascites does not demand much separate consi- deration. Its presence is detected by what is called the sense of fluctuation, or the shock communicated to the hand held on one side of the abdomen, whilst an im- petus is given to its contents by a gentle blow on the other side. This sensation of a fluid is peculiar and well understood by those who have once experienced it. It is decidedly different from the elastic vibration and hollow sound communicated by air pent up in the sto- mach or intestines, which likewise gives a remarkable sense of lightness hardly to be expected in a tumour of so much bulk, a feeling so obvious to the mere * See Case III., page 104* t Baillie's Morbid Anatomy, Appendix, p. 21. COAGULABLE URINE. 141 touch, that there can be no necessity for the experiment of weighing the patient, suggested by Van Swieten.* In the last stage of general dropsy, a tympany has been observed, and has even succeeded to the ascites. It is principally seated in the region of the stomach; and after death, besides the general flatulency of the intestines, that organ has been found enormously dis- tended with air, which was inflammable and not the fixed, as it has been usually asserted to be.f This cir- cumstance should have been expressed in the relation of the morbid appearances, pages 70 and 103, amongst which it certainly was observed. I have been surprised at the long period, many weeks, during which the stomach has continued thus distend- ed and apparently unfit for any process of digestion, and yet life has, been protracted.! Two striking in- stances of it, one in particular in a hospital in London, followed the use of digitalis, which had operated bene- ficially with regard to the swellings, but had greatly debilitated the nerves. Whether this result can be at all the effect of the remedy as well as of the disease, is a grave consideration. These accumulations are sometimes so conjbined, as to confuse the sensation resulting from each. But any nice discrimination will be of less consequence in such a state, where an operation cannot be advisable. A sero-purulent fluid filling the cavity of the abdo- * Vide Van Swieten Commentaria. torn. iv. p. 172. " Prae- cipua signa sunt, si abdomen percussum instar tympani reso- net, et si aeger ad stateram levis sit, cum e contra in ascite aegri ob collectam aquam pondus insigne habeant." t Dr. Baillie, speaking of air in the intestines after death, says, »this air probably differs somewhat at different times; in several trials which I have made, it never showed signs of con- taining any proportion of inflammable, but always a very sen- sible proportion of fixed air."—Morbid Anatomy, p. 129. t Page 102. 142 OF DROPSIES WITH men, and without any anasarca or even bloated appear- ance of the skin, has been attended by some albumen in. the urine.* This circumstance I consider of no slight importance in explaining the real nature of that impregnation. SECTION V. Of the Hydrocephalus Internus, or Dropsy of the Ven- tricles of the Brain. The hydrocephalus has been described in pages 130 and 131, as far as I have found it to be attended by a coagulable state of the urine. The dropsical metas- tases to and from the brain, mentioned by authors, ap- pear to be of this nature, as are probably all those ca- ses which occur after scarlatina. But I suspect that hydrocephalus originates much less frequently in this constitutional dropsy than in other causes to which the character above alluded to does not belong. So much the more discouraging will be the aspect of the disease. That remarkable sign denotes a specific error in the constitution, and has appropriate remedies; whilst the obscurity of its other causes leaves much to conjecture, and when the disease is established, but little to hope. Can there be a more humiliating picture of the state of medical opinion on this subject, and of the value of medical conclusions, than the following extracts from an author of approved credit on the disorders of children, Dr. Underwood? Page 280. " Though I have made mention of mer- cury," says he, " I cannot say I have seen any decidedly good effects from its use, either as a purge or an alter- ative, (when the disease has been clearly ascertained,) * Page 112. COAGULABLE URINE. 143 administered either externally or internally, though I have had recourse to it very early as well as late in the disease." Page 281. " It is proper to observe, that mercury has been strongly recommended by Drs. Carmichael, Smith, Dobson, John Hunter, Haygarth, Moseley, and Dr. Armstrong; but I am informed by other physicians of eminence, that they have not been so successful in the use of it." Page 284. " Dr. Percival recommends joining the digitalis with opium and calomel; though he is inclined to think that the good effects produced by this compo- sition are rather attributable to the combination of the opium and calomel, than to the digitalis." Page 285. " Dr. Temple was led to advise the doronicum germanicum in hydrocephalus, and in a recent instance with marked success, in consequence of an abundant perspiration from the head. Opium and calomel were indeed joined with it; but as it is not known that such effects have been produced from the combination of mercury and opium, he concludes that the doronicum had a considerable share in them." What can the reader conclude, but that nothing is known of this (Jisease, and that the most powerful in- struments are wielded in the dark ? SECTION VI. Of the Diabetes Serosus, or an excessive Discharge of Serous Urine. In some cases, the quantity of urine is so much in- creased, as to give suspicion of a diabetes. The swell- ings are in a great measure prevented by this exces- sive discharge; but no other benefit is derived from it. On the contrary, the system is evidently more embar- 144 OF DROPSIES WITH rassed by the loss of serum, than it would have been even by its accumulation. There is a burning thirst, with fever, dry skin, and rapid emaciation of the whole body. The nerves in particular are greatly affected; the despondency being extreme, and the fretfulness of mind often unconquerable by any effort of reason. More urine is evacuated in the night than in the day ; and the urinary organs themselves sometimes suffer from a feebleness and irritation, similar to what have been observed in the diabetes mellitus. Of the proportional frequency with which these two species occur, I am unable to make a correct estimate. I believe that the former to a certain degree is the more common, but that the quantity discharged in it is never so preternaturally excessive as in the latter, in which, as we are informed, it has amounted to 12 quarts, to 27 pounds, and even 36 pounds daily.* The descriptions of this disease given by the ancients have been general, and have contained no allusion to these qualities of the urine. They have, nevertheless, been considered to relate to the diabetes mellitus almost exclusively, with what justice, may be well doubted. The noted expression used by some of these physicians, hydrops ad matulam, is exactly descriptive of the se- rous diabetes; and many remarks of Aretaeus are ap- plicable to it only. In his detail of the symptoms,! that author dwells principally on the extreme thirst, common to both spe- cies, and wholly omits to notice the boulimy or inordi- nate appetite, which forms so striking a feature of the diabetes mellitus, but is often changed to a loathing of food in the serous. His chapter on the cure he com- mences by stating,}: that diabetes is a species of dropsy, * Rollo on Diabetes, pages 17. 160. 169. t Aretaeus de Morbis Diuturnis, lib. ii. cap. ii. t Aretaeus de Curat. Diuturn. lib. ii. cap. ii. COAGULABLE URINE. 145 both in its cause and its general nature, and differs from it only in the channel by which the humours pass out of the circulation; that in dropsy they are deposited at rest in the cavities of the body, in diabetes are carried off by the kidneys and bladder. He adds, that if relief is obtained in dropsy, it is by that channel, namely, the urinary organs; but that this relief consists rather in the solution of the cause, than in the mere removal of the burthen. The regimen and diet, and in a great measure even the medical remedies, he directs to be nearly the same in both, and particularly recommends in diabetes the use of sweet and astringent wines. This recommenda- tion, if it proceeded from any experience of their utility, and not from a mere theoretical notion, must have been directed against the dropsical excess of urine principally. And it is worthy of remark, that Sydenham, when he prescribes sweet wines in diabetes, appears to have had in his more immediate contemplation that which occur- red in elderly persons after intermittents, no doubt con- nected with a dropsical habit.* It is difficult to view those doctrines of Aretaeus, illustrated as they are by the facts contained in this vo- lume, in any other light than as evidences that he drew his descriptions from the serous as well as the saccharine diabetes. Dr. Heberden's opinion is very similar to that above quoted. Speaking of the excess of urine, and of the intense thirst which usually precedes it: " I have hardly," says he, " known them but in very infirm and old peo- ple, in whom age or distemper had so far injured some of the parts necessary to life, that death must soon have ensued, whether the patient made too much water and was wasted in a diabetes, or made hardly any, and was bloated in a dropsy. It is not very improbable that * Sydenhami Opera, p. 307. (19) 146 OF DROPSIES WITH some trivial circumstance determined the body to take on one of these two diseases rather than the other, and that the removing of either of them would do but little towards saving the patient's life."* If the ancients have overlooked the composition of the urine in these excessive discnarges, more modern wri- ters have been not wholly free from the same neglect, and have often confounded, under the term diabetes in- sipidus, all those cases in which the sweet taste was not detected. The more accurate practice of evaporation lately adopted has accidentally elucidated this subject, and shows in a strong point of view what great discoveries labour and accident may yet make in the history of dis- eases. Dr. Latham, on evaporating the urine of a suspected diabetic patient, observed a large quantity of albumen. Mr. Watts of Glasgow, under similar circumstances, detected the same substance in a much larger propor- tion. Cases of it less severe and obscured by the presence of anasarca not uncommonly occur. Stimulating diure- tics have appeared to me to produce it. I have less hesitation in saying, that mercury has that effect; and the state of the kidneys in two dissections, after exces- sive mercurial courses,! would induce a belief that it is not wholly unconnected with a local affection of those glands. The saccharine and serous diabetes may perhaps be combined; and the quantity of serum present may possibly conceal the sweetness of the taste. Mr. Watts of Glasgow, in the case before mentioned, where the urine was insipid, first obtained by heat a large coa- gulum, and then by evaporating the strained fluid, an * Heberden's Commentaries, chap. xxvi. Diabetes. t Pages 70 and 114. COAGULABLE URINE. 147 unusual proportion of extractive matter, which when treated with nitrous acid and water, afforded a consider- able quantity of oxalic acid.* There is likewise something remarkable in the quality which albuminous urine, when pale and copious, has been found to possess, of continuing long without any decomposition, and even reddening for an unusual period the vegetable blues. This character, however, is by no means constant. And altogether the subject is so new, as rather to demand further investigation than to require or even permit any general conclusions at present. * Watts on Diabetes, p. 74 148 OF DROPSIES WITH CHAPTER XIV. THE SAME SUBJECT CONTINUED. SECTION I. Of the Remote Causes. The predisposition to this disease consists principally of a certain feebleness and inactivity of constitution, called the phlegmatic temperament. Its signs are well understood, and it is beyond any doubt hereditary. On this account dropsy itself has been called an hereditary disorder; and it certainly is so, in the only sense in which any disease is entitled to that appellation. This opinion has always been very prevalent; of which a stronger proof can hardly be adduced, than the supersti- tious ceremonies alluded to by Van Swieten. He states on the authority of Plutarch, that, amongst the ancients, the children of those who died consumptive or dropsical sat with their feet immersed in water, whilst the dead bodies were burnt, that the disease might not pass to them; and from Van Helmont, that, in Ant- werp, the vulgar thought the dropsy would descend to the next heir, unless all the water was drawn off from the dead body.* The same feebleness of constitution is artificially produced by poor diet, bad air, the depressing passions, and large evacuations of any kind, particularly great losses of blood. * Van Swieten, Commentaria, torn. iv. p. 192. COAGULABLE URINE. 149 Some of these are undoubtedly exciting causes like- wise; but as with the debility essential to the disease there is often combined in the present form an inflam- mation from the very commencement, so some of its exciting causes will be found to partake of this latter character. The gout is probably both a predisposing and excit- ing cause. Frequent paroxysms of it, particularly if they are ever retrocedent, bring on a dangerous feeble- ness of the habit; whilst the sudden accumulations on the chest, which occur in such subjects not without some obscure signs of inflammation, appear to resemble a misplaced gout. Some of the most remarkable of the other causes are as follows: Scarlatina.—There is something hitherto obscure in the disposition to oedematous swellings which scar- latina leaves. The time, the symptoms, and subjects of this attack, by no means permit the opinion that it originates in mere debility. On the contrary, the at- tendants are often persuaded, that the patient has caught some fresh cold; and it is certainly not improbable, that the previous irritation and inflammation of the skin may be followed by an opposite state of it, incapable of sup- porting even the common changes of temperature. This doctrine is strongly supported by Mr. Meglie, in the Journal de Medecine, Jan. 1811. He thinks that sudden changes from a hot to a cold temperature, and even the contrary, are the exciting causes of the scar- latinous anasarca; that in order to avoid it, it is proper to submit to the most rigid confinement, in the winter, for about six weeks, and that during this period tender children should not place themselves too near even to a closed window. The obscurity, however, above alluded to, refers only to the origin of the complaint; in its symptoms, it is the plainest possible specimen of the disease of which I 150 OF DROPSIES WITH am treating, a sort of epitome of the dropsical habit, which at other times we find complicated and confused by a variety of extraneous circumstances. The abuse of mercury.—The effects of mercurial courses badly conducted are very severe, but of a cha- racter not hitherto entirely understood. By some au- thors they have been thought inflammatory, by others a disease in which loss of tone predominates; and it is not unreasonable to suppose that they do actually vary in these respects. The predisposition and habits of the patient may determine much; the feebleness of particular organs often fixes the part, on which the principal vio- lence of the distemper is to be exerted; whilst we must refer somewhat to the mode in Which that poison has reached the circulation, to the effect which it has pro- duced on the discharges, particularly those of the in- testines, and to the causes that may have prevented its proper excretion. Thus it is probable that if calomel has been chosen, and a diarrhoea has followed its repeat- ed use, the mercurial habit, that ultimately ensues, will be blended with much weakness; whilst if the mercury has been passed by the absorbents of the skin, and no great discharges have taken place, or the secretions have been checked by cold, a disorder will follow more distinguished by inflammation than debility. Mr. Mathias has made some very excellent remarks on the mercurial habit. The irritation produced by that mineral he considers to be of a very inflammatory kind, adding, that the blood is found buffed in a re- markable degree; and that venae-section is the best re- medy even for a salivation.* A physician, who had great opportunities of witness- ing the use of mercury, Dr. Paisley, thus expresses himself with regard to its effects even in a hot climate, " It is too apt to leave behind it an inflammatory dia- * Mathias on the Mercurial Disease. COAGULABLE URINE. 151 thesis, so much so indeed, that I would recommend to you as a general rule in all severe attacks of disease, where mercury has preceded, to bleed early and freely. For watching, fatigues, and bodily exercise of the se- verest kinds have not greater effects in wasting the thin- ner parts of the blood, and producing a density of it, than mercurial courses."* These remarks deserve much attention, if we would ascertain the nature of the common mercurial habit; they apply likewise in a great degree to the dropsy from the same cause. No stronger examples indeed of in- flammation can be adduced, than some of the cases of it described in this volume. That such a disposition extends to them all, I by no means assert; and still fur- ther, if the symptoms, related in pages 27 and 28, are rightly attributed to mercury, it would appear that even the serous state of the urine is not uniformly present.f There is a species of dropsical accumulation, which is so constantly treated by mercury, that I know not if I shall obtain from every reader an acknowledgment, that mercury may possibly bring it on. It appears to me, however, that no accidents proper to the disease can account for all those fatal conversions to the head, which of late years have so frequendy taken place in the fevers of children; and I have on some occasions been dispos- ed to attribute them to excessive and repeated doses of calomel, which either not moving the bowels, as was expected, have given evidence of being absorbed, or on the other hand, have purged too violently and been succeeded by a diarrhoea without bile, and a prostration of strength from which the little patient has never risen. * Curtis's Diseases of India, p. 371. Letter from Dr. Paisley. t Dr. Wells's observations on the effects of Mercury are of importance in this question. He has proved decidedly, that salivations have a great tendency to produce a serous state of the urine, but that this effect is not uniform. 152 OP DROPSIES WITH Its less severe effects are sometimes of no slight import- ance, a slow and imperfect recovery, a languid feverish habit, and a disposition to scrophula. It need not sur- prise us, that in children this disposition, particularly if so excited, should often fall on the part most liable to every impression, and most actively developing itself, the brain; since even in adults, mercury is inimical to the nervous system. Parents have something to regret, who are so perpetually giving calomel to their own chil- dren, without any distinction or care, as a common do- mestic remedy. And it is difficult to conceive on what view of the subject even practitioners proceed, who in- dulge in its use with less scruple than ever, with less attention as to dose, with less caution as to management, whilst they are observing and lamenting the daily increas- ing ravages of hereditary scrophulous disorders. It can hardlv be in the present day from want of calomel, that such a taint is propagated. Altogether the excellence of this remedy in many, even infantile, cases, its cleans- ing powers, its inflammatory and its debilitating action, render it a two-edged sword. The drinking too freely of cold liquors when heat- ed; and the external application of cold.—Boerhaave's Aphorism is very minute with regard to the former of these. Pptus nimius frigidse subitus, neque vomitu, neque alvo, neque sudore, vel urina, calore motuve ex- citatis, excretus.* The ancient physicians mention the same fact; and Van Swieten asserts that, in soldiers on a march exhausted by heat and fatigue, he has known the drinking of cold water bring on, in some instances, a fatal pleurisy, in others, a dropsy.f The relation, which these two diseases here bear to each other, is very worthy of remark. I have sometimes witnessed similar effects from large * Boerhaave's Aphorism, 1229. t Van Swieten, Commentaria, torn iv. page 192. COAGULABLE URINE. 153 quantities of weak and cold cider, drunk by labourers in the harvest in this county; and there is a saying al- most proverbial amongst them, that when the cider falls into their legs, the fox-glove, called by them, cow-flop, carries it off. If cold acting on the stomach is capable of producing dropsy as well as pleurisy, there seems to be no reason for denying, that it may do the same when applied to the surface of the body ; although,' from finding internal inflammations to be so much more common a conse- quence -jf taking cold, authors have in some measure overlooked the anasarca arising from the same cause. Of the effect, however, little doubt can be entertain- ed. There is even some reason to think, that the swell- ings after scarlatina are partly referrible to cold acting on a tender and denuded skin. And the comparative rareness of the diffused dropsy in very hot climates, which has been asserted on good authority, proves, if true, its great connection with a low temperature and obstructed perspiration. The improper exhibition of bark and steel.—These remedies on many occasions have greatly aggravated the disorder; sometimes they have appeared to produce it, or at least have first made it evident. Stahl's remarks on this subject, in his article De Hy~ drope, are worth consulting. Topical injuries and inflammations of the limbs.— Dr. Monro mentions a man who, in consequence of a sprain of the wrist from lifting a great weight, became completely anasarcous.* The wrist immediately swell- ed, and the swelling spread from thence all over his body.-f Such an instance is probably very rare, nor * Such an exciting cause would argue the effusion to arise, not from mere weakness, but from inflammation; and no doubt the cellular membrane would, if examined, exhibit appearances of this kind. t Monro on Dropsy, page 10. Note (20) 154 OF DROPSIES WITH should I have alluded to it here, but as it seems to bear some analogy to that swelling of one leg, mentioned pages 79 and 80, from which, as from a point, the oede- ma spread universally.* This list of causes might perhaps be increased by the addition of some acute disorders: I am unwilling, however, to assert more than I have seen. But the most important and most fatal of all agents, in producing this complaint, still remains to be men- tioned, an unsoundness of the digestive organs-, which impairs the nourishment of the body, vitiates the blood, and gives vigour and operation to every other cause. The free use of spirituous liquors greatly contributes to such an incurable taint, and independently of that effect has been thought by many physicians capable of exciting a true dropsy. SECTION II. Of the Appearances on Dissection. The information afforded by dissections has hitherto been very imperfect; but the novelty and importance of the subject render all observations of this kind in some degree valuable. I shall briefly recapitulate them : I. Case, page 62, of a woman, who, after recovering from scarlatinous dropsy and pain of the side, died in consequence of a caries of the os sacrum. The pleura of the left lung covered with coagulated lymph, in a spot answering to the seat of the pain; immediately un- der that membrane, and separating it from the lung, a small abscess; other parts nearly natural. II. Case, page 67; supposed to originate in the ex- cessive use of mercury; remarkable for very inflamma- tory symptoms, urine highly serous, a tense sore oedema Sec also page 58 COAGULABLE URINE. 155 moving from one part of the body to another, a pulse by no means interrupted, a preference of the horizontal posture, and the most excessive loss of strength and spirits. Pericardium much inflamed, containing three ounces of a turbid whitish fluid ; pleura somewhat in- flamed, in each cavity from ten to twelve ounces of flu- id ; stomach greatly distended with air, which, on ap- plying a lighted candle to an opening made in it, burnt with a deep blue flame, till the stomach entirely collaps- ed ; slight marks of inflammation and adhesions about the peritonaeum; liver rather firmer than ordinary ; kid- neys unusually solid, and containing two or three small hydatids; an ounce of water in each lateral ventricle of the brain; cellular membrane of the whole body, par- ticularly the loins, presenting an unusual resistance to the knife, and containing an effusion somewhat transpa- rent and coagulated ; fluid, which drained off, coagulat- ing spontaneously on exposure to air. III. Case, page 112, of a woman, who had under- gone enormous courses of mercury, even whilst preg- nant, and was also very intemperate. Liver greatly en- larged and hardened ; kidneys likewise large and hard, and their structure confused, particularly in respect to the distinction between the cortical and medullary part. IV. Case, page 74, distinguished by a remarkable diarrhoea, for the cure of which mercury had been vain- ly used. Ulcers of the caecum and colon; kidneys remarkably loaded with blood; lungs filled with tuber- cles. V. Case, page 83, attributed to cold. Thorax and abdomen healthy, except that in the former, there was an appearance, rather recent, of the adhesive inflamma- tion ; in the head, an aneurism of the basilary artery; and the ventricles filled with coagulated blood; cellular membrane unusually firm, and containing an effusion similar to that described, No. II. The bursting of this aneurism had been the cause of the fatal attack, which 156 OF DROPSIES WITH in its symptoms greatly resembled hydrocephalus inter- nus. VI. Case, page 93, under the article cachexy, dis- tinguished by a whey-coloured urine and sanious sputa. Lower part of the right lung loaded with coagula of blood; liver scirrhous; diaphragm perfectly free; mem- branes of the brain inflamed, half an ounce of water in each ventricle. VII. Case, page 102, a regular pulse, abdomen tym- panitic for some weeks before death. Right side of the thorax filled with water, in which flakes of lymph swam. lung compressed to the size of a man's fist; under its membrane a small abscess ; pleura pulmonalis, on both sides of the thorax, covered with a thick coat of lymph; stomach greatly distended with air, which on trial prov- ed wholly inflammable; liver rather large and firm; kidneys very small and sound, excepting two or three hydatids. VIII. Case, page 117, of a boy, in whom the urine, in a fever, under the use of very large doses of calomel, became loaded with a foetid bloody sediment. Ventri- cles of the brain distended with water, signs of inflam- mation on their surfaces, as well as on the pia mater. IX. Case (for which see the postscript of a young man, in whom the disease, a general anasarca, was ap- parently brought on by cold and exposure to rain, and proved rapidly fatal by the spreading of an erysipelas on the integuments of the chest and abdomen. The pleu- ra inflamed and covered almost universally with an ad- ventitious lymphy membrane; cellular membrane load- ed with water, and with a soft, gelatinous, imperfectly coagulated effusion, interspersed with spots of blood, opposite to the inflamed surface on the skin. Viscera nearly sound. The lymphatic vessels are found unusually thickened and distended in dropsical bodies; so that such subjects are much preferred for anatomical preparations. This COAGULABLE URINE. 157 appears to be a state similar to the dilatation and thick- ening of varicose veins, indicating inactivity and conse- quent accumulation. The serum of the cavities in this disease possesses va- rious degrees of dilution; the fluid drawn off by tapping in the ascites, has resembled soapy water, and that not once only, but after repeated operations ;* and what is discharged by scarifications is almost aqueous. The following remarks occur to me from the preced- ing statement:— 1st. That the urinary organs are often free from any appearance of unsound structure, notwithstanding ti,: great fault in their secretion. 2d. That in two mercurial cases, the kidneys were firmer than ordinary, in one of them very strikingly so, approaching to scirrhus; but whether this is merely accidental, or the effect of such a course, and what re- lation it bears to the discharge of serum, must be left for future observation, f 3d. That an unhealthy state of the liver is likewise not an uncommon morbid appearance; in two instances out of eight it was scirrhous, in one of these greatly en- larged ; in a third, harder than ordinary ; and in a fourth, rather large and firm. 4th. That an inflammatory state of some serous mem- brane, particularly the pleura is frequent, producing the effusion of a serous fluid, which is more opaque and lymphy, and the membrane more disfigured, in propor- tion to the signs of general inflammation and of local pain, and the firmness and quantity of coagulum in the urine. 5th. That where on the surface of the pleura pul- * Page 77. t In a dissection related by Dr. Wells, for which see the postscript, the kidneys were found thickened and confused in their structure. 158 OF DROPSIES WITH monalis lymph has been thrown out, true pus has some- times been deposited between it and the lung; and a purulent expectoration has been often so marked during life, that it is beyond any doubt large abscesses would have been found in the lungs on dissection. 6th. Some attention is due to the state of the cellular membrane described in three cases, No. II. No. V. and No. IX. The appearances No. II. were truly remark- able, and answered exactly to the signs, that had pre- vailed during life, of a sort of inflammatory anasarca, not distinguished by any redness of the surface, but a tension and soreness and puffy swelling passing from one part to another, as if the cellular membrane under the skin had been affected with an erysipelas. A coa- gulating effusion, apparently of a gelatinous nature, is, I believe, not very uncommon in anasarca; and it does not seem to be ascertained, whether or not this coagula- tion has taken place during life. It may not be improper here to mention, that in those painful swellings of the lower extremities, which occur mostly after pregnancy, the urine, though often scanty, is not coagulable. Lastly, whilst in these anatomical observations we find varieties of injury, in the head, thorax, abdomen, and even cellular membrane, we must not forget to add to the account those perfect recoveries which prove the occasional mildness of the disease, and the litde mis- chief which any of these parts have sustained. SECTION III. Of the proximate Cause. The proximate cause of dropsy has hitherto received no satisfactory explanation. In health, the absorption keeps pace with the secretion, and permits sufficient va- pour only to moisten the surfaces. All accumulation COAGULABLE URINE. 159 therefore is disease, and beyond any doubt it must im- mediately proceed from a secretion greater than the ab- sorption. But to produce this excess, is the secretion positively increased, or the absorption diminished, or both ? If the former, is it produced by a laxity of the exhalent vessels, that characteristic of the hydropic dia- thesis as Dr. Cullen thinks,* or by their greater activity? If the latter, is the absorbent system in a torpid state, or labouring under a morbid irritability and stricture ?f An impoverished condition of the blood likewise has been thought to give a tendency to aqueous effusions. Is it impossible, that an altered texture of that fluid, different from mere thinness, and disposing it speedily to separate into its constituent parts, may have the same effect? Neither is it to be forgotten, that absorption may be diminished not merely by a fault of the absorbent ves- sels, but of the secretion presented to them, different from the natural and not suited to their elective powers. Writers, in general, observing the weakness of the habit in this disease, have inclined to the opinion, that it is immediately produced by a loss of strength and firmness in the parts concerned, a laxity of the exhalent system, an inactivity of the absorbents, and a watery state of the blood. Some of the appearances, however, I speak particular- ly of the dropsy with coagulable urine, are not favour- able to the uniform truth at least of this opinion. 1st. The serum of the affected cavities has been often found opaque in various degrees, discoloured, and con- taining pieces of lymph; and in one instance even the fluid of the cellular membrane coagulated spontaneously. This very variety proves a morbid state; and there can * Cullen's First Lines, vol. iv. page 261. t Maclean on Hydrothorax, pages 250. 253, &c. i.60 OF DROPSIES WITH be no doubt, that it sometimes tends towards the inflam- matory. £ven where the contained fluid is more clear and di- luted, and only partially coagulates by heat and acids, it is very difficult to determine in what respects it dif- fers from the healthy secretion. The minute quantity of the latter, and the great difference between the dead and the living body, render all such comparisons imper- fect and inconclusive. The ancients, not without much propriety, termed the natural secretion an exhalation. Mr. John Hunter asserts, that the juices which lubricate surfaces are in a volatile state while the animal is alive. Dr. Darwin goes so far as to assert, that the property of coagulation by heat is acquired by stagnation only.* Dr. Baillie considers, that no decisive trials have been, or from the very nature of the subject, can be made, unless on the contents of the ventricles of the brain, where some water is usually found even in the healthy condition of that organ.f Mr. Hewson is considered by many persons to have decided the nature of this secretion. By gently scraping the surfaces of the cavities with a wet tea-spoon, in ani- mals recently killed, he collected fluid sufficient for ex- periment, and ascertained the following qualities of it; that on being suffered to rest, exposed to the air, it jellies in about half an hour, less firmly in young and weak animals, than in old and strong ones, and requires a longer time for that process, where the animal has been reduced to great weakness, although the blood under the same circumstances coagulates sooner; that it re- sembles in every respect the fluid found in the lym- phatics, and approaches to the coagulable lymph .J *" Darwin's Zoonomia, vol. i. sect. xxix. 4. t Baillie's Morbid Anatomy, pages 304 and 305. \ By the term jellying, the author probably means no more than spontaneous coagulation ; since he applies the same word COAGULABLE URINE. 161 His conclusions from these observations, as applied to disease, are, that this healthy lymph is a mean be- tween the fluid of dropsy and the coagulated membranes of inflammation. The former he asserts to be so di- luted as not to coagulate but by heat and acids, being a serum only; the latter to be a lymph altered to the contrary extreme of rapid coagulation, and showing it- self in inflammatory crusts; and that pus, in a still high- er degree of inflammation, is sometimes secreted by the same vessels.* These experiments are, no doubt, faithfully made, and come from very considerable authority; but they seem liable to many objections, arising from the mode in which the fluid was collected, and the fallacy of rea- soning from the dead to the living body, from other animals to the human subject. Nor should it be over- looked, that all the observations relating to the healthy state are derived from the former, to the diseased, from the latter. Without laying too much stress on these difficulties, it is, however, remarkable, that the comparative experi- ments least liable to objection, in the human subject alone, furnish conclusions very opposite to those of Mr. Hewson. Dr. Baillie states, as the result of his own ob- servations, that the water of hydrocephalus is less di- luted, and discovers more animal matter by the common tests, than the contents of the same cavities, when there has been no previous affection of the head.f Still fur- ther, the only example of spontaneous coagulation of the cellular serum has been in a case of anasarca;% in the to the lymph of the blood, and it does not at all appear that any experiments were made to ascertain its properties with regard to heat, re-solution in warm water, 8cc. * Hewson on the Blood, vol. ii. page 103. t Baillie's Morbid Anatomy, pages 304 and 305. t Page 70. (21) 162 OF DROPSIES WITH same state of disease, the cells have been loaded with an effusion imperfectly coagulated and lymphy, as well as with a fluid; in some a floating lymph has been ob- served, mixed with a diluted serum ;* even the mem- branes have been covered with an inflammatory crust, whilst there has been a true dropsy of the cavity.1 These are specimens of disease, which Mr. Hewson's doctrine would prove to involve a contradiction in terms, a dropsical inflammation. Mr. Hunter's experiments set in its true light a cir- cumstance, rather overlooked probably than denied in such inquiries, that the fluids which lubricate surfaces are in some degree volatile; and that, as the living prin- ciple departs, this quality disappears likewise. His own words will best illustrate his opinion. " Some of the juices of a living animal, whether cir- culating, or out of circulation, as those which lubricate surfaces, are in a volatile state while the animal is alive; for when the scarfskin is taken off", the part soon dries; and if the skin is removed from a newly killed animal, it immediately dries; or if a cavity is opened, the surface of the cavity dries quickly; this shows that some part of the juices must have evaporated from the surface; but let the animal cool before it is skinned, or the cavity is opened, and then give it the same degree of heat that it had when alive, you will find, on taking off the skin, no immediate sensible evaporation ; but the part so exposed will remain moist. This volatility I conceive therefore to be connected with life, and not with the circulation; for that is stopped in both cases before the experiment. Whether it is this volatile part that gives the smell that most recently killed animals have upon being skinned, or opened, I do not know; but it may be observed, that it follows the same rules ; for if the * Pages 70. 81, Sec. + Page 103, &#• COAGULABLE URINE. 163 animal is allowed to cool, it loses this smell, although warmed to the same degree of heat as when alive."* The solid part, then, of these secretions appears, in the healthy state, to be held in a very fine solution, of which the term, watery, gives us no correct idea. In the disease of which we are treating, they are probably thrown out in a less subtle and elaborate form; what other changes take place in the proportion of coagulable matter, and its disposition to separate, is involved in great doubt; but it may be a guide to us in so difficult an inquiry to recollect, that in some instances of dropsy the effusion undoubtedly contains a portion of coagulat- ing lymph, and seems to be in its very essence inflam- matory. 2d. In addition to those appearances of the dropsical fluid, which argue a secretion often different from that of mere relaxation, the membranes likewise are some- times greatly inflamed and disfigured; instances of which may be found in pages 62, 63, 70, 103, 118. 3d. Many of the remedies are antiphlogistic; and there is a certain stage, in almost every case of the dis- ease, in which tonics do material injury. 4th. The frequent buffiness of the blood, and that too sometimes of a peculiar kind, is, not to be overlook- ed in this investigation; and it is worthy of much no- tice, that whilst the blood and the secreted serum are accused of being too watery, the urine, which com- monly contains little or no albumen, is loaded with it in a great and unnatural proportion. This phenomenon could hardly be expected as the result of too thin a condition of the fluids, and a deficiency of coagulable matter; on the contrary, it is a very strong proof, if not of its excess, at least of some newly-acquired properties with regard to separation, and of an altered texture. I add as a fact on which we cannot too often reflect, that * Hunter on the Blood, pages 36 and 37. 164 OF DROPSIES WITH where the urine is most loaded, coagulates by the low- est heat, and most firmly, the blood is likewise most buffy, and the whole system bears the greatest marks of inflammation. ----mm ---- The coagulable state of the urine, being so intimate- ly connected with the presence of an extravasated and stagnated serum, may be thought perhaps to be fur- nished immediately from that source. And it was I suppose an observation of this sort that induced Dr. Darwin to believe, as has been already stated, that the serum passed into the bladder by an inverted motion of the lymphatic system. Such a supposition receives no kind of support from anatomy, and is even contradicted by the valvular structure of those vessels. But is the othtr part of that most ingenious author's suggestion, whose very conjectures are the intuitive glances of a superior mind into the secrets of nature, less open to objection? Is it, in short, possible that, according to the common course of the circulation, the dropsical ac- cumulations may supply the albumen in the urine ? It may be urged as a strong presumptive evidence of the truth of this doctrine, that the discharge alluded to is hardly ever found -but in dropsical habits; and there is no reason whatever to deny, that even in such habits a constant absorption is going on, not indeed equal to the increased exhalation,°yet still so far answer- ing its purpose for many months together, that the pa- tient becomes rather emaciated than much swelled. If the fluid has been so vitiated, as to be wholly unfit for the purposes of circulation, it remains that nature should discharge it by some of the emunctories. The kid- neys, from the comparative simplicity of their secretion, are probably the glands most suited to such an office! COAGULABLE URINE. 165 They appear to be possessed of a sort of elective pow- er, capable of separating from the blood whatever is hurtful to it. The urine is perpetually impregnated both in smell and colour with foreign materials. The examples of its containing even a purulent deposit, in consequence of sudden translations from abscesses in remote parts of the body, are too well authenticated to admit of doubt; and Dr. Heberden's authority may be quoted for this fact,# not from a neglect of what former writers have asserted on the subject, but because no one will consider him to have been either credulous in be- lief, or inaccurate in observation.* This doctrine seems plausible, but there are several very strong objections to it. 1st. It does not at all account for the presence of red blood in the urine, which occasionally renders this dis- charge a true haemorrhage. 2d. The urine has been in some degree coagulable by heat in a body not dropsical, where the cavity of the abdomen has been filled with pus. 3d. The same result has taken place, where no fluid of any sort has been accumulated to supply its materi- als.! * Heberden's Commentaries, page 472. t This was very observable in a man in whom dissection proved the total absence of all dropsy. His symptoms were an imaginary syphilis, accompanied by an earnest desire to take mercury, from which I thought it probable that he had already taken too much of it; hypochondriasis; irritation of the urinary organs; a vomiting in the middle of the night of a black bile and indigested food, or of a very frothy matter; stools of a si- milar nature ; great difficulty of moving the bowels; excessive emaciation and despondency. The whole disease was found to be seated in the stomach. Near the cardia was a cicatrized ulcer, in the inner membrane,. of the size of a shilling; at the great end, and round the pylorus, there were extensive cicatrices of ulcers; and fleshy bands passed quite across that opening, acting as an almost complete valve to it. In one part where the stomach lay over the pan- 166 OP DROPSIES WITH 4th. This discharge has been observed to a consider- able extent in hydrocephalus, where the collected fluid is both diluted and very small in quantity. 5th. It assumes its severest and most aggravated form, whilst all the other circumstances of the disease are increasing; i. e. at the moment when we should expect absorption to be the least active; and instantly decreases, when the relief which the patient experiences shows the accumulated matter to be passing off, or in other words the action of the absorbents to be carried on with increasing vigour. 6th. This supposition is still less capable of account- ing for the almost total absence of albumen in the urine of common symptomatic dropsy, in which, however, we cannot doubt the absorption to be active, if not dur- ing the increase of the disease, at least during its cure. These objections are very strong, nor do they admit of an answer in any part, but by acknowledging that great difference in the nature of dropsies, which it has been a principal object of this volume to point out, and by supposing that, where the serum is present in the urine, it has already been secreted into the affected ca- vities in an unusually disordered state. Some of the phenomena, however, are not explained even on this admission; particularly the presence of red blood in the urine, and of serum where the accumulation has been either purulent or none, and still further its rapid return to a natural state the moment the removal of the swell- ings begins to take place. These facts render it pro- creas, its muscular substance had been destroyed entirely, and the pancreas was quite visible through the healed surface, or rather formed that surface itself. The substance of the pylorus was free from any scirrhosity. There was no open ulcer to be found in any part; all had healed, and in some places with ra- ther exuberant granulations. The black fluid passed up on pressure from the duodenum. Every thing else was sound and in order. COAGULABLE URINE. 167 bable, that the remarkable symptom above-mentioned is not connected with any previous absorption of vitiated fluid, but with some cause more directly affecting the constitution. Either supposition involves considera- tions of great importance. If the coagulable part of the urine is supplied from the dropsical cavity, disease of that cavity is indicated, probably, of the inflammatory kind, more than is essential to a mere dropsy; if some other parts of the system are in fault, the change thus indicated, though at present obscure, is undoubtedly of high importance, and demands particular correctives. The general phenomena of the disease seem to be best explained on the latter of these suppositions; but what the nature of this change may be, whether the blood is presented for secretion in a vitiated state, and in what manner vitiated, or the urinary organs themselves per- form their office imperfectly, is at present not well ascer- tained. So far certainly we may be confident, that this sign can never have its proper weight, unless we view it in conjunction with the other symptoms, and as form- ing part of that great constitutional derangement, by which the organs of digestion and assimilation are im- paired, the blood and its secretions vitiated, the cavities filled with fluid, their fine membranes injured, and even the complexion itself gradually marked with tokens of danger and decay, too decisive to be misunderstood. As. a sign, therefore, of such a state of health, this symptom is invaluable; and to neglect or misinterpret it, will be to deprive ourselves of the strongest evidence which the disease can afford, and of the principal means of relieving it. Suspicions of an inflammatory state in dropsy are not new; and authors have long since mentioned that the blood is buffy in some circumstances of that distemper. 16S OF DROPSIES WITH Alexander Trallian and Paulus iEgineta recommend bleeding in anasarca. Spon in his novi Aphorismi relates a case which was cured by twenty venae-sections, after it resisted hydra gogues and diuretics. Dr. Home in his Clinical Experiments states, that he succeeded by seven bleedings in seventeen days, and that the blood was inflamed. Dr. Stock speaks with greater precision when he re- marks, that the various species of hydropical affection are more frequently attended with a sthenic diathesis, than is generally apprehended; that the arterial action is sometimes tense, but more frequently oppressed, and is found to increase in force and activity after the use of depleting remedies. He adds, that dropsy has been defined by some practical writers to be an inflammatory disease, accompanied by watery effusion.* Dr. Grapengiesser, in his dissertation De Hydrope Plethorico, appears to treat this subject more fully than any other author, and in a very original manner. As the work, however, is not for sale in London, I speak only from the review which is given of it in Dr. Dun- can's Medical Commentaries; to which Mr. Burns, in the course of some remarks on the same subject, has referred his reader, f The author above alluded to considers the plethoric dropsy to occur much more commonly than is suspect- ed. He states it to come on suddenly in robust habits, slowly in weak ones, and to be attended by signs of peripneumony, with an inflamed blood. Much relief is experienced from large bleedings at the nose, and small repeated venae-sections, and from neutral salts. Common diuretics and strong purges do harm. The former species, or sudden attack, he has found readily * Stock's Medical Collections on Cold, p. 158. + Burns on Diseases of the Heart. COAGULABLE URINE. 169 curable by the antiphlogistic treatment, the latter with great difficulty curable by any means, but certainly only by that treatment cautiously adopted. Mr. Cruickshank's experiments, which ascertain that the urine in general dropsy differs from the natural in coagulating by heat, nitrous acid, and the corrosive sublimate, prove likewise that in inflammatory diseases, as peripneumony and acute rheumatism, a similar effect is produced by corrosive sublimate, and sometimes by nitrous acid. Mr. Watts's case of diabetes, No. III. was certainly a dropsical one. The blood drawn was buffy, and a cure was obtained by repeated venae-sections. My own observations confirm, and, I hope, illustrate these, and render it highly probable, that this inflamma- tory disposition prevails in those cases principally in which the urine is coagulable. Buffiness of the blood has been considered by some practitioners as no very conclusive evidence of inflam- mation. I believe, however, that, unless in the preg- nant state, it very rarely indeed, if ever, occurs, but as indicating and supporting some active and morbid pro- cess ; and its presence in pregnancy is rather a confirma- tion of this opinion. That state, though not diseased, is greatly different from common health; and the sys- tem is very actively engaged in the formation of new parts. There can be little doubt, from the uniform har- mony of nature, and her doing nothing in vain, that this buffy condition of the blood, with its power of remain- ing fluid for an unusual time, is the best suited to such processes, and is intimately connected with them. The disorders, likewise, of pregnancy are highly inflamma- tory, and often require venae-section. Still further, when on other occasions inflammation takes place, and lymph is copiously deposited, as in acute rheumatism, the blood becomes similarly affected. (22) 170 OF DROPSIES WITH, &C. Whenever, then, such a process is suspected and blood is drawn, it will surely be a great confirmation of those suspicions, and an encouragement to the practi- tioner, if he finds it to possess those qualities, which nature herself has chosen when she forms new parts, and which so frequejntly attend on a morbid extravasa- tion of lymph. CURE BY BLOOD-LETTING. 171 CHAPTER XV. THE SAME SUBJECT CONTINUED, OF THE CURE. SECTION I. Blood- letting.—Blisters. Stahl remarks, that haemorrhages are cured by mo- derate depletion, but by the use of astringents and to- nics are converted into dropsies; and our practice will be rational in dropsy itself, in proportion as we keep the spirit of this observation in our view. The loss of the serous part of the blood, which so remarkably dis- tinguishes it, presents to us a symptom of a very debi- litating kind; and our first consideration of the "subject might naturally enough encourage us to attempt its cure by those remedies which, from their effects on oc- casions not apparently dissimilar, are called astringents. If, however, the doctrine of Stahl is ever true in an ac- tual inflammatory haemorrhage, it is certainly most strictly so with regard to this flux of serum* Whoever endeavours to restrain it by bark, steel, and similar re- medies, will inevitably see reason to repent that attempt, in an increased tension and fulness, a puffy countenance, a cough if there has been already none, and, in worse cases, a true peripneumony. The very symptom for which he has prescribed will likewise be aggravated. Experience more than enough has convinced me of the truth and importance of this observation. Not indeed, that practitioners can be said generally to act in contra- 172 OF DROPSIES WITH, &C. diction in it; for they have too much overlooked the appearance to which it relates to have made its removal an object of their contemplation. But it is so common an error in practice to impute discharges to debility, and endeavour to check them by astringents, that it can- not be too much provided against. The indications which they have usually followed in dropsies, are, 1st. To evacuate the accumulated fluid. 2d. To prevent a return of the accumulation by to- nic remedies. These arise obviously from the symptoms, as Syden- ham observes, and are correct as far as they extend. But they are not sufficiently comprehensive for all cases, nor have a sufficient reference to some peculiar and strik- ing circumstances of the hydropic diathesis, of which the watery accumulations form sometimes but a small part, and seldom deserve that exclusive attention which they receive. I allude especially to those signs of inflamma- tion of the habit, which are not unfrequently present. That practitioner, I am confident, will treat the disorder most easily, most successfully, most suitably to the feel- ings of the patient, who keeps the probability of it in his view; and his attempts at cure must perpetually prove abortive, unless in selecting his hydragogue me- dicines, he prefers those which are likewise calculated to reduce inflammation. But it may be necessary to go beyond this, and to pursue a treatment more directly antiphlogistic. There are likewise cases in which the indication to evacuate the water can have little place, since hardly any is collected, but in which the system suffers more severely and under a more intense inflam- mation than is usual in very extensive dropsies. Here the correction of that error in the habit must uniformly precede every attempt to strengthen it. The most powerful of these antiphlogistic agents is venae-section, a remedy which no one would wish to CURE BY BLOOD-LETTING. 173 employ in any disease without necessity, and particularly revolting to the general opinion in oedematous swellings. I have, however, directed it in several such instances, and never had reason to regret its use. The state of the blood, and the relief that followed, have usually con- firmed the propriety of the operation. It is most obvi- ously called for by the accession of pneumonia; I be- lieve, likewise, that the disease occasionally falls on the abdomen in such a manner as equally to require it; and that it is likely to be of particular service after mercurial courses, where the urine is greatly increased in quanti- ty, and in the inflammatory anasarca. It is, indeed, sometimes the only evacuation which can be directed for cachectic patients, their stomach rejecting both lax- atives and diuretics; whilst the ease with which they undergo this operation, as well as the relief they expe- rience from it, are truly surprising. A correct guide to it may be found in the firmness, copiousness, and early appearance of coagulum in the urine; its limits, in the improvement of that discharge, the state of the blood, and the relief of the other symptoms. Imperfectly, however, as this subject has hitherto been considered, it will be prudent at first to prescribe it with caution as to quantity, and under those circum* stances in which the nature of the cause and of the signs cannot mislead us. Certainly it is not to be view- ed with that extreme suspicion which is sometimes en- tertained against all weakening remedies in chronic ail- ments ; and there are periods of the disorder in which no other operation can preserve life. When internal inflammation is suspected, blisters near the affected part are very serviceable; if applied to the extremities, in order to evacuate the dropsical fluid, though they often fulfil that temporary object, they pro- duce great danger of sloughing ulcers, and now and then a troublesome irritation in the course of the lymphatics. 174 OF DROPSIES WITH, &C. SECTION II. Purgatives ; elaterium, gamboge, jalap, fyc. tartrate and supertartrate of pot-ash ; and tartarized soda. —Antimonials. The other remedies against inflammation are fortu- nately the same as have been usually prescribed for the purpose of evacuating the accumulated fluid. This indication is fulfilled principally by certain pur- gatives and diuretics. It has been, more, perhaps, than it is at present, the custom to employ drastic purgatives, scammony, gam- boge, elaterium, jalap, the expressed juice of the root of the common fleur-de-luce, hellebore, &c.; and they undoubtedly have the power of evacuating large quan- tities of watery fluid, as their name, hydragogue, implies. The objections to their use are, the temporary heat and fever which they are apt to excite; in allusion to which, Pliny says of the black hellebore, quod medetur hydro- picis citrafebrim; the uncertainty and distress of their operation in patients difficult to be purged; the rapid re-accumulation of the water; and the necessity which exists on that account for their almost daily repetition, till the swellings are entirely removed. It is likewise obvious that, if the complaint is not car- ried off by these means, it must be aggravated by them; and an increased debility will follow, particularly of the digestive organs. Some authors speak of a colliquative force which they possess, and of their dissolving the blood; expressions however incorrect in theory, yet in- telligible in a practical view. And Hoffman asserts that he has seen them in an ascites produce an inflammation of the bowels, followed speedily by sphacelus. CURE BY PURGATIVES. 175 Notwithstanding these grounds for alarm, yet where the habit is indolent and free from gout, and the dropsy extensive, without fever or local determination, they are generally speaking, safe, and productive of a consider- able effect. It is, however, to such cases, certainly the most curable form of the disease by other means," that they are chiefly applicable. In the cachexy, in which the stomach and intestines are very weak, they do such injury, as to be wholly inadmissible; and agreeably to that excellent aphorism of Baglivi, in morbispectoris ad vias urinae ducendum, I have not seen them render any service in the hydrothorax. On the other hand, they have produced in some instances this partial effect, that whilst they have relieved the cellular membrane, they have left the chest oppressed, the urine inflamed and loaded with serum, and the whole system incapable of bearing any tonic remedies. Indiscriminately employed, therefore, they must be attended with much hazard; and as a general plan of treatment, I have observed them greatly fail, even in hands otherwise skilful. Altogether their use is much less extended since the introduction of digitalis, and of the proper mode of exhibiting crys- tals of tartar; and without much injury to the practice of physic, may perhaps be safely superseded by these. ^ If active purging is determined on, elaterium may be given in the dose of two or three grains, or gamboge as recommended in the later practice of Dr. Cullen, three grains repeated every three or four hours, till it has a considerable effect; or from twenty to thirty grains of jalap, with double that quantity of crystals of tartar. A combination of mild with drastic purgatives has been particularly recommended in persons difficult to be purg- ed, whom strong medicines alone greatly ruffle and dis- turb. Formulae of this kind are well known; but I avoid entering into the detail of these, or indeed any for- mulae, because it would be to load the work with an useless repetition of what others have said, and what the 176 OF DROPSIES WITH, &.C persons, for whom I write, know; and my object at present is rather a more precise application of remedies, than any novel combination of them. Drastic purgatives have sometimes been united with chalybeates, as in the celebrated electuary of Dovar, which is a combination of scammony, chalybs cum sul- phure ppt., and crude antimony ; and which was like- wise adopted by Dr. Hugh Smith.* The dose pre- scribed by him is from fifteen to thirty grains of the first of these; and twelve grains each of the two others. I have known the sulphate of iron substituted for the chalybs cum sulphure. This formula has undoubtedly performed many cures; and there is so much debility in the disease, that the addition of tonics to purgatives, never indifferent, is particularly desirable here, when- ever it can be made with safety. In proportion as the complaint assumes an inflamma- tory aspect, the saline purgatives are undoubtedly more required; they are, in the truest sense of the word, aperi- ent, diuretic as well as laxative, and promoting all the excretions. Whilst they unload, they cool, without leaving that extreme debility of the intestines, so much to be dreaded from hydragogues; and the constitution is rendered by their use daily more and more fit for the exhibition of tonics. There can, I think, be no hesitation in preferring those salts into the composition of which the tartaric acid enters; as the tartrate of pot-ash, the supertartrate of pot-ash or crystals of tartar, and the tartarized soda. If from the circumstances of the case a decidedly laxative effect is required, the first or the last of these may be usefully combined in the quantity of half an ounce, with infusion, and tincture, of senna, or tincture of jalap. * Smith's Formulae, p. 20. CURE BY PURGATIVES. 177 But there is likewise something very advantageous in the influence which saline remedies exert, by being given in such a form as to enter the circulation, and of themselves to open the secretions, which are undoubt- edly deficient in dropsy ; those from the skin, the kid- neys, and the bowels, obviously so. With this inten- tion, the supertartrate of pot-ash is usually selected, and is given from half an ounce to an ounce daily, diluted with water only, or with such additions as are necessary to render it agreeable to the stomach. The mildness of this remedy, the length of time during which it can be continued in a smaller dose as a dietetic, the solvent power which it seems to exert over the cause of the dis- temper, place it in the very first rank. How much more satisfactory and more likely to be permanent is such a cure, than that which tears to pieces, whilst it unloads ? It approaches to the cure by diet, which undoubtedly is the most desirable of all, and imitates most nearly the operations of nature. A scanty urine, loaded with a lateritious sediment and with serum, is an indication for the use of this as well as other saline remedies. It is contra-indicated by a pale watery condition of that dis- charge, in which likewise there is generally a predomi- nant acid, and by a certain appearance of feebleness in the kidneys. Often, I believe, it unloads the urine en- tirely. I have known it do so partially only; but with such effect, that tonics easily perform the rest. Antimonial remedies are well calculated to overcome a phlogistic state, and, on the other hand, wherever they render benefit, it seems probable that the disease has possessed that character. The encomiums passed on their use in dropsy, by Sydenham, are not without con- siderable foundation. His expressions are very strong, when he says, that antimonial emetics do not seem merely to evacuate the stomach, but to open some passages from the cavity of the abdomen into the in- 178 OF DROPSIES WITH, &C. testinal canal.* Without, however, employing this mineral so freely and largely as that great author did, much benefit may be derived by joining it in a smaller doze, i gr. of tartarized antimony, or in a fluid form one drachm of the liquor antimonii tartarizati, with laxa- tives. It greatly promotes their operation, and suits the intention with which they are given, and corrects any of their heating qualities. Those who expect to derive most benefit from purg- ing, lay it down as an indispensable rule, that it should be repeated as frequently as the strength of the patient can possibly bear, almost daily, or at the least two or three times a week, till the water is removed. I sup- pose there is much propriety in this direction, and that on any other plan the swellings return rapidly; because we see it adopted with regard to the mildest laxatives, the soluble tartar, cream of tartar, &c. as well as the strongest; and probably in this respect the former have a great advantage over the latter, that they can be per- sisted in daily without detriment to the patient. * These expressions of Sydenham approach so nearly to the opinions entertained by Dr. Darwin, respecting some secret communication between cavities not apparently communicating with each other but by the route of the circulation, that I will subjoin his own words: "Necesseestomnino,utcum tanta merit agitatio concussioque tarn ventriculi quam viscerum, a tarn insigni aquarum corri- vatione quasi circumseptorum, earundem evacuatio per ductus, communi naturae lege haud satis patentes, conatum ita vehe- mentem insequatur. Quod veto dentur ejusmodi coeci meatus, perquos aquae ex abdominis cavitate ad intestina transferantur, de facto liquet: cum quotidi6 observemus Hydragoga tantam aquarum in abdomine inclusarum vim per recessum educere, perinde ac si primitus in ipsi intestinis continerentur."—Syden ham, Opera Universa, p. 489. CURE BY DIURETICS. 179 SECTION III. Diuretics; Squills; Oil of Turpentine ; Cantharides; Sulphate of Copper; Acetate of Pot-Ash, #c.; To- bacco; Digitalis; Infusion of Broom-tops, tyc.— Of Tincture of Opium.—Tapping.—Scarifications. The urine is so generally affected in dropsical swell- ings, as very naturally to suggest the use of diuretics. Medicines of this class, however, are allowed by the best authors to be uncertain in their effect; nor is at all reasonable to expect, that the same remedy should be indiscriminately serviceable in such very different con- ditions of the urinary secretion as have been above described. I have stated, from an experience which I trust can- not mislead, that squill is much to be depended on, where, with an oppression of the chest, the urine is scanty, high-coloured, full of sediment, and without se- rum. Its use, however, is not limited to this state. I have sometimes seen it render service, where the urine is partially coagulable. But in proportion as that symp- tom becomes more marked by its extreme constitutional characters, inflammation, and a weakness of the digestive organs, it fails in its effect, or is even injurious. Par* ticularly the debility and loss of appetite that result from it are often rapid and excessive. I have seldom had so much reason to regret the use of medicine, as of squill in these circumstances; and where they are present, even the affection of the chest, so greatly relieved by it at other times, does not justify its exhibition. It is in the inflammatory dropsy particularly, that those authors who at all notice its existence, assert the common diuretics to be improper. This assertion 180 OF DROPSIES WITH, &C. must be accepted with some limitations, and with a due consideration of their general properties. Those diure- tics which possess a stimulating power, as the oil of turpentine and the other natural balsams, and the can- tharides, or an astringent and tonic one, as the prepara- tions of copper, are without doubt wholly unsuitable to such a state. Yet some authors have spoken much in their praise in dropsy. The powder of cantharides, from £ gr. to one or two grains, has been recommended in extreme cases by Lieutaud, and asserted by him to form the basis of an active empirical remedy. The preparations of copper have been highly extolled by Boerhaave, Dr. Wright, and others. That these re- medies have no specific power in correcting that re- markable condition of the urine so often mentioned, I have ascertained by repeated experiments; I have even thought that the tincture of cantharides has increased this tendency to coagulation. The authority, however, of such physicians leaves me in no doubt, that this treatment may render benefit under some circumstances of the disease; what they are, we can at present only conjecture from the obvious and known qualities of the remedies themselves. In proportion as stimulating diuretics are improper, we naturally turn to those, which cool and attenuate, or which diminish inflammatory action. Such are; 1st. The saline remedies already mentioned, under the head of laxatives, particularly the crystals of tartar. One of the neutral salts, the acetate of pot-ash, has so high a character in this respect, that it has even received the distinguishing name, among the old writers, of sal- diureticus, with what justice, I can hardly determine. Dr. Htberden thinks that the Rochelle salt and the so- luble tartar have an equal claim to it. With the pot-ash I have not succeeded. Nor is there any reasonable expectation, that where the crystals of tar- tar are advisable, the alkali can be beneficial; perhaps, CURE BY DIGITALIS. 181 however, it may be well suited to those circumstances of the disease, in which the urine is pale, and not scanty, and remains long free from putrefaction. 2d. Tobacco.—Dr. Fowler's reports leave no doubt of its efficacy; and its very enfeebling influence on the constitution leaves as little, that the disease which it overcomes must be at least combined with some stric- ture or inflammation. I speak, however, from no par- ticular experience of its efficacy. 3d. Digitalis.—This plant has certainly made a great: addition of late years to our means of cure. For although before the time of Dr. Withering's publication on that subject it had been employed very frequently, both in this and other countries, as a domestic drug, yet its ex- hibition wme pain of the chest. All those symp- toms were greatly aggravated when I saw him. The oedema was soft, the scrotum particularly distended, . the bowels costive, and the abdomen bloated. His urine was scanty, grew speedily foul, and deposited a sediment resembling mucus in its appearance. It barely red'1- ned the infusion of litmus within two hours after it is made, about twelve hours after had lost that property, and soon grew very foetid. Exposed to heat POSTSCRIPT. 213 at the same time with serum of the blood from a healthy person, it grew rather turbid before the serum thick- ened, viz., at about 150°, and at 160° was uniformly opaque and milky, and when forced a little further, but never so high as 190°, broke into soft white curds, mix- ed with a very little fluid. The serum became a pretty firm solid at 165°, and differed further from the coagu- lated urine, by being much less opaque. A delay that occurred in finishing the Appendix, en- abled me to subjoin to it, in the first edition, an account of the termination of the above case, which I now take the opportunity of transferring to this place. I tried the infusion of digitalis with some hopes of success ; but even in moderate doses it brought on a diarrhoea, which tincture of opium with difficulty check- ed. The tincture of squills every way disagreed.* Crystals of tartar likewise affected the bowels violently ; and the swellings increased. He became dull, unwil- ling to move, sleepy, confined himself almost to his bed, * In speaking of the liquid preparations of squills, and of the increase of their dose by drops, p. 51,1 had particularly in my contemplation the tincture of squills; and as it is sometimes convenient and safe to intrust the increase of dose to the dis- cretion of the patients, that form of prescription must, perhaps in some degree, be retained; there are, however, many great objections to it; and it should, as much as possible, be laid aside, particularly in drugs which affect life: since the nature of the fluid, the size of the phial, the thickness of its lip, even its cleanness, have an effect on the size of the drop, too consi- derable to be neglected. In reducing the drops of this tincture to minims, it will probably be sufficient for practical purposes to consider the minim as equal to two drops. On the other hand, the size of a drop of vinegar of squill is larger, and ap- proaches nearer to water; which circumstance, if overlooked, may occasion some confusion. With regard to the tincture of digitalis, a similar caution, when converting drops into minims, is still more important, since, according to Mr. Shuttleworth's experiments, a drop of that preparation is even less than one of simple proof spirit. 214 POSTSCRIPT. lay down nearly horizontally, had very little cough, with hardly any pain of the chest, and eat heartily. His extreme sensibility to cold was very striking; there was likewise great deficiency of red colour in the skin and lips, and such a feebleness of the circulation, that I really despaired of doing any good by blood-letting. In this state he continued nearly a month, when he was brought to the Hospital, and whilst remaining in the hall for admission felt some shiverings. In the evening a slight erysipelatous blush appeared on his breast, with an intense soreness to the touch. It spread to the in- teguments of the abdomen, and in two days he died. The body was opened the next morning. The vis- cera of the abdomen were generally sound; the liver quite natural, all the peritonaeal membranes without a cloud. The kidneys were thought large, and in their cortical part of a colour somewhat browner and duller than usual. * In the thorax, the lungs were connected to the ribs generally by very recent and soft adhesions. On ex- amining them further, it appeared, that the pleura cos- talis was lined with a thin layer of red and soft lymph, which, on being separated with care, left the real mem- brane nearly smooth. The pleura pulmonalis was co- vered with a similar adventitious membrane, which ad- mitted of the most entire separation from it. This pro- cess was less complete on the left side of the thorax, where likewise was about a pint of bloody fluid.* The * A most complete example of this double membrane was observed at the Lunatic Asylum a few weeks since. A gentle- man, who had been insane for some months, but was not sus- pected of pulmonary complaints till after his admission into the house, died suddenly within a fortnight after that period, in consequence of a very large haemoptoe. During his short re- sidence there, he had complained of no pain, had a quick pulse, an incoherent agitation of spirits, remarkable timidity mixed with violence, and almost every day some intervals of reason. POSTSCRIPT. 215 lungs were rather overloaded with blood, but contained neither tubercle, nor defined hardness; trachea inflamed ; heart small, natural; in the pericardium, about three ounces of clear fluid. The membranes of the brain were entirely free from inflammation; and its lateral ventricles contained hardly any fluid; but its substance was remarkably soft, al- though the body was opened not above nineteen hours after death, and was free from putrefaction. Besides the watery serum which flowed from the in- cisions made in the cellular membrane of the body, it was in many places loaded with an effusion half-coagu- lated, soft, and of a gelatinous appearance. Underneath An uncommon sense of coldness was very marked in him, so that he would lay himself down near the fire; and he was ob- served to have a nightly cough with dark sputa. On opening the body, besides the lungs being found full of small vomicae, the left lung was invested with a very thick ad- ventitious membrane, separable in long strips somewhat resem- bling buff. Another membrane in close adhesion with this, lined the pleura costalis, not so easily separable and redder; and at the lower part, where the lung usually moves on the di- aphragm, the natural surfaces were separated from each other by a double covering of this sort, closely adhering, and each more than 2-10ths of an inch in thickness. The pleura of the diaphragm was hardened and inflamed, and lymph was deposit- ed between it and that muscle. The abdomen was entirely sound; the brain likewise, a per- fect example of healthy structure and natural state of the ves- sels. This was, probably, therefore, a case of paraphrenias, though less acute than those described by Boerhaave and others. It was under the more immediate care of my friend Dr. Dani- ell, by whose obliging permission I insert it here. To him the public are much indebted for his exertions in the medical de- partment of the institution, at a time particularly when such charities were less generally known than they begin to be at present; and the excellent arrangements, which he has greatly contributed to make, give certainly to his present colleague duties of a comparatively easy nature. 216 POSTSCRIPT. the seat of the erysipelas on the breast, this was inter- spersed with many minute coaguia of blood. On the above dissection little comment is necessary. We find an urine, which becomes nearly solid by heat, to be attendant on effusions evidently inflammatory, without any very marked disease of the viscera them- selves. It is obvious from the difficulty with which the stomach bore remedies, that if any treatment could have saved life, it would have been venae-section in the early stage. APPENDIX. ON THE ANGINA PECTORIS. The following cases appear to be correct examples of the Angina Pectoris; and I hope that the dissections annexed to them will not be unacceptable to the reader. The interest that has been excited by that remark- able disease is reasonably due to its very singular symp- toms, and the great ability with which Dr. Heberden first described them. Some obscure mention of them is indeed found in preceding authors; but it is such only as is sufficient to show, that this illustrious physi- cian copied from nature rather than from his predeces- sors, and drew the picture more faithfully. There is one circumstance alone, in which the no- velty of the subject necessarily rendered his informa- tion partial and inconclusive. I allude to the appear- ances ascertained by dissection. This deficiency has been in a great measure supplied by succeeding wri- ters; and the injury sustained by the great organs of circulation has been usually found much more severe and extensive than Dr. Heberden seems to have sus- pected. With regard to the cure, almost every thing remains to be done; but we need not despair of at length obtain- ing it, when we shall have determined more precisely the nature of these changes, and the constitutional dis- orders in which they originate. (28) 218 ON THE ANGINA PECTORIS. For the first case, with the remarks annexed to it, I am indebted to my late friend and colleague Dr. Parr, whose high professional character gives them a consi- derable authority, and which I have thought it right to communicate in his own words. CASE I. " J. S., aetat. 64, a stout man, with a full and short neck, not inactive, nor subject to any particular com- plaint in the former part of his life. About eight years before his death he was confined for some time in pri- son for debt, and soon after his release was seized with a pain at the lower part of the sternum, extending over his breast, and down his arms to the tops of his fingers, together with great oppression of breathing. In a few minutes all the inconvenience was removed, which was so slight that it was little noticed, and attributed to rheumatism. In the course of six years, the attacks gradually increasing, had become very violent, and came on chiefly while walking, but ceased on stopping for a few minutes. Some months afterwards they awa- kened him in the middle of the night, and at length oc- curred on almost every exertion. In addition to the former symptoms, the fingers during the attack were benumbed, the stomach swelled, and he felt a violent pain at the heart. The recurrence of the paroxysms was irregular, their return not apparently influenced by the weather; and riding as well as walking occasionally produced them, as did likewise particularly the strain- ing to procure an evacuation. " As the disease appeared to be what Dr. Heberden called angina pectoris, twenty-five drops of laudanum were given at night; and on the attack of a paroxysm, some nervous drops, with laudanum, tincture of castor, and volatile aromatic spirit. To obviate costiveness and to discharge water, which appeared to be accumu- ON THE ANGINA PECTORIS. 219 lating in the chest, the cream of tartar was given in moderately large doses. Under this plan the fits were less frequent and violent, and their duration shorter. The cremor tartari soon lost its effect; and pills with equal parts of soap and aloes were substituted for them. A blister also was applied to the part of the sternum where the fits commenced. This remedy appeared to remove their apparent source from the sternum to the middle of the biceps muscle; but this continued for a short time only ; and their origin was soon removed to the upper part of the sternum, just under the clavicles. Copper being at that time a favourite remedy in ner- vous paroxysms, a quarter of a grain of cuprum ammo- niacum was given three times a day. For the first three days after taking this medicine, he had no fit; a circumstance which had not occurred for three years. The paroxysms however returned, and continued to the period of his death, which was at last very sudden. " On dissection, the thyroid gland was found greatly enlarged, seemingly from air in the cellular texture. Near the sternum the lungs adhered to the pleura, and they did not collapse when exposed to the air. Their substance was sound; but in the bronchia nearly three quarts of a dark-coloured bloody fluid were discovered; and in the cavities of the chest were two quarts of serum. The arch of the aorta was enlarged to at least double its usual size, and thickly set with small ossifications; The valves were nearly closed, and the interstices be- tween their edges and the artery were filled with small irregularly shaped bones. Little pieces of bones were interspersed in the muscular substance of the heart, and the carneae columnae were remarkably hard. The ar- teries, which arise from the aorta, were somewhat en- larged. " I shall subjoin some remarks at that time suggest- ed to Dr. Heberden on the subject. Is it not probable, that the appearances here, and in other cases on dissec- 220 ON THE ANGINA PECTORIS. tion, show only the effects of the disease, and that the attack was at first no organic or inflammatory affection of the vessels near the heart, but partook of the nature of a spasm ? Almost all the' symptoms are explicable on the supposition of a contraction of the arch of the aorta, or the arteries that go to the arm; and we know that spasm exists at times in all the muscles which car- ry on the vital and involuntary functions. This view will likewise point out the source of the changes disco- vered on dissection. The effusion in the trachea was probably the fatal stroke. These, however, are mere conjectures. " This case occurred about the year 1774." CASE II. William Duffell, a sailor of a robust make and very open chest, aged 65, was admitted into the Devon and Exeter Hospital under my care in September, 1798. He was subject to very severe attacks of pain in the region of the heart, attended by the most dreadful anxie- ty and sense of faintness. They were brought on by the slightest exercise, and obliged him to remain per- fectly still for some minutes, when the pain moved to- wards the left shoulder and clavicle, but never down either arm, and he became easy. Eructations always accompanied and in some degree relieved them. At other times he was free from any uneasiness, lay in bed on*either side without the least degree of orthop- noea, and could take a pretty full inspiration. His pulse was usually about 80 in the minute, rather quick and thrilling. He had formerly suffered much from rheumatism ; his present complaints attacked him about eight months before his admission, and seemed to come on rather suddenly and severely, being attended at first by a symp- tom which in the progress of the disease almost disap- ON THE ANGINA PECTORIS. 221 peared, fits of suffocation, as he called it, after his first sleep; in which he was obliged to go to the open win- dow for relief. I directed for him no remedies of any importance, except an issue on the inside of his thigh; and he had been in the Hospital but a few days, when the mere ef- fort of putting on his coat without assistance produced a very violent paroxysm, which lasted nearly an hour, and during which I saw him. His countenance was much shrunk and contracted; his respiration, though certainly not more rapid than ordinary, yet carried on with great anxiety and distress; the pulse very feeble and intermittent; the faculties of his mind unimpaired. The eructations were violent and incessant, and he en- couraged them as giving some relief. He recovered from this fit, but two or three hours afterwards, whilst using some very slight exertion, fell down and expired instantly. The body was opened the next day. We found the abdominal viscera sound and in a natural state, except that there was more air than usual in the intestines; most of the cartilages of the ribs ossified ; the external surface of the pericardium and all the anterior mediasti- num somewhat overloaded with fat; a small quantity of turbid water in the cavity of the pericardium; the sur- face of the aorta, about the distance of an inch from the heart, slightly inflamed; some small ossifications in the valves of both ventricles, and the muscular substance of the heart itself remarkably soft and flaccid; the semilu- nar valves of the aorta sound, excepting two small ossi- fied spots; but the aorta itself, from the heart to the diaphragm, thickened and dilated, its inner surface lying in folds and wrinkles, with many ossifications between it and the muscular coat. At a little distance from the semilunar valves, there was a more considerable deposi- tion of bone than in any other spot; and an incipient ulceration of the inner membrane answering to the ap* 222 ON THE ANGINA PECTORIS. pearance of inflammation, mentioned above, in the ex- ternal surface of the aorta. There was not a greater quantity of fluid than natural in the cavities of the tho- rax ; the lungs were sound, but somewhat overloaded with blood, and connected to the pleura costalis by very extensive adhesions. This case happened before the publication of Dr. Parry's very ingenious work on syncope anginosa, and the coronary arteries of the heart were not particularly examined. CASE III. This occurred to me at Totness, in the spring of 1807, and is as follows: Peter Bastoe, aetat. 60, of a spare habit of body, narrow-chested, rather free in his mode of living and subject to rheumatism, had for more than twelve months before his death been liable to attacks of pain at the pit of the stomach, which after a few minutes passed off between the shoulders and down both arms as far as the elbows. A considerable uneasiness likewise ran down- wards to the bladder, with a most distressing and irre- sistible inclination to make water. These paroxysms were originally produced by walking up hill, and after- wards by every little exertion of body and mind, and excess of diet. As the disease advanced, they became more frequent, and were excited by slighter causes, till at length they occasionally came on in bed, after his first sleep. At these times he was obliged to rise, and the strangury became particularly troublesome. Once, a very hearty meat-supper was the cause of the attack. It lasted two hours. He lay totally insensible, his re- spiration slow and nearly suspended, his pulse beating with the most extreme weakness and intermissions, and the urine flowing involuntarily. The next day, besides a good deal of languor and debility, he had some cough; ON THE ANGINA PECTORIS. 223 this symptom, however, was not usual to him. The severe nightly paroxysms were generally foretold by palpitations, and a smart stroke of the artery; but, dur- ing them, I understood him to be free from any sensa- tion of that kind. At other times his pulse was 80 in the minute; and I observed nothing very remarkable in the stroke of the artery. He lay down easily in bed, and indifferently on either side, till within two months before his death, when he preferred the right side; and so free was he from any dyspnoea, that to the last, he was in the habit of playing the bassoon in public concerts. The pain in the arms was at first very marked, but rather decreased in its severity and extent, as the disorder advanced. I could not learn that he had had any obstructions of the urethra in the former part of his life; nor after repeated- ly questioning him, did it so much appear to me, that these painful efforts to make water brought on the fit, as that they followed almost instantaneously the anxiety at the heart. I consider it possible, however, that his symptoms might be connected with a calculus of the kidneys; and the medicines which I at first directed were given under that idea. But he derived no service from them. I was equally unsuccessful in my attempts to palliate the symptoms by opiates or any other means ; and not many weeks after, whilst walking in the street, he complained of extreme faintness, dropt, and was taken up dead. We were next day permitted to open the body. We found the substance of the lungs sound, but the left lung every where adhering pretty firmly to the pleura; no more than a natural quantity of fluid either in the right side of the thorax or pericardium ; the heart large and fat, but very flaccid; the aorta, as it emerged from it, rather inflamed externally; the internal membrane, as far as the aorta descendens, in many places thickened 224 ON THE ANGINA PECTORIS. and of an irregular surface, and with several spots of in- cipient ossification; the semilunar valves ossified, die bony deposition in one of them being nearly of the size of a common garden pea, and apparently sufficient to give considerable impediment to its action ; the corona- ry arteries ossified. In the right coronary, for more than an inch from its origin, the deposition of bony matter, not from all sides uniformly towards the centre, but across the cavity from one side towards the other, had been so great as very nearly to obliterate its canal; the left was enlarged, and, as far as could be traced, its coats were almost completely converted into bone. The other valves of the heart and of the pulmonary artery were quite sound. The viscera of the abdomen were natural; particular- ly in the kidneys, ureters, and bladder, there was not the least appearance of disease; but I am unable to speak with precision of that part of the canal beyond the bladder. CASE IV. W. Sprague, aetat. 50, Hospital, 1810, suffered from severe attacks of pain in the region of the heart. The commonest exertions produced it, but particularly walking up hill, stooping, or costive discharges. It was attended by palpitations. On resting, it passed off in a few minutes upwards to the shoulders, and down each arm as far as the elbows, particularly the left. At the same time a kind of forcing pain ran rapidly down- wards to the bladder, and ended in an irresistible incli- nation to make water. Such were his sensations of this kind, that it was very difficult to persuade him that he was not affected with the gravel, although certainly none ever appeared in his urine ; and he often told me that he was free from strangury, except during the paroxysm. He occasionally found some relief by leaning forward ON THE ANGINA PECTORIS. 225 and raising his arms above his head against the bed- post, as if to give his chest greater expansion. I had no opportunity of seeing him in those attacks, and there- fore cannot speak to the state ojf the circulation during them ; but he repeatedly said, that they were attended by palpitations of the heart, and by a difficulty of breath- ing ; the exact nature of that distress he was wholly un- able to describe. He laboured habitually under some degree of pyrosis; the pulse was generally 80, quick and thrilling; and there was a very constant expression of anxiety in the countenance. He had been much troubled with a chronic and pain- ful rheumatism till within the last twelve months ; since which his chest had been attacked; and it is remarkable, as in Duffell's case, that at first he used to suffer most severely in the night, being waked from a sound sleep by a sort of painful spasm; after a few weeks, his rest in general ceased to be disturbed in this way. I directed him the pills of soda and soap, as apparent- ly most suited to the circumstances of the attack. An issue was also opened in one of his thighs. But the hard labour, which he persisted in going through, per- petually renewed his complaint; and his symptoms in- creased rather rapidly. One night, after eating some- thing difficult of digestion, he was waked by a severe paroxysm, which continued for some hours, when he expired. On opening the body, we found a great deal of fat in the anterior mediastinum; the lungs quite sound; about a pint of pale serum on the left side of the thorax, somewhat less on the right; no adhesions; in the peri- cardium no more fluid than natural; one white lymphy spot on the surface of the heart; the surface of the great vessels rather inflamed, the right ventricle and pulmo- nary artery sound; valvulae mitrales somewhat ossified ; aorta thickened and most completely covered as far as the arch with very solid ossifications, round and upon (29) 226 ON THE ANGINA PECTORIS. which in some places the inner membrane had ulcerated. The ossification was particularly hard and thick in a spot very near one of the semilunar valves; but the valves themselves were quite free from any degeneration of this kind. The coronaries were dissected for many inches, and their canals laid open; they were found in a natural state, except two very small and thin white spots or rudiments of ossifications in the left coronary, about an inch from its origin, which did not produce the least unevenness or rigidity in the inner surface ; and if any such changes can be said to be harmless, these were undoubtedly so. Their size was very minute, not one- tenth of an inch in diameter. In the abdomen the intestines were much filled with air; but every part was sound in its structure; I speak particularly of the urinary organs, which were very carefully examined. CASE V. The following, as an instance not common, of the disease being connected with external violence, will perhaps be deemed worthy the attention of the reader. R. B., aetat. 60, a coachman, three months before he consulted me, received a violent blow from the pole of a carriage, which forcing him against a wall produced some litde contusion of the surface of the chest, and an internal pain, for which he was blooded, and used a lini- ment. He continued affected in his breathing on motion, and two months afterwards, whilst he was pitching some hay into a loft, he felt a violent pain in the region of the heart spreading rapidly to the left arm, with faintness and inability of movement. A similar paroxysm came on several successive nights, waking him with an ap- proach to deliquium and great anxiety. It continued to return on every exertion, and went off only by rest. ON THE ANGINA PECTORIS. 227 But after he had quitted his situation, and was liable to less fatigue, the attacks became milder. Twenty years since he suffered severely from rheu- matism, and after his first accident, what the apothecary considered to be gout appeared for two or three days in both his feet. He received some advantage from very mild laxa- tives, and the keeping a seton open on his chest; and by avoiding the occasional causes, and using great ab- stinence, has now for several years regained a firm state of health. Previously to considering the anatomical evidence furnished by these cases. 1 wish to make some obser- vations suggested by the symptoms. 1st. The symptom of palpitation mentioned in the fourth case, is not perhaps generally present in the an- gina pectoris; but it seems to make no material altera- tion in the character of the disease. Palpitations are often rather a diminished than an increased action of the heart, the ineffectual and feeble efforts of a distressed organ. They not only precede and are observed in the intervals of syncope both from a nervous and organic cause, but are sometimes united with a total cessation of the pulse at the wrist. Of the former fact, I was lately witness to an example, in a patient affected with angina pectoris, who felt palpitations and tremblings of the heart, from slight causes, but never in the parox- ysm itself. Of the latter a remarkable instance is given in Deidier des Tumeurs, which Dr. Parry quotes from Senac as a case of ossified coronaries. The symptoms are as follows: A lady, aetat. 84, had been troubled for some time with a singular oppression at the chest, not connected with dyspnoea. She had a constant distressing palpita- tion below the ensiform cartilage, and returns from time to time of paroxysms characterized by the appre- 228 ON THE ANGINA PECTORIS. hension of instant death, by the total cessation of the pulse at the wrist, cold extremities, a perfect freedom of the head, and a great increase of the palpitations. The semilunar valves were found ossified; the aorta contracted at its curvature, and ossified from its origin to its termination in the iliacs; the same process had extended to its branches, especially the left coronary, which was hard, cartilaginous, and half ossified. The other circumstances, both of. the case and dissection, I pass over, as not throwing any particular light on the present subject.* 2d. The uncommon effect of the blister, in the case communicated to me by Dr. Parr, is well worthy of notice, and renders it highly probable, if such a proof were wanting, that a muscular spasm forms part of the complaint. It has been already mentioned in Dr. Dun- can's Medical Commentaries, vol. iii. 3d. The pain of the arm appears to be very variable both in its extent and the time of its coming on. In some instances it is found to precede, in others to follow the fit; it sometimes attacks both arms, as we see in case third and fourth, sometimes only the left, and it terminates in almost any spot from the insertion of the deltoid to the fingers' ends. In the second case, it reached no farther than the clavicle and shoulder. When extending, however, as it usually does, it becomes a very important sign, which strongly arrests the attention of the patient by its singularity, often gives the first no- tice of the nature of the complaint, and may much as- sist the medical practitioner in forming his diagnostic. 4th. The strangury as it appeared in the third and fourth cases, is unusual, and has, I believe, been whol- ly overlooked by medical writers. But Lord Clarendon, * Deidier des Tumeurs, page 329.—See also Mr. Weldon's case, Medical and Physical Journal, vol. xvi. where palpitation is noticed as present in the paroxysm. ON THE ANGINA PECTORIS. 229 in the History of his own Life, records a similar fact respecting his father, and in terms so just and descrip- tive, that I have subjoined the account in his own words.* The circumstances in which it differs from the cases above mentioned, the reader will be at no loss * " His father had long suffered under an indisposition (even before the time his son could remember) which gave him rather frequent pains, than sickness; and gave him cause to be terri- fied with the expectation of the stone, without being exercised with the present sense of it: but from the time he was sixty years of age, it increased very much, and four or five years be- fore his death, with circumstances scarce heard of before, and the causes whereof are not yet understood by any physician; he was very often, both in the day and the night, forced to make water, seldom in any quantity, because he could not retain it long enough, and in the close of that work, without any sharp pain in those parts, he was still and constantly seized on by so sharp a pain in the left arm, for half a quarter of an hour, or near so much, that the torment made him as pale (whereas he was otherwise of a very sanguine complexion) as if he were dead; and he used to say, < that he had passed the pangs of death, and he should die in one of those fits;' as soon as it was over, which was quickly, he was the cheerfullest man living; eat well such things as he could fancy, walked, slept, digested, conversed with such a promptness and vivacity upon all argu- ments (for he was omnifarium doctus) as hath been seldom known in a man of his age: but he had the image of death so constantly before him in those continual torments, that for many years before his death, he always parted with his son, as to see him no more; and at parting still showed him his will, dis- coursing very particularly, and very cheerfully of all things he would have performed after his death. When he had nearly completed his seventieth year, he, one day, whilst at church, found himself a little pressed as he used to be, and therefore thought fit to make what haste he could to his house, and was no sooner come thither into a lower room, than having made water, and the pain in his arm seizing upon him, he fell down dead, without the least motion of any limb. The suddenness of it made it apprehended to be an apoplexy, but there being nothing like convulsions, or the least distortion or alteration in the visage, it is not like to be from that cause; nor could the physicians make any reasonable guess from whence that mor- tal blow proceeded." Vol. i. page 16. 230 ON THE ANGINA PECTORIS. to discover, and will probably attribute that difference to the existence of some disorder in the urinary organs themselves. Dr. Parry has stated this disease to partake always of the nature of a syncope. And undoubtedly when the paroxysm has amounted to any degree of severity and immediate danger, these signs have usually been very obvious. Not only the pulse has indicated it, but the partial cessation of breathing,* the shrunk countenance, the cold extremities, and that remarkable sensation of dying, which Seneca well expresses, when he says, aliud, quicquid est, segrotare, est; hoc est, animam agere. The faculties of the mind, on the other hand, often remain unimpaired; and this combination of symp- toms, so unusual in syncope, forms altogether the most distressing spectacle that can be well imagined. There is likewise great pain in the region of the heart, attended sometimes by a remarkable soreness in the affected spot. The pain always, in some degree, stretches towards the left arm, often to both, even downwards through the ab- domen to the bladder, and, as I once observed, down the loins to the outside of both thighs and legs ; but the extent of this sympathy varies much, and must be ex- pected to do so, according to the predisposition of the patient, and the exact nature of the organic injury. Now and then an entire insensibility, with total loss of pulse, has taken place. In many of those shorter and less intense attacks, which medical persons do not com- monly witness, it is probable that the same character prevails, though in a less degree. I must add, however, that if I can at all trust the statement of a patient in his own case on such a subject, very strong palpitations, and a smart stroke of the artery, have preceded and * In one patient whom I several times saw in the paroxysm, the pulse was 40, weak and interrupted, and he felt conscious, that the act of breathing required a voluntary effort. ON THE ANGINA PECTORIS. 231 even foretold severe nightly deliquia ;* and where this fit may be strictly said to begin, may admit of doubt; are not these different states rather parts of one great paroxysm, commencing with an increase, and terminat- ing with a failure of the circulation ? The syncopes, from an organic cause, have been remarked often to possess this character, long before the angina pectoris received its name; and it is worthy of notice, that even in the true and acknowledged form of that disease, the muscle of the heart has not always been found in the same condition, but in one instance emaciated, soft, and rotten ;f and in another, large, very hard, and strong ;| in a third, the left ventricle was remarkably strong and thick. § These opposite changes hardly seem compatible with an entire similarity of diseased action during life. In the first instance, there is reason to suppose that this organ was habitually very deficient in force, and badly nourished; in the two last, it must have been at least well nourished, and often probably too active, or exerting an activity suited to some un- usual resistance. Having endeavoured to ascertain what constitutes the fit of angina pectoris, the next question is, what causes it; and upon this head, the information derived from dissection is 'strikingly uniform. I am very far indeed from denying that exceptions have occurred, and may occur again ; but looking at the mass of evidence, and not at the exceptions, the prevalence of an ossification somewhere about the origin of the aorta can hardly es- cape us. I will as briefly as possible enumerate the principal appearances in these dissections, and shall fol- low Dr. Parry's opinion with regard to the genuineness * See Case III. t Memoirs of London Medical Society, vol. i. Doctor John- stone's case. f Morgagni Epistol xxvi. Article 31. § Medical Transactions, vol. iii.—Dr. Heberden's, 232 ON THE ANGINA PECTORIS. of the disease, as far as his publication extends, i. e. to the thirteenth case. 1st Case. Morgagni Epistle xxvi. art. 31.—Aorta dilated and ossified, heart large, and very hard and strong. 2d. Medical Transactions, vol. iii. Dr. Heberden; dissection by Mr. J. Hunter.—A few specks of begin- ning ossification of the aorta, left ventricle of the heart remarkably firm and quite empty. Adhesions of the lungs to the pleura on the left side. 3d. Medical Transactions, vol. iii. Dr. Wall.—Heart very large and fat; a pint of water in the pericardium; semilunar valves of the aorta perfectly ossified and im- movable; aorta considerably enlarged, and in some degree ossified. 4th and 5th. Medical Observations and Inquiries, vol. v. Dr. Fothergill. In one of these instances, besides water in the chest and accumulation of fat in the me- diastinum, there was near the apex of the heart a white spot of the size of a sixpence, like a cicatrix. In the other, the muscular substance of the heart unusually pale, and in many places, having the appearance of in- cipient ossification; the valvulae mitrales and aorta slightly ossified; and the coronaries completely con- verted into bone. 6th. Duncan's Medical Commentaries, vol. iii. Dr. Percival.—Liver, particularly the left lobe, full of hard white tumours; stomach scirrhous, where it came in contact with the liver ; heart and its vessels sound. 7th. Memoirs of the London Medical Society, vol. i. Dr. Johnstone.—The heart remarkably soft and flaccid, and easily admitting the finger to pass through its sub- stance. 8th. Memoirs of the London Medical society, vol, iv. Dr. Black—Coronaries completely ossified; left auricle remarkably thin; aorta much dilated, so as to appear rather like a bag than an artery, and resembling in its substance white leather. ON THE ANGINA PECTORIS. 233 9th. Home's Life of Mr. John Hunter.—On exa- mining the body of that very eminent anatomist, who died with decided symptoms of the disease ; there were adhesions of the lungs to the pleura on the left side; pericardium thickened; heart unusually small; spots of lymph on its surface ; its muscular substance very pale and loose; coronary arteries converted into bony tubes ; valvulae mitrales ossified in many places ; incipient os- sification in the semilunar valves of the aorta, aorta en- larged, and its inner membrane covered with white spots. 10th, 11th, 12th, 13th. Dr. Parry on Syncope An- ginosa. In the first (by Dr. Jenner,) the symptoms of which are not detailed, but said generally to be those of angina pectoris; coronaries ossified. Second (by Mr. Paytherus.) Accumulation of fat in the mediastinum; pericardium inflamed; coats of the coronaries thickened, approaching to a cartilaginous state; their inner surface incrusted with lymph, which was traced and drawn out from their smallest ramifica- tions ; heart remarkably empty; in the bottom of the right ventricle an oval sloughy spot; coats of the aorta thickened in two places, and several white spots in its inner membrane. Third, Semilunar valves slightly ossified; aorta con- siderably enlarged; coronaries ossified. Ejpurth, One of the semilunar valves of the aorta os- sified ; aorta dilated, and somewhat ossified ; coronaries ossified. 14th. Memoirs of the London Medical Society, vol. vi. Dr. Black.—Coronaries completely ossified through their whole extent; aorta somewhat dilated. 15th. London Medical and Physical Journal, vol. xvi. Mr. Weldon.—Aorta thickened in its inner mem- brane in numerous spots, though without any bony de- posit ; coronaries sound; right lung filled with abscess- es ; left lung firmly adhering to the pleura and pericar- (30) 234 ON THE ANGINA PECTORIS. dium. This patient died from the effects of pneumo- nia, and had remained for some years before his death nearly free from the paroxysms of angina pectoris. 16th. London Medical and Physical Journal, vol. xvii. Mr Ring.—Coronaries ossified; the mitral valves and semilunar valves of the aorta in different parts dis- eased and thickened, as if in an incipient state of dssi- fi cation. 17th, 18th, 19th, 20th, related in this Appendix. In the first, (Dr. Parr's,) the heart and the aorta and its valves ossified, with considerable adhesions of the lungs; Second, Aorta enlarged and ossified, with universal adhesions of the lungs; Third, Aorta and its valves and coronaries ossified, with adhesions of the left lung ; Fourth, Aorta ossified to a very great extent. We may observe, that in three only of these twenty cases, Dr. Fothergill's first, Dr. Percival's and Dr. Johnstone's, there was no appearance of ossification of the great vessels ; but in the first an hydrothorax, with fat in the mediastinum ; in the second an unsound liver; in the third an unusual softness of the parietes of the heart. The last of these states seems equally capable of pro- ducing an irregular and feeble action of that muscle, as any ossification can be; and it was likewise very puoba- bly dependent on some obstruction of die coronaries not sufficiently noticed. Of Dr. Percival's I shall only remark, that it was briefly related, and but once seen by that physician ; and that there is an unsoundness of the liver or biliary con- gestion, which produces symptoms bearing a character of great resemblance to the angina pectoris, but, as far as I have seen, marked by a more active circulation, relievable in a great measure by venae-section and vo- mits as Dr. PercivaA's case was, and greatly injured by ON THE ANGINA PECTORIS. 235 opiates. The practice, therefore, is very different, and the distinction between the two diseases should be pre- cise. In Dr. Fothergill's case, the changes found on dissec- tion were certainly not sufficient to account for the symp- toms ; and unless, as Dr. Parry has suggested, some ossification of the coronaries was overlooked, it must remain one of the exceptions before alluded to. In all the remaining cases, there was some alteration of structure tending to ossification about the origin of the arterial system, in the greater part, very extensive. An unsoundness of the aorta in various degrees is the most frequent appearance, being found in fifteen of these seventeen cases. In nine the coronaries likewise were ascertained to be diseased; in one the coronaries alone;* in several the valves and heart itself. That when this process begins in the trunk of the aorta, it should spread to the branches, and particularly perhaps to the coronaries, was to have been expected. But dissection shows, that it has not always done so before the paroxysms have proved fatal. In two dissec- tions, where the coronaries are not mentioned, and may have been overlooked, yet the heart was noticed as re- markably firm and well nourished. Morgagni's words are, cor magnum potius et durum valde ac robustum ; and in Dr. Heberden's case the left ventricle was said to be remarkably strong and thick ; a state very unlikely to coincide with a deficient nourishment, and habitual want of activity. Mr. Weldon asserts the coronaries to have been sound, in the instance which he relates; and of the fourth case recorded in this volume I shall only add, that those vessels were examined with the utmost care in the presence of very able judges, and no * This case, where the coronaries alone were ossified, is the only one the symptoms of which are not accurately detailed, but said generally to be those of angina pectoris. See Parry on Syncope Anginosa, page 3. 236 ON THE ANGINA PECTORIS. unsoundness of them was perceived, but the two small thickened spots before mentioned. In two of these seventeen cases, Dr. Heberden's and Mr. Weldon's, the appearances are said to be slight, and not sufficient to satisfy the anatomists who conducted the dissection. What quantity of disorder is necessary in order to impair the action of any part, is not easily determined. It is still more difficult to make a correct allowance for the pain and disturbance, which often usher in changes of structure, and which may be very severe, even before the effect is produced satisfactory to the eye of an anatomist. Such small alterations of them- selves, it will be allowed, do not prove a great deal; but when they are found in a suspected part, and are the least of a series of proofs, they acquire an additional value by that connection. We should, likewise, in es- timating such appearances, have some reference to the constitution of the patient, and allow it to be possible, as it undoubtedly is, that circumstances, connected with that cause, may have given activity to disorganizations apparently of little consequence. Morbid anatomy pre- sents us with the alterations of structure only, and even those but imperfectly ; during life there has been added something peculiar to the living solid, which infinitely modifies the effects of disordered structure. Ossifi- cations occur in those parts of the arterial system prin- cipally, which are most exposed to external impressions, or to the increased impulses of the circulation. They appear, however, not to be the effect of these accidents simply ; since the causes alluded to are very common, and indeed almost universally occurring, whilst ossifica- tions are at least comparatively rare. It is reasonable, therefore, to suppose, that where this change takes place to any considerable extent, there has been a predisposi- tion to disease in the arteries themselves, perhaps some feebleness of their original structure, which makes them susceptible of injury from slight violence. Sometimes ON THE ANGINA PECTORIS. 237 this aneurismal diathesis extends to every artery in the body; and then no doubt can be entertained of its con- nection with an internal cause. Even when the mis- chief is originally'more local, its disposition to spread extensively to the neighbouring vessels is very remark- able ; and the mode in which the unhealthy passes gra- dually into the healthy structure, argues something very different from a mere accidental injury.* Some writers have connected these changes in the arterial system with a constitutional disorder. Lancisi considers hypochondriacal, scorbutic, and syphilitic persons to be most liable to them. Morgagni entertains the same opinion with regard to the effects of a syphilitic taint. Scarpa, a high authority on these subjects, thinks, " that even aneurism of the aorta is much more frequently produced by a slow morbid degeneration of it, than by violent exertions of the whole body, blows, or an in- creased impulse of the heart. " He adds, that the artery is nourished and increased in the same manner as all the other parts of the body; it is vascular and organized, and therefore must admit of the diseases to which vascular and organized parts are liable; and that it is a fact, of which no doubt can be entertained, that the proper coats of the aorta are subject from a slow internal cause, to an ulcerated and * The late Dr. Parr, whose opinion on pathological questions is of high value, has suggested, as appears by some queries subjoined to the first case, that the original attack partakes in all instances of the nature of a spasm, and that the arteries, gradually only, become inflamed and ossified. In confirmation of the possibility of such a spasm, and of such gradual injury of the arterial coats by means of it, the late Mr. John Hunter's case occurs to me. During the first paroxysm which he ever suffered, and that a very severe one, brought on by anxiety of mind, the pain was seated about the pylorus; to which it may be added that calculi were found in the gall-bladder aftet? death. 238 ON THE ANGINA PECTORIS. steatomatous disorganization, as well as a squamous and earthy rigidity and brittleness. The former of these he considers as mostly connected with lues venerea. " Both of these morbid states cornmence, he thinks, in the inner membrane, or immediately under it. At first, the surface loses its beautiful smoothness, and be- comes irregular and wrinkled. It is afterwards inter- spersed with yellow spots, which are converted into grains and earthy scales, or into steatomatous and eheese-like concretions, which render the internal coat very brittle, and so slightly connected to the muscular, that upon being merely scratched with a knife, or the point of a nail, pieces are readily detached from it; and on being cut, it gives a crackling sound, similar to the breaking of the shell of an egg. This ossification can- not be said to be proper to old age, since it is some- times met with in patients not much advanced in life. In most cases the canal is constricted; in the highest degree we find true ulceration, and at last aneurism in all stages." It may be added, that the symptoms of this change are often so obscure, as to give very uncertain evidence of its existence in the living body. We wonder some- times at the extensive havoc that has been produced with so little warning. Morgagni, in a man who died suddenly from rupture of the aorta, and whose case I am surprised not to see quoted with other examples of diseased coronaries, found the aorta and its branches co- vered internally with prominencies and pustules, which extended especially into the subclavians, carotids, and coronaries; one of the coronaries was besides dilated to nearly the size of the left carotid; the coats were easily separable from each other, and the prominencies con- tained a pulpy matter; and yet this patient had no symptoms referrible to such a cause, but some emacia- tion for the last two or three years, and for the same period an occasional feeling like that of an approaching ON THE ANGINA PECTORIS. 239 deliquium; interno quodam sensu, ac si deficeret.* In others, on the contrary, there is reason to observe, that the very first rudiments of ossification are marked by considerable sufferings. Whether it is, that in such instances the disease is less confined to the internal membrane, or that there is superadded a stricture from some constitutional cause, the action of the parts is greatly impeded, and they are incapable of that dilatation and contraction required on great exertidns, in conse- quence of which arise pain and the signs of obstruct- ed circulation. Nor is it so extraordinary that these effects should be produced in some, as it is unaccount- able that they should be absent in any. This slow ossific process, much more the active one superadded to it, may probably in its early stages be sometimes removed by proper treatment, or by the ef- forts of nature; the parts may as yet be but little alter- ed in their structure; and that little, time may perhaps in some degree correct. It is possible that the patient may pass a long life without the recurrence of such symptoms. But it is more than probable, that irregu- larities, exertion, cold, suppression of gout, or the dry- ing up of drains, will some time or other bring them back, and with them a gradual but finally very decided change in the structure, as well as functions, of the suf- fering organ. It becomes unable to support the circu- lation through the common accidents and exertions of life. The fit comes on from the slightest movement, and even in that necessary pause from exertion which sleep occasions, f Nor is it to be wondered at, that the neighbouring parts should in some degree suffer, that * Morgagni Epistolae, xxvii. Artie. 28. t It is worthy of remark, that in two cases, I. and IV. this nightly distress, and a desire to fly to the open window for re- lief, came on amongst the first symptoms, and gradually disap peared as the disorder advanced. 240 ON THE ANGINA PECTORIS. there should be superficial marks of inflammation on the membranes, water accumulated in the chest or pe- ricardium, and what has appeared to me to occur in an unusual proportion, adhesions of the lungs to the pleura on the left side, and very near the heart. In the paroxysm, it is hardly possiole that they should be quiescent, amidst the distress of that vital organ. The heart itself has been known to retain a palpitating motion, though the pulse disappeared at the wrist. The stomach sympathizes, sometimes with the bladder. There are often signs of an affection of the diaphragm, of the other muscles of the thorax, the pectoralis major which passes to the left arm, and even the deltoid. That this propagated pain is a muscular as well as a nervous sympathy, there is every reason to believe, both from the parts where it sometimes terminates, and from an affection decidedly muscular, which I have ob- served in one instance of this disease, and in several of rheumatism or gout suddenly attacking the heart. The muscles connecting the arm to the chest were not only painful, but their small fibres were affected with a twitching and vellication remarkably noticed by the pa- tients, and in some degree visible to the observer. Whatever difference of opinion may still subsist as to the constitutional cause, which brings on changes of structure in the arterial system generally, and the parti- cular varieties of those changes, it is undeniable, that gouty and rheumatic habits are most subject to the an- gina pectoris; but whether it is that ossifications near the heart occur more frequently in such habits, or that a slighter degree of them produces a great impression, may admit of a doubt. This disorder makes a slow progress with indolent, rich, gouty, persons ; but I have seen it most rapidly destructive, in a spare rheumatic habit, subject not indeed to the acute form of rheuma- tism, but to nightly pains without swelling. Particu- larly, if under these circumstances the patient is still ON THE ANGINA PECTORIS. 241 obliged to encounter manual labour and hard living, he cannot last many months. It is remarkable that the subjects of the angina pecto- ris are almost exclusively of the male sex. The treatment of this disease is very undetermined and inefficient; nor can it be otherwise whilst so many symptoms obviously spasmodic are mixed with mal- organization, and the commencement and even nature of this latter are not agreed on. Where the habit is gouty, every thing that will drive that disorder to the extremities, a most arduous attempt, is advisable; and what will correct the disposition to it; for which purpose soda and magnesia, I believe, answer best. If the cause is rheumatic, it is still more difficult to correct that distemper, or even to transfer it to the sur- face. In all, rest both of body and mind is to be enjoined, with drains, and a moderately relaxed state of the bow- els. The diet must vary with the general health of the subject, but should, I think, be as temperate as that will admit. In the aneurismal diathesis, abstinence to a great extent has been recommended by Valsalva, Guattini, and others, and by Dr. Fothergill in the angi- na pectoris, to remove a supposed cause of it, an accu- mulation of fat about the heart. Dr. Heberden, how- ever, who had much experience in those cases, and whose opinion is entitled to great weight, thinks that a generous diet is proper, and that we should not look for the cure in those plans which lower the strength. In determining this point, the cause of the attack should be duly considered. Gout can rarely be driven to the surface by a very low diet, but at the same time admits of great caution in the choice of food, and is benefited by it. It is, however, hardly necessary to enlarge on (31) 242 ON THE ANGINA PECTORIS. that point here. Rheumatism is more inflammatory, and may seem to call for great abstinence, particularly with regard to wine; but that it ever will be removed from its seat in the chest by this plan, I can by no means assert. Something, perhaps, may be thus done, towards suspending the progress of the disease. Where the symptoms depend on neither of these acrimonies, but on an original affection of the parts, or external vi- olence, as in Case V., an unusual moderation in diet may probably be adopted with advantage, as recom- mended for aneurism by the authors quoted above. Issues in the thighs have been partially successful. It may be some encouragement to add, that a gentle- man, who had never for a single week been free from the disease for ten years together, lost every vestige of it for the last nine months of his life, during which he suffered from ulcers of the lower extremities. The sur- face of the chest, opposite the heart, has been sometimes recommended for such a drain. I have not found ex- perience to justify the hopes entertained. The inflam- mation excited by the caustic appeared to me, in one instance, to irritate, and bring on the paroxysm. And the superior advantage of irritations in the lower extre- mities is strongly confirmed by the following case: A. B., who had had one attack of the gout, about twenty years befcre, was recommended by me to open an issue in the region of the heart, on account of fits of the Angina Pectoris, exquisitely marked. During the forming and separation of the sloughs, the paroxysms greatly increased, and placed him in extreme danger. In this urgent state, mustard cataplasms, quickened with oil of turpentine, were applied to the feet; and in ten minutes he was perfectly relieved. His unwilling- ness to bear pain induced him then to remove them. The distressing sensations on his chest quickly returned, and he was obliged to submit to a renewal of the ca- taplasms, which again operated almost as a charm. An ON THE ANGINA PECTORIS. 243 imperfect gout continued in the great toe for some weeks, and for a long tune after he had a true sciatica. Against an issue in the left arm, the same objections do not hold, as against those on the chest; and it may be added in favour of it, that it has proved very ser- viceable in some severe affections of the heart. In the paroxysm, little has generally been attempted. But when we recollect how much of spasm mixes itself with the attack, and that, perhaps, even the heart and aorta are in some cases affected in that manner, as is rendered particularly probable by the dissection in Dr. Heberden's case, opiates may be thought likely to ren- der service. Dr. Hunt of Dartmouth taught me the safety of such a practice, who in a case of this kind, in which we were consulted together, gave on the emer- gency, before my arrival, ninety drops of tincture of opium. The patient alluded to had experienced many attacks of the angina pectoris; on this occasion it was provoked by some very slight bodily exertion ; and he had remained for a long time in an entire deliquium, as far as the circulation was concerned, but a full posses- sion of the faculties of the mind ; an awful state, hardly belonging to this world, and which whoever witnesses can never forget.* The tincture of opium in divided doses soon began to relieve him; and when I arrived about an hour after, the pulse had recovered some strength, and the pain and angor cordis were removed. I have imitated this practice in other cases, but not with entire success. It appears, however, to be safe, and where the habit is gouty, to be very beneficial. Tincture of opium is likewise used with advantage, as Dr. Heberden informs us, to prevent the attack at night. * The late Mr. John Hunter suffered such a paroxysm, in which the pulse at the wrist ceased for three quarters of an hour, and he found himself at times not breathing; yet sensa- tion and the voluntary actions were perfect—See Home's Life af Hunter, page 46. 244 ON THE ANGINA PECTORIS. A tea-spoonful of aether has now and then carried oft the paroxysm. We may add, as a remedy worthy the trial, the im- mersion of the affected arm in water, as hot as can be borne. I have used it on Morgagni's authority, and found great relief from it in some anomalous complaints of the heart, where the left arm was painful. From what has been advanced, page 242, it is obvi- ous, that rubefacients to the lower extremities should not be omitted, particularly where gout is suspected. A respectable practitioner in this county, obtained re- lief for many years by that application; one night he asked for them, as he often had done, but before they could be prepared, he had breathed his last. In another instance they had been used with advantage; but on the fatal attack, they failed to produce any pain or in- flammation, though applied repeatedly, and of great strength; and the patient lingered for many hours, sen- sible, but without a pulse. It has been already remarked, that the paroxysm of the angina pectoris partakes generally of the character of a deliquium; and on that account, it has received from Dr. Parry the appropriate name of syncope anginosa. Are there any cases to which that term is not applicable, in consequence of the pulse remaining unaltered ? I leave it to those who have seen the disease in a slighter form than I have done, to determine this point. Dr. Heberden undoubtedly had such cases in his view, since he says, that the pulse is at least sometimes not dis- turbed by this pain, and, consequently the heart is not affected by it. It appears, likewise, that causes seated in the abdo- men may produce symptoms having a character of great ON THE ANGINA PECTORIS. 245 resemblance to the disease above described. Dr. Per- cival's case renders this probable. It has occurred to me to see three instances of the same kind. The per- sons alluded to, besides having a sallow complexion, pain of the epigastric region, bilious, or clay coloured discharges, &c, were likewise subject, on exercise, but particularly after loading the stomach, to a straitness of the lower part of the sternum, palpitations, excessive anxiety about the heart, pain stretching thence to the mammae and both arms, and a quick hurried pulse. Bleeding gave temporary relief; but opiates were ex- tremely injurious. Two of these persons died with signs of a scirrhous liver; a third was cured by calo- mel, and now, twelve years after, enjoys robust health, and is capable of much exertion. Such patients greatly want evacuations by mercury, and cannot bear the least restraint of the bowels. I remarked in these an increase of the circulation; but many adventitious causes, or even the greater intensity of the original cause, may, I believe, convert palpitations into deliquia; and we shall then be greatly deceived in our conclusions, unless we take other circumstances into the account. After all that can be done on such subjects, we shall, I fear, ever have to lament the difficulty of applying to particular cases those rules which are precisely laid down by authors. Every case has some peculiarities. Noso- logy treats of genera and species; nature gives us indi- viduals ; and in these we meet varieties and combina- tions both of local and constitutional disease, which fre- quently embarrass the most accurate observer, and set all arrangement at defiance. THE END. ADDITIONAL APPENDIX. No. I. FROM THE MEDICAL RECORDER. A Case of Dropsy, communicated by Dr. Culbertson, of Chambersburg, Pennsylvania, dated February 28, 1818. Gentlemen, In conformity with your request, I now send you the subjoined communication on the subject of general Young's case of Dropsy. In a practical point of view, I think this case must be considered an important one ; and if such it should be deemed by you, and you should consider it as calculated to promote the advance- ment of the healing art, or in any way to subserve the cause of medical science, you are at perfect liberty to communicate it to the medical public, through the me- dium of the Medical Recorder. CASE. On the i3th of July, 1817, I was first requested to wait on general Robert Young of Alexandria, aged about forty-eight years, then on a visit at his brother's in this neighbourhood. I found him labouring under 248 ADDITIONAL APPENDIX. a most oppressive dropsical complaint, of the combined form of ascites and anasarca. I was then informed by him briefly, that he had been affected with this disease for nine months or more; that he had undergone a long course of medical treatment for it without avail, under the direction of the most respectable medical gentle- men ; and that, finally, his case had been abandoned by his physicians, and considered as hopeless and incura- ble. General Young had left his house in June, with the view of visiting the Bedford springs, at which time he was so excessively weak and debilitated, as to be un- able to walk across his room without assistance. He had now just returned from the springs, and though he was not reduced in size, yet had gained considerably in strength. He was now able to take moderate exer- cise on horseback; his appetite tolerable, and thirst moderate; but his complexion was sallow and bad, and his whole countenance of a bloated appearance. His pulse was most remarkable for its irregularity; it was very frequent, though irregularly so; and very small, yet occasionally discovering a full, strong, and tense beat. The urinary secretion was in small quantities— not perhaps exceeding a half pint in twenty-four hours; was of a whitish turbid appearance; and, on being per- mitted to stand, deposited a firm mucous kind of sub- stance. And what rendered his case still more com- plex and unpromising in its issue, was, its being com- plicated with a partial paralysis of one side—the arm, in particular, of this side, being entirely powerless and useless, and the muscles fast wasting away. This affection was secondary, and, no doubt, resulted from the circle of circulation being more limited, in conse- quence of pressure on the abdominal arteries, thereby throwing a preternatural quantity of blood to the head. The carotive artery of the paralytic side was affected with the most extraordinary, violent, and irregularly A CASE OF DROPSY. 249 agitated action; and the head was subject to a distress- ing course of tightness, and occasionally, severe pain. The general informed me that, on his way from Bed- ford, he had accidentally met with a Dr. Newman, of Old Town, Maryland, and who, under the circumstan- ces just now stated, very properly and correctly advised the loss of blood. With this view, I was now consult- ed. I soon found, however, that my patient was strong- ly prepossessed in favour of bleeding, as he was deter- minedly opposed to the use of almost every other re- medy. I endeavoured to impress on his mind, the im- portance, and even the necessity of the co-operation of digitalis, and mercury particularly, in aid of the lancet; but in vain—he, unfortunately, having the most fixed and inveterate prejudices against those medicines. It will, therefore, readily be seen, that I had little latitude allowed me in my prescription; and accordingly, being almost exclusively confined to the lancet, 1 was deter- mined to use it freely and liberally, in order to ascertain really what effects would result from its use alone, in so formidable a form of disease as the one under which my patient laboured. I -therefore immediately drew from his arm thirty ounces of blood. It was somewhat sizy; it coagulated speedily and firmly, and its compo- nent parts were in due and natural proportion. July 14. He expressed great relief from the bleeding of yesterday. Can walk, and exercise on horseback, with more freedom and ease than before. 'Repeated blood-letting sixteen ounces. Take sal. nit. and keep up a constant action on his bowels by means of the following pills, which were prescribed for him by his attending physician previous to his leaving home. R. Aloe, socot. 3ss G. gombog. > an 9.. G. scammon. } ^ J Pulv. rad. scillae 3ss Ol. junip. gt. 30 Sapo. castil. q. s.—M. ft. pil. No. 4* (32) 250 ADDITIONAL APPENDIX. July 16. Continues much the same as on the 14th. Blooded him to-day twenty-four ounces. Appearances of the blood the same as before. He is freely purged. July 19. Expresses himself as greatly relieved. Says that the stiffness of his knees and legs, of which he complained much, is entirely gone. He takes exercise freely on horseback, and is gaining his strength fast. He is also rapidly recovering the use of his paralytic arm. The urine, however, still continues in small quantities; and, on the whole, he rather appears to be increasing in his size. Is still confident that bleeding will cure him. Took from him twenty-four ounces of blood. July 25. Continues as on the 19th. Blooded him to- day thirty-two ounces. July 27. Blooded him thirty-six ounces. The pulse does not appear to be affected in any way by the loss of blood. He still expresses great relief from the bleedings. July 29. Blooded him thirty-six ounces. Take crem. tart. August 1. Is not so well to-day. Complains that the last bleeding, for the first time, produced giddiness of the head, and weakened him considerably. He is very much disheartened, and is losing his confidence in die lancet. Is increasing rapidly in his size; though he ascribes it to the use of the crem. tart, which had been prescribed for him on the 29th. I now think it prudent, for the present, to advise a discontinuance of the bleedings. August 4—7—10. Has been using what he calls a " diet drink ;" which, on account of its being nauseous and very unpleasant to take, has been held in reserve as the dernier resort, in case other means failed. It appears that considerable, though temporary ad- vantages, had resulted from the use of this compound, previous to his leaving home; and he is now determin- A CASE OF DROPSY. 251 cd to give it a fair trial. His debility is increasing, and his disorder is gradually growing worse. August 13. He is now almost altogether confined to his bed; and notwithstanding the use of his favourite nostrum, is reduced to the necessity, to obtain present relief, of submitting to the operation of paracentesis ab- dominis. On this occasion, Dr. Dean, a medical gen- tleman of this place, was requested in attendance with me; and accordingly this day we drew from his abdo- men five gallons of water. We now embraced the opportunity of representing to general Young the importance of system in his treat- ment ; and at the same time held out sanguine hopes of success in his case, provided he would lay aside all nostrums, and place himself under our exclusive direc- tion. This, after great doubting and hesitation, he agreed to. August 14. Dr. Dean and myself again attended to- day, and found our patient greatly relieved by the ope- ration. He made considerable more urine last night, than he had been in the habit of doing. His pulse, how- ever, still continued as irregular as before the operation. After a careful investigation of the case, we concur- red in the propriety of again commencing the treatment of it by bleeding; and following it up with the digitalis and mercury. Accordingly we immediately drew from his arm thirty-two ounces of blood; used frictions over his abdomen with strongly camphorated mercurial ointment, and secured on it, in addition, a flannel com- press, saturated with the same ointment, with a roller firmly and tightly applied. No preparation of mercury whatever was given internally. After to-day we were deprived of the assistance of Dr. Dean's advice, in con- sequence of his indisposition. August 15. Urine is again diminished in quantity. Repeated the blood-letting thirty-two ounces; and con- tinued the mercurial frictions. Take infus. digital, with 252 ADDITIONAL APPENDIX. sal. nit. dissolved in it—one table-spoonful morning and evening. August 16. Complains much of being weak. Gums are considerably affected with the mercury. The abdo- men appears to be again filling with water. I now feel myself compelled, though I confess with great reluc- tance, to discontinue the bleedings. Continue the mer- curial frictions and the digitalis; increasing the latter to three table-spoonfuls a-day. August 17—18—19. The mercurial agitation is greatly increasing—the mouth very sore. Water is re- accumulating in the abdomen rapidly. He is in almost a constant state of perspiration, and has been usually in this state. The digitalis nauseates the stomach a little, though nothing like vomiting. It does not appear to affect the head; though it appears to occasion some in- distinctness of vision. The bowels are in a regular way. Continue medicines as before. August 20. Is rapidly growing worse. Complains of great debility. The accumulation of water in the abdomen nearly as great as before the operation. My anxiety for the result is now excessive: indeed I alto- gether despair of success; and the last lingering hope of my unhappy patient is almost in a state of exhaus- tion ; and his despondence is the more increased, inas- much as he has not only no faith, but, on the contrary, the most inveterate prejudices against the remedies employed for his relief. Now, however, appeared to be the critical period; and the result affords as proud a triumph to the science of medicine, as it amply rewards him for his persever- ance and all his sufferings. On inquiry to-day, general Young informed me, that he had always observed, that in proportion to the water drank, was the quantity of urine made. I was struck with the importance of the fact; at least I viewed it so in his case; and immedi- ately determined to take advantage of it. I therefore A CASE OF DROPSY. 252 desired him to drink freely of cold water; which he did, though without feeling any great desire for it; and the effect exceeded the most sanguine expectations that I possibly could have entertained. In a short time after drinking the water, a determination to the kidneys took place, succeeded by the most copious urinary discharg- es ; at least two gallons in the first twenty-four hours; and this effect continued until the whole water was completely evacuated from the system. In giving the details of a case, it is of all importance that every im- portant circumstance in any way connected with it, should be accurately and correctly stated : it is for this reason, therefore, that I state the above fact. What agency had the cold water, or had it any, in producing the effect which I have attributed to it ? On the 23d the salivation ran very high—the mer- curial frictions were therefore discontinued. The infu- sion of digitalis was continued a few days longer, when it was also left off. By the 31st, the system was completely relieved of all its serous collections; at which time, and not before, the pulse regained its healthy regularity of action. The mercurial action continued very high until the 10th of September. The gums and cheeks being ex- cessively sore and deeply ulcerated. From thistime the salivation gradually subsided; his appetite returned; he was able to take moderate exercise on horseback; and, in short, regained his strength so fast, that by the 20th of the month, he was able to return to his home by the common mail stage. And I am happy to add, that, by a letter received from general Young, as late as the 3d instant, he still continues well, and there is no appearance of any return of his former complaint. In conclusion, I may be permitted further to add, and no doubt it will be considered surprising, that general Young, on weighing himself after being reliev- 254 ADDITIONAL APPENDIX, ed of his disease, discovered that he was reduced one hundred pounds below his usual healthy standard. REMARKS. The case just now recited is still imperfect. A com- munication from the respectable medical gentleman who attended the subject of it in its early stage, is yet wanting to make it complete. We could then with more certainty appreciate the importance of the means used, which happily eventuated in success, by contrast- ing them with those that had been, though unsuccess- fully, used. It happens however, generally, that the purging plan had been principally depended on, and very perseveringly urged, as the general informed me that he had been purged every day, without intermis- sion, for two months; yet it would seem without any good effect resulting from it; indeed, on the contrary, his disease still continued gradually to gain ground. This case, no doubt, will generally be considered, and deservedly so too, as principally important from the circumstance of the extent to wljjch blood-letting was carried—and particularly when this is taken in con- nection with the successful issue of it. By many, however, the effects of blood-letting on this occasion will be considered as questionable, inasmuch as no ap- parent permanent good appeared immediately to result from it; and by others, its propriety at all will not only be disputed; but, without doubt, it will at once be con- demned as a rash and dangerous practice. Without pretending, or even expecting to reconcile every difference of opinion that may be entertained in relation to the treatment of this case, I must beg leave, though briefly and without comment, to state, that my opinion is, from the most attentive observation on all the important attending circumstances, that blood-let- A CASE OF DROPSY. 255 ting was absolutely indispensable to a successful re- sult; and that a cure could not have been effected without it. On the other hand, however, it will as readily be admitted, and little reflection from a review of the case, will be sufficient to convince us, that the result could not, with even a shadow of propriety, be attributed to blood-letting alone. This, indeed, would be looking for more than reasonably could be expected from any single remedy. In short, I believe, that the combined co-operation of the lancet, aided by the digi- talis, and both backed and confined in their operation by mercury, were all necessary to produce the success- ful result in this case. It may, however, be admitted, and without any detraction from the character of the lancet, that it was carried to a greater extent oh this occasion than perhaps would have been necessary, pro- vided the other co-operating means had been earlier employed in aid of it. This case, I think, at least must tend to produce the all-important practical effect, of doing away all shyness and timidity on the part of the practitioner in the use of the lancet on similar occasions. It will also serve to show the extent to which blood-letting may be carried, when considered necessary, not only without injury, but with the happiest effects. In short, I do most sincerely and cordially add my most unequivocal testimony to that of Dr. Newman, in favour of the importance of the most extensive prac- tice of blood-letting in dropsy. And, further, I do most honestly believe, with Dr. Newman, that the " right use of the lancet" in this formidable form of disease is not generally, or well understood. When Dr. Newman declared this opinion in his newspaper publication of the preceding case, I considered him presumptuous; and whatever little vanity I Still may consider as con- nected with the hasty and imperfect character of that publication, yet it ought not, and will not prevent, on 256 ADDITIONAL APPENDIX. my part, the fullest acknowledgment of my most ho- nest conviction of the correctness of the Dr's. opinion in its fullest extent, relative to the use of the lancet in the disease above alluded to. Is it believed that blood- letting is of all-importance in the most inflammatory cases of pleurisy ? I believe it to be equally necessary in dropsy. I believe it may, and frequently must be carried to a much greater extent in the latter disease, and with less risk of unduly debilitating, or doing injury to the system. In fact, I believe, there is scarcely any form of dropsy in which the lancet may not be used to a greater or less extent; but in some cases certainly to a much greater extent than in others. I now have a dropsical patient under my care, from whom I have in six days taken, at four bleedings, one hundred and twelve ounces of blood with the best effect; and he is now stronger and more able to exercise than when I first saw him. When I urge, however, the use of the lancet in dropsy, I must not be understood as using it to the exclusion of other remedies—far from it: I be- lieve the lancet, digitalis and mercury particularly, as the happiest combination of means that can be advised for the treatment of this formidable disease. Blood-let- ting, however, must not be practised as is generally done, by merely practising one or two small bleedings, to prepare the way for the use of other medicines; but it must be used profusely and repeatedly. Its use, in short, not to be governed by the quantity taken, but the effect produced, and the necessity that may still exist for its further continuance. But I have done—it not being my intention, on this occasion, to pursue this subject further. My remarks have been almost exclusively confined to blood-letting, conceived as an important remedy; indeed, I may say, an indispensable one, in the treatment of dropsy; and if what I have said should have the effect of engaging and fixing the attention of physicians to this important A CASE OF OVARIAN DROPSY. 257 point in their treatment of this disease, I shall have attained fully my object. I am, gentlemen, yours very respectfully, S. D. CULBERTSON. To the Editors of the Medical Recorder. A Case of Ovarian Dropsy, successfully removed by a Surgical Operation. Communicated by Dr. Nathan Smith, Professor of Physic and Surgery at Yak College. The subject of this operation was a Mrs. Strobridge, of Norwich, Vermont, aged 33 years. The following account of the case, previous to the operation, was taken from the patient:—Seven years before, she perceived a small tumour in lier right side, situated in the right iliac region ; when about the size of a goose egg, she could move it with her hand to the opposite side of the linea alba, and to some distance above the umbilicus. The patient had borne five chil- dren, two previous and three subsequent to her discov- ering the tumour. The youngest child was 10 months old, and was nursed at the breast when she submitted to the operation. Soon after her first pregnancy, from the commencement of the tumour, and when, as she thinks, it was about 4 or 5 inches in diameter, it sudr denly disappeared, probably burst into the abdomen. In 4 or 5 weeks it was as large as before. Before and after the bursting of the tumour she had turns of faint- ness, which lasted from two hours to half a day. During parturition of her second child, after the commencement of the tumour, it having acquired a considerable size, it burst again, and nothing was perceived of it till eight months had elapsed. In four davs from its reappearance (33) 258 ADDITIONAL APPENDIX. it was as large as it had ever been. It was again burst by a fall; great soreness of the abdomen, and confine- ment of the patient for several weeks was the conse- quence. The tumour filled again in a fortnight, and from this time continued to increase; it did not burst in the delivery of her last child, which was ten months previous to the operation. The patient's health was not much affected by the tumour. She was costive; and the size of the tumour incommoded her in the ordinary- duties of her family, especially in stooping. On exa- mination I found a large tumour in the right side of the abdomen ; it was considerably moveable, and I could produce a distinct fluctuation through it. Having decided on the operation, and determined the mode of operating, on the 5th of July, in the presence, and with the assistance, of Doctors Lewis, Mussy, Dana, and Hatch, I commenced the operation as follows:— The patient being placed on a bed, with her head and shoulders somewhat raised, an assistant rolled up the tumour to the middle of the abdomen, and held it there. I then commenced an incision about an inch below the umbilicus, directly in the linea alba, and extended it downwards three inches. I carried it down to the pe- ritoneum, and then stopped till the blood ceased to flow, which it soon did. I then divided the peritoneum the whole extent of the external incision. The tumour, now exposed to view, was punctured; a canula intro- duced, and seven pints of a dark coloured ropy fluid was discharged into a vessel; about one pint was spilt, so that the whole fluid was about eight pounds. Pre- vious to tapping the tumour, by inserting my finger by the side of it, I ascertained that it adhered to some ex- tent to the parietes of the abdomen, on the right side, between the spine of the ileum and false ribs. After evacuating the fluid I drew out the sack, which brought out with it, and adhering to it, a considerable portion of the omentum. This was separated from the sack with A CASE OF OVARIAN DROPSY. 259 the knife; and two arteries, which we feared might bleed, were tied with leather ligatures, and the omentum was returned. By continuing to pull out the sack, the ovarian ligament was brought out, this was cut off, two small arteries, secured with leather ligatures, and the ligament was then returned. I then endeavoured to separate the sack from its adhesions to the parietes of the abdomen, which occupied a space about two inches square; this was affected by a slight stroke of the knife at the anterior part of the adliesion, and by use of the fingers. The sack then came out whole, excepting where the juncture was made, and I should think it might weigh between 2 and 4 ounces. The incision was then closed with adhesive plaster, and a bandage applied over the abdomen. No unfavourable symptoms occurred after the operation ; in three weeks the patient was able to sit up and walk, and has since perfectly re- covered. I was induced to undertake this operation from the following considerations:—The patient, though her health was not greatly impaired, was sensibly affected by the disease. She was quite certain that the increase of the tumour, in a given time, was augmented; pro- bably, at no very distant period, it would destroy her. I had, also, an opportunity to dissect the body of a pa- tient, who had died of ovarian dropsy, after being tap- ped seven times. In this case the sack was found to be in the right ovarium, which filled the whole abdo- men ; but it adhered to no part except the proper liga- ment, which was not larger than the finger of a man. I have seen two other ovarian sacks which were taken from patients after death. They had been tapped seve- ral times; the sacks were equally unattached, except to their own proper ligaments. Hence, I inferred, that in a case of ovarian dropsy, while the tumour remained moveable, it might be removed with a prospect of suc- cess. The mode of operating, practised in the above 260 ADDITIONAL APPENDIX. case, is the same as I have described to my pupils in several of my last courses of lectures on surgery. The event has justified my previous opinions. *#* The author, at the time of reporting the above case, was ignorant that Dr. Dzondi had proposed the attempt to cure ovarian dropsy by the introduction of a tent following puncture, that the dropsical sack might slough, and be with- drawn by forceps.—Vid. Medical Recorder, Vol. III. p. 63. A Case of Encysted Dropsy. Read before the Georgia Medical Society, on the 1st of March, 1823, by J. S. Habersham, M. D. of Savannah.—Communicat- ed by Dr. Ducachet, of New- York. Mrs. E. K., the subject of this distressing disease, consulted me some time in 1821, and gave a history of her case as follows: In the year 1805, some time subsequent to the birth of her only child, she discovered a tumour of small size, in the left hypochondrium, distinctly to be felt, when she made pressure above the ilium. The tumour con- tinued stationary for several years ; becoming, however, occasionally painful, though more particularly after much exercise. She experienced no other inconve- nience, until about the year 1819, when she perceived that the enlargement was progressing, and continued gradually extending towards the pubis; it then became again stationary. She could now discover an enlarge- ment in the right side, commencing, as did the former in the left. I cannot account for this fact in any other way, than by viewing it as a translation of disease, from one ovarium to the other. In taking any unusual exer- cise, she felt such pain, as prevented her resting on the right side. The urinary secretion, which had never A CASE OF ENC\STED I)K0PS\. 261 before been materially deranged, in a few months, and in proportion to the enlargement of the tumour, lessened considerably in quantity, and required some efforts for its discharge. Mrs. K. now felt great pain in the back; her respiration was laborious, and she became much distressed when pressure was made about the scrobicu- lus cordis. Her catamenial discharge continued unin- terrupted, and in the usual quantity. At this time she submitted her case to an empiric, who treated it as a nervous disease. She then took additional advice, and was informed that she was becoming dropsical; she was accordingly treated with diuretics, though without experiencing the least relief. Her urine was still void- ed in very small quantities. The tumour had now be- come so much enlarged, that she was sensible, from its fluctuation, that it contained water; and being now sa- tisfied that her case was dropsical, she strenuously ad- hered to the diuretic plan, and cheerfully took the re- medies suggested. She was now advised to undergo a course of mercury, and persisted in its use, until ptyalism was carried to an extent, which proved that the disease was not to be conquered by that medicine, whether used as an alterative or as a salivant. Having used, for a long time, a great variety of diuretics, and tried the most drastic cathartics without advantage, she was now advised to visit New-York, under the hope that some benefit might be gained, by applying to a physician who was reported to have been very success- ful in the treatment of dropsical diseases. Her case was again viewed as an ascites, and she had the courage to submit to a thorough, but inefficient course of remedies. She now became hopeless, and resolved to submit her case to Dr. Hosack, with a fixed determination, to un- dergo any remedy his enlightened judgment should suggest. As she was furnished with a written opinion of her case, I have transcribed it with her permission. " Mrs. K.'s complaint consists, in my opinion, of a 262 ADDITIONAL APPENDIX. tumour in the abdominal cavity, probably of a sar- comatous nature, accompanied with a serous collection, produced by the tumour. Shortly after her arrival, the collection of water was so great, that Dr. Kisam and myself thought proper to evacuate it, and drew off about two quarts. Our chief attention has been directed to the means of preserving her general strength, and in- creasing the urinary discharge, which is diminished by the determination to the abdominal cavity." It was proposed that the tumour should be punctured, to which she readily assented. The operation was performed in the left linea semilunaris, higher up than usual, and they must have punctured the left ovarium, as will be shown by the dissection. I am at a loss to conjecture why they should have made choice of the left side, un- less from her representation that the first enlargement was discovered there, and, moreover, that the whole ab- domen was now so uniform in its distention, that the larger tumour of the right side could not be distinguish- ed. They procured, as stated above, two quarts. She was then advised to take the rubigo ferri, in combina- tion with ginger, but could not continue its use. Short- ly after her return, I was consulted, and on examining the abdomen, found an immense distention and evident fluctuation; and although there was but slight oedema, such was the enlargement, that it was with difficulty I could form an idea as to the situation of the tumour, which she described as having been distinctly felt, be- fore the distention had become so great. I could, how- ever, observe that the right side was more tense than the left, and that uiis hardness extended across the linea alba. Having the concurrence of Dr. Kollock, I punc- tured the linea alba, and felt myself somewhat discon- certed at finding such unusual resistance to the progress of the lancet. Apprehending that the tumour had ex- tended across the linea alba, I freely introduced the whole blade of the instrument, which but slightly enter- A CASE OF ENCYSTED DROPSY. 263 ed the cavity. I was enabled, by the use of the female catheter, to obtain about two gallons of serum. I could now plainly discover the size of the tumour, which be- came perfectly circumscribed, with its circumference (as nearly as I could judge) about that of a large plate. It evidently contained more fluid, and in a few days be- gan to increase in size. Being now satisfied of the cor- rectness of her statement, I looked upon it as a case of encysted dropsy of the ovarium, and confident that no advantage could be derived from the use of diuretics, and in order to remove the fever, I administered cathar- tics, and whenever the pulse would allow, tonics. The enlargement became so extensive in six weeks, that I was requested to operate again, and procured more than two gallons of serum, of the usual consistence. In three weeks, I made a third puncture, with the abscess lancet and large trocar, in the presence of Dr. Daniel. The secretion was now altered from a thin serum to a ropy coagulable lymph, of the consistence of the white of an egg, two quarts of which was procured. I made a second puncture, and obtained twelve pounds of a dark, but much thinner gelatinous consistence. Sub- sequent to this last operation, she had much fever, ac- companied, in a few days, with lancinating pain, rigours, low pulse, great debility, and night sweats, which led me to suspect the formation of matter. The tumour was now confined to the right side, much more cir- cumscribed, and still extending towards the left; but not sufficiently in the linea alba to allow of my operat- ing at that place. I now prevailed on my patient to submit to a fourth incision, giving her the assurance of my impression, that after the evacuation of the matter, adhesion would take place, and a further collection be prevented. The operation was made about four inches, in an oblique line, from the umbilicus, where the tu- mour presented most, and I opened the cyst which con- tained the matter. It flowed very freely, and I drew 264 ADDITIONAL APPENDIX. away two pounds of straw-coloured pus. The orifice in the tumour receded so much, that I punctured that part which presented itself to the opening in the integu- ments, and obtained sixteen pounds of tne same ropy, coagulable lymph, of a darker clour, the tourth part of which, I feel convinced, was pus. 1 must here observe, that the discharge of urine, after the preceding opera- tions, had never increased very sensibly until after the evacuation of pus. At this time she passed considera- ble quantities through the night, amounting to two or three pints. The increase continued for a few days. At this time she complained of a most insupportable burning in the soles of her feet, accompanied with a great numbness of the limbs, which appeared to have lost not only much of their power, but also of their feeling. The catamenia still continue uninterrupted, and have even become more frequent, occurring every fortnight. The tumour continued to enlarge, and ex- acerbations of fever at night, attended with great heat in the back and loins, denoting a fresh accumulation of matter, now supervened. Nov. 17di, 1822. Opened the tumour to-day in the presence of Drs. KoUock and Marshal. As the orifice made at the last operation had never closed, and con- tinued to discharge matter occasionally ; with the con- currence of these gentlemen, I freely introduced the lancet into it, and so rapid was the discharge through the canula, that, apprehensive lest it might induce faint- ing, I arrested it for a short time. The discharge con- sisted of very fetid pus, of which I procured sixteen pounds. The operation was performed in a recumbent position, the patient lying on her right side. Although her strength was not materially affected, we thought it not advisable to proceed any further, although it was evident to us that much more fluid remained. I now introduced a tent four inches into the tumour ; and left my patient much more comfortable than usual. A CASE OF ENCYSTED DROPSY. 265 18th, 9 o'clock A. M. Rested better, passed a quart of urine during the night. Withdrew the tent; one pound of pus; complains of some pain in the tumour; not so much heat in the back and loins. Advised sponging with aether. 9 o'clock P. M. Removed the" tent; 12 oz. pus; heat diminished; more appetite; allowed the use of brandy and wattr. 19tn, 9 A. M. Heat more troublesome last night; less pain; 8 oz. pus; pulse feeble; passed a quart of urine through the night. Countenance improved; entertains strong hopes of recovery. 9 P. M. Much as yesterday; 8 oz. pus. 20th, 9 A. M. 8 oz. pus; less pain. Prescribed pills of the Carbonas ferri, six grains every two hours. 9 P. M. 12oz. pus; some nausea. Mint tea. 21st. Tumour diminished in size; passed three pints of urine through the night. Advised porter. 12 oz. pus. 22d. Slept well. 22 oz. pus. 23d. 32 oz. pus; irritable stomach. 25th. 26 oz. pus; as the abdomen continues to en- large, with fluctuation, it is evident that there is a fur- ther collection in a cyst which has not sufficient com- munication to discharge itself by the orifice. She now requested that this part should also be punctured. I proceeded to perform the operation, and opened the left portion of this immense tumour, and drew away five quarts of serum. 26th. Rested better last night; stomach not so irri- table ; advised porter, withdrew the tents; 24 oz. pus. As the tumour had receded so much as to render it impossible to introduce the last tent, and was very pain- ful, I closed the orifice in the integuments, intending to puncture it again should any fresh accumulation take place. 27th. Tumour continues painful; complains of (34) 266 ADDITIONAL APPENDIX. much debility; distressing heat along the spine and loins; stomach not so irritable; continues porter, the only thing she can take. 12 oz. pus. 9 P. M. Had an ague of three hours continuance, followed by intense heat. M M. wet cloths to be ap- plied to the back and loins. 12 oz. pus. 28th, 9 A. M. 12 oz. pus; takes port wine. 9 P. M. Irritability increases. MM. Tinct. opii. camp. 12 oz. pus. 29th, 18 oz. pus; stomach not so irritable; passes urine freely. MM. Tinct. opii. camp. 30th. 20 oz. pus. Heat very distressing; not so much irritability; urine is now discharged in very small quantities; and a further collection is taking place in the same cyst I last opened. Dec. 1st, 18 oz. pus. 2d, 12 oz. 3d, 20 oz. 4th, 12 oz. 5th, 16 oz. 6th, 20 oz. 7th, 16 oz.; high fever attended with rigours. 8th, 24 oz. pus. 9th, 16 oz. 10th, 16 oz. 11th, 20 oz. 12th, 24 oz. 14th, 22 oz. 15th, 16 oz. 17th, 12 oz. 18th, 20 oz. The tumour has diminished two-thirds; cold extremities. 19th, 16 oz. pus, 20th, 12 oz. 21st, 24 oz. 22d, 10 oz. 23d, 24 oz. A CASE OF ENCYSTED DROPSY. 267 24th, 16 oz. 25th, 17 oz. 26th, much worse As the pus is now constantly discharged from the orifice, I withdrew the tent with an anxious hope that death would soon relieve her sufferings. Dissection. The abdominal cavity presented a very singular appearance, when this immense tumour be- came exposed. It completely filled the cavity, and was so full of pus that the intestines were entirely hidden by it. The uterus was no ways enlarged; the left fallopian tube much enlarged, and the ovarium of that side had formed adhesions. This was also enlarged, and had the appearance of having been much diseased. The stomach highly inflamed; the kidneys but slightly so. The bladder enlarged but not inflamed. The tumour proceeded from an enlargement of the right ovarium, the greatest circumference of- which was about thirty inches; when laid open it discharged six pounds of fetid pus. It was encysted and cellular, containing hydatids, some of which were as large as a goose egg. Extensive adhesions had formed about the incisions, made at the different operations. A Case of Ovarian Dropsy. By Thomas D. Mitchell, M. D., of Frankford, Pennsylvania. The subject of the disease in question, was a woman of regular, temperate habits, about 60 years of age, and the mother of several children. Until within about eighteen months previous to her decease, she had en- joyed as good health as females of her age ordinarily experience. In September of 1822, I attended her for 268 ADDITIONAL APPENDIX. a severe attack of what appeared to be bilious colic, at- tended with difficulty in discharging her urine. In November following, she sent for me in an attack of complete suppression of urine, which was with much difficulty relieved. These attacks are here noticed un- der an impression, that they had not a little dependence on the incipient state of the disease which ultimately destroyed my patient. Subsequently to the latter at- tack, her complaints of irritability of the bladder were frequent, and she was in the constant practice of taking small quantities of spiritus nitri dulcis to obtain relief. Early in 1823, I was again in attendance. Her ab- domen was a little enlarged, and she occasionally com- plained of something moving about as she turned her- self from one side to the other in bed; as also of a drag- ging sensation accompanying the said motion. The discharge of urine was likewise much diminished at intervals of a few days, never continuing long at one time. Examination discovered more tumefaction in the right than in the left side, and although water was evidently present, part of the swelling was doubtless owing to flatus, which occasioned her much uneasiness. She was a good deal harassed with temporary faintness, fluttering at the heart, burning in the soles of the feet, and costiveness. Her appetite however was generally good, sometimes voracious. The symptoms collec- tively, led me to the conclusion that the disease was ovarian dropsy of the right side, and the appropriate remedies were accordingly administered. For a few days she would appear to be considerably better; and again all the untoward symptoms would occur. In the month of July, the symptoms increased in number and violence. She had about her the whole array of nervous disorder that could be supposed to accompany a disease such as hers; and the pain in the uterine region became constant, burning, and in an almost intolerable degree distressing. Together with, A CASE OF OVARIAN DROPSY. 269 this, she was much teased with pruritus of the vagina and os tineas, although those parts were perfectly sound, as far as examination could ascertain, and there was no discharge. The tumefaction not at all increasing, my opinion began to change, and the disease appeared now to be scirrhus uteri, though by no means a well mark- ed case. I put her on the use of calomel in small doses, and cicuta gradually increased to large doses. Of this she became weary in a few weeks, because the great desideratum with her was not obtained, viz. immediate relief. Some of her well disposed friends advised the use of Swaim's famous panacea, and believing it to be of little importance what she took, as respected the fi- nal result, I consented that she should make trial of that which, in any curable case, I would wholly deprecate. This nostrum, instead of benefiting, actually injured the patient, and it was necessary to call in medical aid. Being in the city at the time, she sent for Dr. Physick, who considered the case an obscure one, but inclined to the belief that a large sac was formed on the mesen- tery. He depleted her both generally and locally, but without advantage. In one of his examinations of the parts, something suddenly cracked, and the tumour which he had been pressing with his hand disappeared. On her return home, I continued Dr. P.'s practice for some time, at his request, and because I believed it to be the most proper. The pain notwithstanding increased rapidly, and I was obliged to lay aside all the remedies then in use, and exhibit opium freely. This course was continued for several months, during which time a variety of concomitant symptoms were daily combated by suitable remedies. In May 1824, the tumour, which had become large, knotted and very painful, suddenly disappeared, and there seemed to be a total transfer of the disease to the brain. She was highly delirious and forgetful; all pain having disappeared, the opiates so freely given hereto- 270 ADDITIONAL APPENDIX. fore were discontinued. The bowels became regular, and the appetite tolerable. June 2d.—She was con- siderably swollen, and her mental powers completely wrecked. Dr. Pickering now saw her with me, and we agreed to give her calomel with squills and opium, and to reduce the dropsical effusion. These were soon discontinued. June 4.—Great hallucination of mind; nervous and hysterical; complains of burning in the uterine region; not so much swelled; the water appears to be encysted, and it seems to me as though the cyst were formed by an expansion of the uterine tumour. Her appetite is pretty good; bowels costive; sleeps very little. June 5.—Complained severely of burning in the uterus, until about midnight last; she then ceased to complain, and in now quite composed and silent; clam- my cold sweat; feeble intermitting pulse; respiration difficult. June 6.—No change. June 13.—No change in the last week, excepting a disagreeable tightness about the stomach. July 2.—Very much altered; constantly picking the bed-clothes; eyes glassy; speech very much changed; gangrenous smell; frequent intes- tinal evacuations of black matter. July 10.—Died this morning; for two days past, although speechless, and apparently dying, was very sensible to pressure on the uterine region. Examination after death.—July 12th, 6 o'clock, A. M.—In company with Doctor Pickering and two students of medicine, I proceeded to inspect the dis- eased parts. On opening the abdomen, a very large mass, appearing to be a sac well filled, presented it- self, lying in the right hypochondriac and iliac regions, and extending over to the umbilical region. The blad- der, very much distended, was evacuated in order to get a better view of the whole in situ. I then passed my hand under the large sac and easily raised it out of the abdomen, together with the uterus, of which it A CASE OF OVARIAN DROPSY. 271 proved to be an appendage; it was, in short, a dropsical enlargement of the left ovary. The uterus was very much shrivelled, as might be expected from the age of the patient, but was perfectly sound, with the exception of a small tubercular spot. The sac, originating from the left ovary, and lying in the right side of the abdo- minal cavity, accounted for the dragging sensation and the rolling motion so frequently complained of by the patient. The neck of the sac was long and slender; not more perhaps than three quarters of an inch in di- ameter, while the sac itself was in its largest diameter about 9 inches, and in its smallest from 6 to 7 inches. On further examination, the large sac was found to con- tain, or to consist of not less than eight other sacs or cysts of various sizes, some about the size of a hickory nut, and others much larger. All the cysts were very tense and gave to the finger the sensation of hardness and irregularity, similar to what was so often discovered on applying the hand to the abdomen by Dr. Physick and myself, as well as by the friends of the patient. It was the sensation thus communicated, that favoured the notion of a scirrhus uteri. On puncturing the sac once and again, but part of the fluid escaped ; and I should have been compelled to make many openings in order to have evacuated the whole, which however was not my design, as I wished to preserve the parts tolera- bly entire. The sac held most probably, about three pints of fluid of a gelatinous quality ; in colour, a pale yellow. The inner side of the sac was very irregular, rough and much thickened. There was little or no ef- fusion into the abdomen, and the remaining viscera of- fered no marks of disease. Remarks.—The patient often wished to have an ope- ration performed, that the diseased part might be ex- tracted. But this was objected to, on account of the m great obscurity of the case; and it is now evident that 272 ADDITIONAL APPENDIX. an incision in the right side of the abdomen, the main seat of complaint, could not have succeeded, as the sac originated in the left side. It has been noticed that in one of Dr. Physick's ex- aminations of the patient, something cracked, as if a bladder had burst, and the tumefaction disappeared. This was doubtless occasioned by the rupture of one of the larger cysts, and the fluid contents being similar to what we find in ascites, produced but little inflammato- ry action in the peritoneum. The same thing occurred when, in May last, there was a sudden dispersion of the . uterine swelling, the principal cyst bursting, caused a diffusion of the fluid throughout the abdominal cavity, and occasioned general tumefaction to a small extent. These sacs were probably regenerated, or smaller ones were made to expand in such a manner as to give the appearance manifest on dissection. But the very se- vere and constant pain which the patient suffered for many months, is not satisfactorily explained. ADDITIONAL APPENDIX. No. II. FROM THE UNPUBLISHED MEDICAL WRITINGS OF THE LATE CALEB H1LLIER PARRY, M. D., F. R. S., &.C. &C. &C. Dropsy not from increased action of Exhalants. If dropsy were the effect of the increased action of exhalants, analogy would lead us to infer that the more the vessels were tired, the less they would act; and, therefore, that extravasation would become rela- tively less, as the disease advanced. The contrary, however, is the fact, as appears-from the increased necessity of tapping at shorter periods. Dropsy and Haemorrhage rarely concur; but when they do, both are capable of being relieved, by dimi- nishing the action of the heart. Haemorrhage is more usually a constitutional affection than inflammation, or than dropsy. A proof of the coincidence of acute rheumatism with dropsy is, that many persons, who have had the former disease, die many years after of the latter. The Hemorrhagic and Dropsical State both owing to undue Determination—The haemorrhagic and drop- sical state being usually the same, it is not to be won- (35) 274 ADDI1T0NAL APPENDIX. dered at that the latter should occur to persons subject to the former. When, however, dropsy follows large natural haemor- rhages, it does not accompany them, but supervenes when they have ceased. Hence it appears to be a collateral effect of the constitutional state, or a kind of vicarious discharge, rather than the consequences of the preceding haemorrhage. On the contrary, it is proba- ble that haemorrhage, by removing excessive fulness of vessels, often prevents dropsy. If this be tnfe, we may naturally expect that the converse may sometimes happen, and that haemorrhage supervening to dropsy may also cure it. When dropsy is associated with large artificial haemorrhages, I observe that, as in the case of haemor- rhages which are spontaneous, it does not usually ac- company them, but comes on after they have ceased ; and I have concluded that it is the effect of nutriment absorbed too suddenly for the relative state of the ves- sels, which therefore strive, if I may be allowed the ex- pression, to get rid of it by every possible outlet. This principle is well illustrated by the following case. Mr. H. at the middle period of life, of great and just pro- fessional reputation Li this city, and about a year before confined for many months to his bed with acute gene- ral gout, was attended by Mr. G. Norman and myself, for a violent inflammation in one eye, accompanied with great pain and fever, and threatening the speedy loss of that organ. In the space of four days, twenty-five ounces of blood were taken from the temporal artery on the same side, and seventy-five ounces from the arm, many leeches were applied to the temple, and the vessels of the conjunctiva were frequently scarified. From these powerful means, aided by purging, nause- ating doses of ipecacuanha, and iced water almost con- stantly applied to the forehead and crown of the head, the disease in a few days disappeared; but suffered a DROPSY. 275 relapse, in consequence of his leaving his bed-room too suddenly, and taking a meal of animal food. It was, however, once more removed by another blood-letting to the amount of twenty-four ounces. Shortly after- wards he returned to his professional pursuits, and for three days dined only on chicken. His legs now be- gan to be affected with oedematous swelling; and as it was considered that this affection was owing to too sudden a resumption of full diet, he left off animal food, and purged himself; in consequence of which, at the end of three days more, the oedema vanished, and he now, after an interval of many months, continues to enjoy a degree of health and strength, to which for several years before he had been a stranger. Evidence of Dropsy being a Salutary Effort.— In Mrs. F., aged thirty, the pulse, under a state of hectic of long continuance, from suppuration some- where in the pelvis or abdomen, discharging continual- ly by stool, being from at least 120 to 136 in a minute, came down to 96, with diminution of heat, and disap- pearance of night sweatings, in proportion as she began to be affected with ascites. In her, during the course of the complaint, the glands under the sk;in in various parts had become affected with swelling and inflamma- tion, which, however, by degrees subsided many weeks before this hydropic appearance ; a mark of disposition in increased circulation to produce successive irregular determination. The constitution was thus relieved, by evacuation, from increased impetus. So in liver complaints, peritoneal inflammation, pleu- ritic inflammation, &c, the effusion relieves symptoms, which would probably end in suppuration or ulcera- tion, and thus prove sooner fatal. The oedematous swellings in gout, rheumatism, tooth- ach, &c. are of the same salutary nature. It will be seen, from consulting the daily reports of 276 ADDITIONAL APPENDIX. Mrs. F., that afterwards, that is from Feb. 19th, as oedema began, and very much increased in the legs and thighs, and on the 22d, and 23d, began even to affect the hands, and from the shortness of breath, ex- travasation probably began also to take place in the chest, the pulse became still gradually slower. This was not from digitalis, of which she took none; nor probably from squills, of which, also, none had been taken for some days; nor from extravasation in the brain, delirium which had sometimes, and vertigo which had frequently, occurred, having at the same time near- ly ceased. But it must have been from mere extrava- sation taking off vascular irritability. At the same time, for the three nights preceding that of the 23d, the sweats of the hectic kind, which had long existed, but had diminished as the pulse became slower, now entire- ly ceased. The discharge of matter continued much as before, that is from half an ounce to ^j once in 3 or 4 days; and the urine seldom amounted to three-quar- ters of a pint or a pint in 24 hours, and always high-co- loured and with a copious farinaceous sediment. Dropsy, a curative Process.—When Lord G. came to Bath, in the month of May 1808, he was in his 67th year. His talents and intrepidity as a naval officer are sufficiently known; but it is not equally known that on all trying occasions his anxiety to acquit himself of his duty to his country and his own breast were absolutely destructive of his happiness and repose. Much of this anxiety he felt in London, when about to take the com- mand of the Channel fleet in June 1807; and then he began to experience some shortness of breathing on any considerable muscular exertion. On his arrival at Bath, Sept. 25, he was labouring under difficult and hurried respiration, so that not only walking, but even speaking, was uneasy to him. He was obliged to lie with his head and shoulders raised, DROPSY. 277 and could not sleep on either side, but had no cough. His urine did not amount to three-quarters of a pint in 24 hours, was of a darker colour than porter, and had a copious sediment. His ankles were not swelled; he had no pain or fulness in the region of the liver, or any other part of the abdomen, and no yellowness or disco- loration of the skin. His pulse was 84 in a minute, and his respiration 32. His tongue was rather dry, but not furred. He was much emaciated, and had an almost total loss of appetite. He had been treated with purga- tives and chalybeates. The remedies now ordered were a grain of quicksil- ver rubbed down with manna, and the same quantity of dried squill, twice a day, and twice or thrice a day an effervescing draught of citrate of potash, with fifteen drops of Mr. Tickell's preparation of ether. In three or four days the urine increased to three pints in the twenty-four hours, and Lord G.'s health was greatly mended. The pulse being now of the natural standard, and the appetite continuing bad, Lord G. was desirous of drinking the Bath water, from which, on a former occa- sion, he had derived considerable benefit. The Cross Bath water was given at first once and then twice a day, in the quantity of only four ounces at each dose, and the other remedies were to a certain extent continued. In a very few days the pulse began to quicken, the urine to decrease, and the breathing to become more laborious, and that without any improvement of the appetite. The Bath water was now omitted, and the medi- cines were given in the full dose as before. The urine was again soon restored, the breath amended, and the pulse reduced nearly to its natural state. With this diminution of the morbid symptoms re- turned an eager desire of drinking the Bath water, with the view of improving the appetite and strength. It 278 ADDITIONAL APPENDIX. was permitted; but with a still worse effect than before. Fever, paucity of urine, dyspnoea, were again in a few days excited; and a cough was superadded, accompa- nied at length with a spitting of blood, which threatened immediate suffocation. Squills and the effervescing draughts were substituted for the Bath water; and again with the effect of removing the fever and pulmo- nic affections, and of restoring the urine to its natural quantity and colour. All thoughts of any further use of the Bath waters being now relinquished, Lord G. continued occasionally to take his diuretic medicines, and to regulate the alvine evacuations. After some weeks, passed nearly in the same state, with a proper quantity of clear urine, the stools were observed to be to6 pale, and some oedematous swelling began in the feet, and gradually ascended, first to the knees, and then to the scrotum. The mercurial course was now renewed, with no other obvious effect than that of keeping the bowels more regularly open. At this time, notwithstanding he was daily taking six grains of dried squill, Lord G. began to relish his food better than at any former period; soon after which, his belly began to swell, and, in about a fortnight, evi- dently fluctuated on the usual examination. As the swelling of the abdomen increased, that of the lower extremities somewhat diminished; and the appetite at the same time appeared to mend, the sleep and facility of breathing improved, and the urine remained in its natural state. In this situation Lord G. continued for several weeks, with little increase of weakness or of emaciation. Dur- ing this period mercurial ointment, in small quantities, was every day, for about a month, well rubbed into the abdomen, so as at length to occasion slight soreness of the mouth; after which, as it produced no sensible effect on the swelling, it was discontinued. Under these circumstances Lord G. employed vari- DROPSY. 279 ous remedies till the middle of December; when, the urine being more deficient, the combination of quick- silver with squill, and the effervescing draught with ether, were once more tried, but did not seem to increase the quantity of urine. About this time, not having visited Lord G. for se- veral days, I was greatly surprised, on repeating my visit on the 21st of December, that, notwithstanding* there had been no unusual evacuation of any kind, the belly was much diminished in size, and no longer fluc- tuated to the touch. He was, however, labouring un- der more fever, with very restless nights, which made it necessary to give him fifteen drops of laudanum at the hour of sleep. This succeeded in quieting him; and his pulse became slower. The laudanum was con- tinued to the amount of twenty-five drops, with the medicines last described; and these remedies so acted on the kidneys, that on the 25th of December he made nearly a gallon of clear well coloured urine, which afterwards varied from two to one quart in the day. A considerable degree of drowsiness now came on, but without mental alienation. On the. 27th of December, the pulse was 96, and the respiration 32. At half-past 1, P. M. on the 31st of December, his pulse was 80, regular and soft, his respiration 32, and he seemed to be quietly asleep. This state continued till he died, without a struggle, at half past 8, in the evening. Cure of Dropsy.—I have long considered the ope- ration of remedies in curing dropsies, as influencing and removing their cause, whatever that may be; more especially disordered action of the heart or arterial system. Of this state, deficiency of urine is a usual, but not constant effect; for I have seen at least ten cases, at 280 ADDITIONAL APPENDIX. various ages, from fifteen to sixty, of dropsy, chiefly anasarca ending in hydrothorax, in which the quantity of urine has spontaneously been from the beginning, till two or three days before death, fully equal to that which was natural, as for example, from two to four pints daily, clear, and even sometimes pale, and yet the patients have all died. Nay, I have never seen a pa- tient recover under these circumstances of a natural state of urine. On the other hand, I have known many examples of patients labouring under dropsy of different kinds, with defective and high coloured urine, who have perfectly recovered, all the effused water having been absorbed; and yet the remedies producing the cure did no more than just restore the urine to its healthy quantity and colour. The connection of deficient urine is, therefore, only an effect, and by no means a cause. Case of Bleeding in Dropsy.—About the year 1784, I attended a young man, who had peritonaeal inflammation with stoppage in the bowels, which were with difficulty relieved, and were immediately followed by ascites. The fever continuing, I caused him to be largely blooded from the arm, and ordered him saline and opening medicines. The fever soon ceased, and the ascites disappeared, with little aid from the reme- dies usually exhibited as diuretics. Some years afterwards I was called to visit a noted horse dealer, between fifty and sixty years of age, who was a great drinker of spirits, and laboured under dis- eased liver, with ascites, anasarca, a quick pulse, and an extreme paucity of urine, very high coloured,* and depositing a copious lateritious sediment. A great va- riety of remedies having been tried without effect, I had eight or ten ounces of blood taken from the arm. It exhibited a very thick and tenacious crust of coagulated DROPSY. 281 lymph. Without the aid of any other remedy, the pulse was reduced in frequency; and the urine during the next twenty-four hours was quadrupled in quantity, and became clear and proportionably pale. At this period another physician being consulted, to whom blood-let- ting in these complaints appeared a most dangerous practice, I was not disposed to urge its repetition in a case, which, though it had suffered some temporary remission, was much too far advanced to admit of a cure from that or any other remedy. Bleeding in Anasarca, fyc.—Col. G. O., a short, rather corpulent man, between fifty and sixty years of age, who had been a free liver, and subject to frequent fits of the gout, became my patient in consequence of great oedematous swellings in his legs, paucity of urine, and total loss of appetite, for which, as they were sup- posed to be connected with a gouty diathesis, he was sent to Bath for the use of the waters. At my first visit I found him labouring under these symptoms, to which were added a sense of great heaviness in his head, a flushing of his face, disturbed sleep, an occa- sional stertorous inspiration while he was awake, de- pressed spirits, a very dry tongue, and full, strong, and a rather quick pulse. At this time, Aug. 1790, I was young in my pro- fession, but not altogether unobservant of the facts which presented themselves to me, and as it had hap- pened to me to see more than one case extremely simi- lar to that which I have described, in which the patient either had afterwards epilepsy, or was relieved by co- pious haemorrhage from the nose, I ventured to predict that one or other of these events would occur to Col. O., unless they were prevented by a timely artificial eva- cuation of blood. It will readily be conceived what impression this proposition, at that period of medical knowledge, made (36) 282 ADDITIONAL APPENDIX. on the minds of the patient and his friends. What! - bleed a man at an advanced period of life, of a gouty habit, in such a state of debility, actually labouring un- der dropsy, and who clearly wanted blood, rather than suffered from a superfluity of it? Never surely was there so wild and extravagant a proposition! Notwithstanding these objections, I persevered, and was fortunate enough to gain my point. Ten ounces of blood were taken away by cupping. The patient felt immediate relief of all the more important symp- toms. The weight in his head and stertorous inspira- tion were removed, the tongue became less dry, the pulse softer and slower, he had that night many hours of comfortable and refreshing sleep, and waked with some appetite. But though the remedy was considerably beneficial, it was insufficient for the purposes of the constitution, for on the following day he was seized with a spon- taneous bleeding at the nose, which was very copious, and in a few days no symptom of indisposition remained. Bleeding in Anasarca, &c.—Captain B., aged about forty, a stout and rather corpulent man, had been for many years subject to gouty attacks of a very inflam- matory kind; but having escaped them for several months, began to be affected with oedema of the feet and legs, accompanied with quick and strong pulse and great difficulty of breathing. This gentleman also con- sulted me, in consequence of having been sent from home for the purpose of drinking the Bath waters. When I saw him on the 6th of December 1799, his legs and thighs were swollen to an enormous size; his pulse was extremely full and regular, and 120 in a mi- nute ; and his breath was so laborious, that he had not even attempted to go to bed for forty successive nights, and was obliged to keep himself in a perfectly erect posture in an easy chair, without being able to recline DROPSY. 283 in any direction. His urine was very small in quantity, of a deep red colour, and depositing a copious lateri- tious sediment. Instead of giving Mr. B. the Bath water, or any other stimulant, I ordered ten or twelve ounces of blood to be taken away by cupping, and a grain of digitalis to be administered twice a day, with pretty large doses of a solution of potash, given with lemon juice during effervescence. * By this process he was enabled on the very first night to repose in a somewhat recumbent posture in his arm chair, and had some comfortable sleep. The next day his pulse was at 104, his urine much increased, and his breathing so much improved, that he was able to go to bed, and obtained much refreshing repose. The remedies were continued, with another cupping. The urine remained in a state of clearness and habitual increase, and the anasarcous swellings and dyspnoea proportionally diminished; so that after three or four days he slept without any interruption in a perfectly horizontal posture. The state of reduction in his pulse was as follows: On the 8th of December, the pulse was 104; on the 9th, 100; on the 10th, 92 ; on the 11th, 90; on the 12th, 92; on the 13th, 92; on the 14th, 88; on the 15th, 85 ; on the 19th, 80: on the 4th of January, 72. Soon after this, without the use of any other reme- dies, Captain B. had a smart fit of inflammatory gout in the extremities, and left Bath in good health and spi- rits. Mr. C. Crook attended this gentleman with me. Dropsy cured by Hemorrhage.—Mrs. Gen. M., aged forty-eight, had the measles very severely in the month of March 1808, followed by vomiting and an eruption of another kind on the skin, which continued 284 ADDITIONAL APPENDIX. for a fortnight. Before this eruption disappeared, there came on very large anasarcous swellings, which occu- pied the whole of the limbs and face, giving the entire skin the usual appearance of confirmed leucophlegma- sia. The urine was at the same time natural as to quan- tity and colour. The eruption now went away, but the swellings continued in a most alarming degree till the 9th of August, w hen her head violently aching, she was seized with a bleeding at the nose, which continu- ed for two or three days, auring which she lost upwards of a quart of thin and very pale blood. The discharge was accompanied with a quick and weak pulse. The anasarcous swellings immediately disappeared. When, however, the haemorrhage had ceased, the pain and throbbing in her head increased, accompanied, at times, with violent startings when she was about to sleep; and, while she was awake, with frequent and sudden cramps in her hands and other parts, which af- fected the former with very painful contractions, and then as suddenly went off. The pulse was about 100 in a minute, and the carotid arteries, in their diastole, greatly stretched, and hard like a piece of catgut. Some weeks after, Mrs. M. was seized with epileptic fits, of which she died in twenty-four hours. Dropsy cured by Spontaneous Haemorrhage.—Mr. P., aged between fifty and sixty, master of a tavern in the neighbourhood of the Royal Exchange, London, had been a considerable time indisposed with shortness of breath and dry cough, for which, being recommend- ed change of air, he came to Bath, and consulted me. I recommended him such remedies as appeared to me suited to the removal of incipient hydrothorax; by which, it seems, he was in a short time restored to health. Several months after his return to London, he was attacked with similar symptoms, accompanied with (edematous swellings of his lower limbs, which by de- DROPSY. 285 grees reached to the abdomen. Having found no relief from the remedies which had been recommended to him, he determined once more to visit Bath. When I saw him, he was scarcely able to walk or lie down in bed ; his legs, thighs, and abdomen, were much swelled from anasarca, and an evident fluctuation in the latter showed that fluid was contained in its cavi- ty. His urine was very high coloured, and small in quantity. I ordered him to take a grain of quicksilver rubbed down with manna, twice a day, and dried squills in as great doses as his stomach would bear. Of the squills, he took at first six grains daily, and was fortunately able in a few days to increase the dose to sixteen without sickness. Mercurial ointment was also rubbed on the abdomen every evening. From these measures great benefit was soon derived. In about three days the urinary secretion began to in- crease, and in two more became very large. The swell- ings abated; and at the end of somewhat more than a fortnight, no disorder remained but weakness. This happened in the month of August 1804. The following relation of a subsequent occurrence with re- gard to the same patient has been communicated to me by Mr. Cruttwell, Surgeon. At the beginning of the year 1805, Mr. P., who had been anasarcous for a long time, was suddenly alarmed by a bleeding from the scrotum. He resided at Hamp- stead, so that I did not reach him till some hours after the appearance of the haemorrhage: I found him pale and faint; and the bleeding had ceased. The attendants computed that he had lost a gallon of blood; as a great quantity had flowed upon the bed, and had been receiv- ed in cloths. More than three pints had been caught in a large chamber pot, and preserved unmixed for my inspection. It had separated into crassamentum and serum; and the proportion of the latter seemed more 286 ADDITIONAL APPENDIX. abundant than is common. Mr. P. was of course much weakened by this accident: but he recovered his strength very rapidly. ' His dropsical symptoms were very decidedly relieved, and he was restored to a great- er degree of health than he had experienced for many years. Anasarca cured by Bleeding (chiefly.)—April 18th, 1809, Mr. T., aged sixty, a very fat man, has for many years worked hard, and afterwards, at night, generally eat and drank very freely. For some years past he has had a difficulty of breathing, which has prevented his lying down in frosty weather, and has been subject to coughs, often attended with copious spitting of blood. Ever since Christmas last the dyspnoea has increased, with an utter inability to breathe in an horizontal pos- ture. He has, also, been subject to great drowsiness and giddiness. Five years ago, soon after the healing up of an old ulcer in his leg, these complaints commenced, notwith- standing the opening of an issue in his knee. A week ago a seton was inserted in his neck. Yesterday, about three o'clock in the afternoon, while in bed, he was seized with a peculiarly violent attack of difficulty of breathing. His face, hands, and thighs, are now very oedematous, in consequence of which his limbs are so stiff that he can scarcely walk. His urine is in very small quantity, high coloured, and turbid. Pulse 88, full and strong. Right eye considerably in- flamed. Mittr. Sanguis e Brachio ad |ix. Sexta quaque hora sumat Haustum e Potassa effer- vescentem, cum Scillae recentis gr. iv. Tincturae Digitalis guttis xv. April 19th. The crassamentum is firm, difficukly diffusible in the serum, and covered with a strong crust of coagulated lymph, which is concave, and twice the DROPSY. 287 thickness of a crown-piece. The serum is somewhat milky, and of natural proportion. Immediately after the operation his breathing was greatly relieved, and he had a tolerably good night. He has made full three pints of urine, of a good colour and clear. Eye much better. Swellings greatly decreased. Pulse 78 and soft. —Pergat. April 20th. He has had two motions in the night, and two to-day. Cough and breathing a great deal better, though some difficulty still remains. Urine two pints. Swellings entirely gone. Pulse 96, and soft.— Mittr. sanguis ad gviii. Persistat in usu Haustuum. April 21. The crassamentum in all three cups is very tough and indiffusible, and the serum is some- what milky. One cup has no crust of coagulated lymph, but the two others are covered with a thick coat as before. Three motions, and two pints of urine, since last report. He has to-day complained of some sickness. Tongue tolerably clean. Eye nearly well. He has no where any vestige of swelling ;•. and the waistband of his breeches admits of being taken in five inches since the day of my first visit. He coughs much more strongly and deeply than he did; and his breath is so much improved, that he can now lie down on a single pillow. He feels himself much lighter, and in all respects better. Pulse 78, and full.—Sumat Haus- ttim ter die tantum, April 22. He was yesterday very sick from the me- dicine. Two motions. Breathing as well as it has been at the best for several years past. Urine two pints, and natural in colour. Pulse 88, and full. Let him take only two-thirds of his draught thrice a day. April 24. Urine three pints daily. Bowels open. Skin cool. Tongue clean. Pulse 72, and soft. He sleeps well, has no swellings, and his breath is much better than usual, with scarcely any cough. 288 ADDITIONAL APPENDIX. Let him abstain from spirits, and take no fermented liquors but small beer. Dropsy removed by Bleeding.—Mrs. L. aged about twenty, caught cold by walking in the snow in the month of November, or December, 1810; subsequently to which time she became subject to affections of the head and limbs, which after some time terminated in paleness of the skin, and anasarca of the limbs, and even face. The catamenia continued to flow regularly and well. In April 1811, after headach, which con- tinued for a week, she was seized with an epileptic fit, which for a while deprived her of her senses, and was followed by another in the course of the same day. She was blooded copiously from her arm, and from the temporal artery. The crassamentum was small in pro- portion to the serum, but firm, and covered with a thick crust of coagulated lymph of the cup-like form. Immediately after these bleedings, the anasarca began to lessen, and in two days entirely disappeared. She was gradually relieved from the affection of the head; but at the end of a week, the swellings returned in some of the limbs, and with them came on sleepiness, which in two days ended in carus, and twenty-four hours afterwards in death. Good effects of Blood-Letting in Dropsy.—Major General S., aged between fifty and sixty, an officer of cavalry, who, during the campaign in Portugal in the autumn of 1811, laboured under a violent fever, came to Bath in the beginning of the year 1812, under some suspicion that the complaints which then affected him originated in gout. These complaints were a very irregular and intermit- tent pulse, with great dyspnoea ; b.th extremely increas- ed by the least muscular exercise, and the latter making it difficult for him to lie down, and obliging him often DROPSY. 289 to start up out of his sleep in order to prevent suffoca- tion. His urine was deficient in quantity, his bowels were costive, his stools of a dark colour", his stomach disposed to flatulency, and his legs oedematous up to the knees. Under these circumstances I had him freely purged, gave him squills with digitalis, and occasionally calo- mel, and, in conformity with his own wish, permitted him a very small quantity of the weakest Bath water. These means, continued for two or three weeks, re- lieved the difficulty of breathing, increased the quantity of water, improved the stools and appetite, and made the pulse perfecdy regular. Still, however, great difficulty of breathing on motion continued; and the starting up in the sleep, and the swelling of the legs, were in no degree abated. The pulse at the same time, though regular, became quick, and extremely strong, full, and hard. The tongue was also dry, and the urine continued defective in quantity. This was his state at the end of a fortnight. I now recommended that the Bath water should be discontinued. Blood was taken from the back, by cup- ping, to the amount of ten ounces, and he was desired to persevere in the use of the other remedies. Wine and other cordials were wholly interdicted. Immediately after the bleeding, he was much more light and free from feelings of indisposition than he had before been. His pulse was much softened; and the starting up in his sleep from a sense of suffocation was nearly removed. The urine increased, and the oedema of the legs suffered a proportionable diminution. The appetite was good, and the tongue became clean. In about three weeks he had little complaint; but the pulse being still too hard, I thought it prudent to repeat the cupping to the same quantity as before. This was done; and shortlv afterwards, all sense of (37) 290 ADDITIONAL APPENDIX. suffocation vanished, and the oedema wholly or nearly disappeared. On the 1st of July, 1813, I saw Gen. S. on his way through Bath. His pulse was strong, but perfectly regular. He was free from oedema, and suffered no apparent dyspnoea from walking up hill to my house. Bleeding in Hydropic and Gouty Constitutions.— Mr. P., aged between sixty and seventy, long subject to gout, which, however, had for many months ceased to attack him, was seized with a cough and such a difficulty of breathing, as, in process of time, made it impossible for him to lie down in bed. These symp- toms being attended with a weak and irregular pulse, gradually followed by oedematous swellings of the legs, were supposed to originate in atonic gout; in conse- quence of which he was sent to Bath, for the purpose of drinking the waters. Finding that in addition to these circumstances, the urine was high coloured, turbid on standing, and very deficient, I was averse to the employment of the wa- ters, and gave him gentle aperients with squills, digi- talis, and draughts of potass and lemon juice in the state of effervescence. From these remedies the urine soon became copious and clear, the swelling of the legs dis- appeared, and his respiration returned to the natural state. Shortly afterwards, he was suddenly seized with a loss of sense, accompanied with every mark of pressure on the brain, without hemiplegia. I now most willingly availed myself of this opportu- nity to employ a measure, which I regretted that I had not before practised. Accordingly, Mr. P. was several times bled, both generally and topically; and each time with the most apparent relief. In a few days, all symptoms of disorder in the head were removed; but were almost immediately followed DROPSY. 291 by a violent thrush, which also in a short time disap- peared : and now, not many days afterwards, when he appeared to be free from complaint, he was seized with a smart fit of inflammatory gout in his extremities, which went through its usual course, and left him in comfortable health. (Edema diminished by local Bleeding.—Mr. K., aged about fifty, a native of the West-Indies, and a free liver, who had never suffered any known morbid affec- tions of the liver, but for eight or nine years had been afflicted with oedematous swellings of both legs, reaching up to the knees, ineffectually tried for that complaint a great variety of remedies, and, among others, a course of mercury, so as to excite salivation. Eleven or twelve weeks before I saw him he had sustained considerable injury about the left hip and thigh from a fall; and the parts still continued to suffer great pain all round the head of the thigh bone, either when he moved the thigh, or was warm in bed. The pulse was quick and hard, and the oedematous swellings remained in the usual state. I ordered blood to be taken from the arm. It had the usual inflammatory crust. Two or three days afterwards, fourteen leeches were applied to the hip, and the discharge of blood encouraged by involving the leeched part in lukewarm poultices of bread and water. Much blood was thus evacuated. The next day, the oedematous swelling of that leg was much diminished, while that of the other leg remained as before. Another application of the leeches a few days afterwards produc- ed a still farther reduction of the swelling of the left leg, while that of the right suffered no change. Bleeding in Dropsy with diseased Liver.—Blood in Mr. C, aged about thirty, very inflamed and cupped, tough in the cruor, not diffusible in the serum, and large in proportion to it. Serum clear and of natural 292 ADDITIONAL APPENDIX. colour. If bleeding is good for the inflamed state of liver, what matters it whether there is watery effusion Or not, either in the abdomen or elsewhere ? Quere as to Dropsy.—As this probably arises from indirect debility, might it not be a good thing to exa- mine how far it is apt to occur among the poor and indi- gent, who at the same time are temperate ? and whether, among the better classes, a complete resolution of this and many other cases of long continued increased ac- tion might not be effected by the total, or almost total, abstraction of food, allowing only the use of water, cold? Evacuation by Leeches, relieving (Edema.—In Mr. B., who had a paraphymosis, from the irritation of a bougie, and travelling a long way in a carriage too soon afterwards, without any venereal complaint, in which the prepuce and skin of the penis were greatly swelled, transparent, and oedematous, after many days previous though ineffectual remedies, the disorder was immedi- ately relieved by the application of one leech, and totally cured by two others. Effect of Purging in Dropsy.—In Mr. P., aged about sixty, much accustomed to gout, long suffering mental affliction, and an habitual drinker of spirits and water, though not to intoxication, an obscure fluctua- tion came on in the abdomen, and considerable oedema- tous swelling in the legs and thighs, though without any violent disease of the liver. Various diuretics had been administered in vain. A small dose of cryst. tartar. jalap, and gamboge was given, which operated very co- piously eight or ten times, fatigued him very much, and seemed to produce delirium. Seven drops of laudanum were given twice in the evening, from which he slept quietly. In the course of the next twenty-four hours it was repeated three or four times, though with- DROPSY. 293 out producing sleep. During the two following days he had no motion, and the urine continued of the same light colour, and in no greater quantity than before. His head still continued light, though he was not vio- lent ; the pulse rather quick, and very full and bound- ing. The day of the purging the oedema began to diminish, so that in two days after it was nearly gone, and no fluctuation remained in the abdomen. In Mrs. V. the oedema was certainly carried off by the purging; but it had no effect on the ascites. Effect of relative Over-Nutrition in producing Dropsy.—Mr. P., of middle age, long labouring under vomitings after almost all his food, with quick pulse, and emaciation, with other marks of hectic from some disease of the abdomen (not liver,) had the vomiting cured by medicines directed by me; at the end of a week after which he was seized with anasarcous swell- ing of the feet and legs. After this had continued a few days, a purging came on, and in two days more, the anasarca went off and never returned. Excellent effect of Digitalis in Dropsy and Hemorrhage.—Capt. A., of middle age, while in the Indian Ocean he was sitting in his shirt in the cabin of a country ship of which he had the command, was suddenly struck with a cold blast of wind through the open windows, in consequence of which he was seized with a cough, accompanied with considerable dyspnoea. In this state he came to Bath, where, on account of a widely spreading eruptive complaint, he was advised to drink the saline aperient water of Middlehill, near this city. His eruption was relieved, but the cough was much aggravated, and was soon attended with an expectoration of blood, which was much diluted, but sometimes amounted to half a pint in twenty-four hours. After a long continuance of this haemorrhage, and much fever and emaciation, dropsical symptoms super- 294 ADDITIONAL APPENDIX. vened, and yielded to none of the remedies prescribed by the late ingenious Dr. Ewart, under whose care he had placed himself. When, at this period, I was called into consultation, the legs and thighs of the patient were swelled to an enormous size. There was also a palpable fluctuation in the abdomen, and the quantity of urine did not ex- ceed half a pint in the twenty-four hours. The pulse was 136 in a minute, extremely small, weak, and irre- gular. The cough and bloody expectoration continued in their fullest extent, and Captain A. was unable to remain in bed, except with his body erect. He was then taking squills and steel, and had an issue, or seton, in the side, which was regulated by Mr. Grant, surgeon. This case appearing to me in every view proper for the administration of digitalis, which was then newly re- adopted into practice, that medicine was accordingly given in substance, to the extent of about three grains in a day, in addition to the other remedies which I have specified, and which were continued in the same dose as before. In the course of three days a sensible and most beneficial operation of the remedy ensued. The pulse began to diminish in frequency, and to become proportionably more regular and full; so that in the space of a week it was reduced to 48 in a minute, and was equal, and of natural strength. The improvement of the urinary discharge kept exact pace with that of the pulse. It lost its sediment, became more pale, and at the end of a week amounted to six or seven pints in the day and night. The swellings and haemorrhage declin- ed, and the breath improved in the same proportion; so that within a fortnight from the first administration of the digitalis, without the least sickness or other inconve- nience from its use, Captain A. was able to sleep with perfect ease in the horizontal posture, was free from cough and haemorrhage, and in other respects perfectly exempt from disease. DROPSY. 295 He left Bath some weeks afterwards, and on his re- turn, at the interval of some months, had suffered no relapse of his complaints. Tendency of Stimulants to produce Effusions, es- pecially when given in a state of Convalescence.—A gentleman, aged nineteen, much addicted to field sports, who from his earliest youth had freely indulged in the use of wine and women, and whose father died of ab- scess in the liver, in the autumn became affected with syphilis, for which he underwent the usual mercurial process. During this course, having exposed himself to cold in hunting, he began to have a cough, accom- panied with fever, which however did not deter him from an occasional repetition of similar indulgences, till he was seized with evident pleuritic inflammation, for which no active measures were at first employed. Af- terwards, however, copious bleedings, and all other cir- cumstances of the antiphlogistic regimen, were assidu- ously used. When under this plan all symptoms of active inflam- mation had been subdued, I first visited him. His pulse was still, in the evening, considerably above 100 in a minute, though slower in the morning, and was soft and weak; his skin cool, and his tongue moist and clean. He could not readily make a deep inspiration. Walking produced much breathlessness; and when he lay down, his respiration was considerably incommoded by a sensation of a heavy weight falling in his chest to that side on which he happened to lie. He had no cough. His countenance was pale. His urine was high colour- ed and defective in quantity, and his feet and legs were considerably oedematous. There was some suspicion, though no absolute certainty, of preternatural hardness in the right hypochondrium, which was somewhat sore on pressure. His appetite was moderate, and his stools unduly pale. 296 ADDITIONAL APPENDIX. These circumstances impressing me with a convic tion that hydropic effusion had taken place in the thorax, I recommended a continuance of the antiphlogistic diet, a combination of squills and digitalis, with effervescing draughts of potass and lemon juice, together with oc- casional doses of calomel as a purgative. In a few days, the pulse came down to 72 in a minute, even late in the afternoon; the urine resumed its natural colour and quantity; and the breathing was much improved. Thus he went on for some time, evidently conva- lescent, when some anxious friends, fearful of debility and other visionary evils, recommended to him animal food and wine. In a few days after this change of plan, his pulse became again quicker, so as to exceed 100 in a minute, his belly began to swell, and an evident fluctuation became perceivable in the abdomen. A rigid abstinence was again enforced, and squills and calomel had recourse to. He once more mended, the pulse being restored to the natural state, and the fluctuation being removed. In the end, he perfectly recovered. Curious Evacuation of Water in Anasarca.—In Mr. J., seventy years of age, after twenty years oedema of legs, sixteen pints of water flowed out in a full stream from the legs, on scarification, from eight or nine punc- tures. The legs and thighs were totally reduced. If anasarca is the consequence of excessive deter- mination (and it certainly is increased by heat,) it ought to be curable or capable of relief by cold. Upon the same principle, the inflammation on the skin, and the erysipelatous state, or whatever state it is which begins with redness and bladders, and ends in sloughs, should be prevented or alleviated by cold. ADDITIONAL APPENDIX. No. III. FROM THE CLINICAL REPORT ON DROPSIES, BY DR. VENABLES, PHYSICIAN TO THE HENLEY DIS* PENSARY, &C. &C. CASE I. Frances Avery, aged 47, a thin, poor, spare-look- ing woman.—Dispensary. September 10, 1823. Complains of a most severe and distressing dyspnoea; " can scarcely get her breath;" any exercise, such as merely walking across the room, creates such a degree of dyspnoea, that she gasps and catches for air; violent fits of coughing follow, which last for ten or fifteen minutes; orthopnoea; the face flushes and becomes purple, the lips assume a livid hue, and the whole countenance indicates the greatest dis- tress. The skin feels hot, dry, and rough to the touch; the pulse quick, irregular, hard, and slow; only 50 beats in the minute. The bowels constipated; the urine scanty and high-coloured, and on settling deposits a sediment; does not coagulate on the application of heat; tongue foul, and covered with a yellow fur; the abdo- men swollen, and on percussion, fluctuation distinctly perceived. Anasarca of the ^ancles, with pitting on pressure. Mitt, sanguis ad ^x. Ht. pil. col. comp, (38) 298 ADDITIONAL APPENDIX. no. vj.—st. j. sing, horis, ad alvum promovend. R Pulv. digitalis gr. xij. pulv. ant. gr. xx. ipecacuanha gr. x. confecti aromat. q. s. ut ft. pit xij.—st. j. bis in die. 12. The symptoms detailed above, nearly as at the time of that report. Complains of restless nights, pal- pitations at the heart, and frequent attacks of night-mare, with startings from sleep. Has taken her medicine with very little relief, or even perceptible effect. The aperient pills have regulated the bowels. The blood drawn exhibited, on standing, signs of inflammatory action. Perstat, et admov. hirud. no. x. sterno, et postea vesicatorium. 17. Symptoms somewhat relieved; the dyspnoea and coughing not so violent; the restlessness and palpita- tions continue, though she thinks they are not so severe or violent as before. Perstat; et st. ext. hyoscyami gr. iij. hord somni, et repet. eras vespere. 19. All the symptoms abated. The evacuations, however, somewhat dark-coloured. R Calomel, gr. vj. pulv. digitalis gr. x. ext. hyoscyami gr. viij. M. ft. pil. xij.—st. j. node maneque. 24. Some increase of the dyspnoea; the symptoms generally, however, improved; the cough is not so readily excited; the orthopnoea relieved, as she can now lie down in nearly a recumbent posture. Admov. vesi- catorium sterno, et perstat ut ante. 26. All the symptoms rapidly disappearing; the abdomen decreases in size; the urine plentiful; the bowels free; the fever and pectoral symptoms very much abated. Perstat. October 3. All the symptoms completely relieved. She feels weak, and sometimes the urine diminishes in quantity. R Infusi cascarilla gviij. infusi digitalis gij. M.—st. cyath. j. ter in die. 20. Has not attended since till this day ; complains of a return of the symptoms; the urine diminished; ON DROPSIES. 299 pyrexia, with hard pulse. Mitt, sanguis ad 5x.* R Cremor. tart. 3ij. jalap. 9ij. M. ft. pulvis, cujus su- mat gr. xij. ter in die. 27. The powders purge very much; the urine not quite so plentiful. R Cremor. tart. §ss., jalap. 3jss. gum kino 3ss. theriaca q. s. ut ft. elect.—st. coch. j. min. bis terve in die. She persevered in the above medicine till the 12th Nov., when, through an imprudent exposure to cold while washing, she was again attacked with acute febrile symptoms, which threatened a return of all her former distress. Eight ounces of blood were now drawn off, and the electuary directed to be repeated. Nov. 17. The bleeding immediately checked the fever, and she now feels perfectly well, with the excep- tion of weakness, from the active treatment to which she has been subjected. She was now directed to take the tartarized iron, as a tonic, and was discharged, cured, on the 24th of the month. Observations.—This was as severe a case of hydro- thorax as I have witnessed. The appearance of this woman was not what would be considered as warrant- ing bleeding. The pulse was unusually slow, but after bleeding it rose, and acquired a much greater frequen- cy. This often happens; when the quantity of blood is such as to oppress the heart, or that there is such pulmonary obstruction as to impede the circulation through these organs, the motion of this fluid becomes preternaturally slow. Venesection, by relieving the ac- tual disease, and lessening the influence of its causes, removes the obstruction, and the blood acquires a great- er degree of velocity. I am much inclined to believe, that the lungs in this case were in that morbid condition which Laennec has termed " Pulmonary Apoplexy."f * The blood drawn from this patient did not buff in any instance. t See Laennec, translated by Dr. Forbes: and also Dr. For- bes's own work on the Stethoscope and Percussion, &c. 300 ADDITIONAL APPENDIX. Although haemoptoe is a general attendant on this con- dition of the lungs, yet I question whether it be an ab- solutely necessary consequence. However, I question- ed this woman upon the subject of spitting of blood, but she answered in that hesitating and equivocal man- ner which led me to doubt the accuracy of her asser- tions. Some people seem to imagine, that to admit of being afflicted with disease is a sure mode of becoming affected; perhaps she thought the converse of this equally good reasoning, and that to deny the presence of symptoms was a sure way of diminishing their violence. It will be observed, that a frequent repetition of the blood-letting and blistering was absolutely necessary, to establish any thing like permanent relief.* Surely, it could not be to the want of diuretics, nor to a diminish- ed secretion of urine, that the aggravation of the symp- toms, which occasionally took place in this instance, should be attributed. The increase of the symptoms was usually attended with pyrexia ; this proved a stimu- lus to the heart, and excited inordinate action.f The impermeability of the pulmonary tissue to the blood, propelled with an unusual velocity, no doubt, contribut- ed much to the dyspnoea, cough, and other kinds of pectoral distress experienced in this case. CASE II. Lucy Bartlett, aged 26, needle-worker: leuco- jphle^matic appearance.—Dispensary. September 26, 1823. Complains of flatulence, and distention of the stomach after eating; eructations ; lan- guor and hstlessness; palpitations; cephalea, and occa- sionally vertigo. She can with very great difficulty * I have since seen this woman repeatedly at church, and she seems to enjoy very good health. t At least, in a comparative sense. ON DROPSIES. 301 make herself understood, in consequence of imperfect articulation, from a defect in the palate, owing, appa- rently, to scrofulous ulceration. Complains principally of pain in the sides, extending along the cartilaginous margins of the ribs. Pain in the shoulder-blades, ex- tending up the neck, frequently assuming the character of what is vulgarly called " Crick in the neck." The pulse hard, but otherwise natural; febrile exacerbations, with full and perfect intermissions; respiration free; bowels' regular, but the evacuations unnatural and dark- coloured ; urine very plentiful, pale, and limpid during the apyrexial intervals, but scanty and high-coloured at the febrile accessions. The abdomen a little swollen, with a sense of fluctuation, on percussion. The ancles anasarcous, with pitting on pressure. The symptoms of long standing. The history of this case cannot be well traced. R Pil. hyd. 9j. pulv. zingib. gr. xij. ipecacuanha gr. x. M. ft. pil. no. viij.—sumat y sing. noctibus. R Infusi senna §x. sulph. magnesia §j. tinct. jalap. 3iij. M. sumat cyath ij. quotidie mane. October 3. Alvine evacuations improved in appear- ance, and the bowels act more regularly ; the dyspeptic symptoms, however, still continue, and the digestion seems very weak. The anasarcous swellings as at last. R Pil. hyd. gr. x. pulv. digitalis gr. xx. ext. gent. 3ss. M. //. pil. no. viij.—sumat j. sing, noctibus. Ufa- tur misturd laxante prout necesse sit. 15. Pulse slow (40,) and fluttering; frequent vertigo, with perpetual cephalea; digestion improved; dropsical symptoms remain as at first application. Omitt. pil. R Pulveris rhei 3ss. pulv ipecacuanha comp. gr. x. M. et divide in pulv. no. vj.—st. j bis in die. 20. This day 12 grains of squills were substituted for the Dover's powder, which she took in doses simi- lar to those prescribed above. 24. Th< dropsical swellings no way relieved; the urine plentiful; bowels regular; digestion very much 302 ADDITIONAL APPENDIX. improved; febrile accessions troublesome. Repet. put- veres c scill. ut ante. November 3. Has continued to take the powders since last report, without any alleviation of the dropsi- cal symptoms. Feverish accessions at night, attended with increased temperature; thirst; great languor and uneasiness; occasional palpitations, with startings out of sleep, and sometimes night-mare; pain in right side; bowels regular; urine plentiful; pulse small, hard, and wiry ; somewhat accelerated, about 84; respiration free. Mitt, sanguis ad §viij.* R Supert. potassa 3ij. the- riaca q. s. ut ft. elect, inter diem sumend. 7. Complains of pain in the side being still trouble- some ; the other symptoms relieved. The skin, how- ever, feels harsh and dry, and the perspiration suppress- ed. The electuary purges and gripes her. Omitt. elect, admov. vesicatorium lateri qua dolet. R Pulv. dig. gr. iij. ipecacuanha gr. vj. pulv. ant. gr. viij. ext. hyoscyami gr. iv. Ft. pil. no. vj.—st. j. sing, noctibus. 12. The febrile symptoms abated; the anasarcous swellings disappear towards morning, but return again at night; pulse better, and its hardness much reduced; skin soft and moist. Repet. pilula ut ante. 19. All the symptoms have disappeared, with the exception of some degree of the pain in the side. A cloudiness being observed in the urine, she was desired to take the squill pill, in combination with digitalis. From this period, she gave up attending the Dispen- sary, conceiving that her health admitted of no farther amendment. Observations.—This is a case, which, comparatively speaking, excites but little interest. There are, how- ever, one or two circumstances in its history, to which I am anxious to direct the attention of the reader. She * This blood did not buff, nor put on any of those appearan- ces usually considered indicative qf the inflammatory diathesis; ON DROPSIES. 303 applied on the 26th September, suffering from indiges- tion, with all its concomitant languor and general dis- turbance. There was also, evidently, subacute or chronic he- patitis and splenitis. Anasarca of the feet and ancles, with a degree of ascites, are likewise noted as existing! Medicines were prescribed with the view of correcting the dyspeptic symptoms, and this with tolerably good effect. On the 3d October, digitalis was given, in com- bination with the stomachic medicines, with the view of acting on the dropsical swellings. This was continued, till it affected the head and pulse so much as to render a discontinuance of it necessary. The urine was passed in sufficient quantity from the first; but neither this cir- cumstance, nor the active exhibition of digitalis, seemed to have the slightest influence in reducing the dropsical accumulations. Squills was next tried, and with what effect, the report will show. She took, as appears from the report, the most active of those remedies comprised in the class of diuretics, and persevered in their use, with very little intermission, from the first application till the 3d November. The urine, during nearly the whole of this interval, is reported sufficiently plentiful; but yet the dropsical swellings remained unaffected. One of the most powerful of the class of diuretics was given, till its specific effects upon the nervous system were clearly developed; yet the dropsy remained as at first. Can, then, diuretics be the appropriate remedies for dropsies? It would be wrong to establish therapeu- tical principles upon the phenomena or history of a sin- gle case; but the question has been, I may say, fully answered by the foregoing observations. On the 3d November bleeding was practised, and almost immedi- ately after, the dropsical swellings subsided. The blood drawn indicated none of those signs which are generally considered as marking the inflammatory diathesis; a clear proof that venesection may be not only safely but 304 ADDITIONAL APPENDIX. advantageously practised, even where the more marked symptoms of the inflammatory diadiesis are wanting.* CASE III. Michael Grace, aged 24, bargeman, a stout, able, young man.—Dispensary. 7th November, 1823. Applied with a deep, erod- ing, angry-looking, syphilitic ulcer upon the glans penis. A deep excavation had been effected from the ulcerative process. He denied that the sore was one of any considerable duration, or that he had used any medicine whatever. The correctness of this statement, however, I strongly suspected. He is now extremely irritable and feverish; cold chills, with a burning hot skin; great propensity to sit over the fire; foul tongue; thirst; loss of appetite; hard, full, and frequent pulse; bowels full, and rather constipated; cephalea; languor; hurried respiration. Mitt, sanguis ad |x. R Ext. colocynth. comp. 3ss saponis gr. x. M. ft. pzVviij.— st. ij. sing, bihoriis ad effect, j* Sulph sodse 3.J vin. antimonialis 3j. aqua fontana 3 viij. M.—st. cyath. j. quater in die. 8. The febrile symptoms, though still considerable, much abated. The pulse hard and frequent; the bow- els have been well moved; the urine small in quantity and high-coloured; the penis painful; some slight de- gree of dyspnoea. The blood drawn much inflamed. Cont. pil. et mistura ut heri. 9. The violence of the symptoms very much reduc- ed. Perstat. 10. Symptoms of excitement still abating. Perstat. * I lately met this girl in the street, and on examining her, I found that the anasarca of the extremities had entirely disap- peared. She complained merely of a constant dull pain in the side, for which I recommended the application of leeches and blisters alternately, till its removal be effected. ON DROPSIES. 305 12. All the inflammatory symptoms have entirely disappeared. The penis very painful, and the ulcer shows no disposition whatever to heal. Sumat pil. hyd. gr. v. ipecacuanha gr. j. sing, noctibus. Admov. cataplasm, refrigerans* ulceri penis. 14. Feels somewhat better; the penis not so sore. Perstat. 17. Does not feel quite so well; pyrexia; thirst; foul tongue ; clammy taste of mouth; languor, and iistless- ness; coma, or drowsiness; abdomen tumid, and tym- panitic ; no soreness of mouth, nor has the mercury shown any of its specific effects on the constitution. Omitt. pil. hyd. Repet. pil. et mistura ut Itimo. 21. Feels rather better; the tympany of the abdomen has nearly disappeared, and the other urgent symptoms are much abated. Perstat. 24. I was absent, I believe at Oxford, but I find by the Dispensary book, that the gentleman who did me the favour to attend in my place, prescribed as follows: —R Pil. hyd. 3j. pulv. opii gr. iij. ft. pil. xij.—st. j. alt. noctibus. I did not see this patient again till the 1st Dec. He had, either through mistake or design, taken two pills every night. 1st December. Considerable pyrexia; thirst; foul tongue; hot and dry skin; respiration hurried; pulse hard, quick, and frequent, 108—115 ; bowels constipat- ed ; cephalaea; pain in the eyeballs, which are suffused with red vessels. The abdomen much swollen, and tympanitic; fluctuation very sensible; anasarca of the legs and ancles, which are greatly distended, and pit on pressure. Complains of great soreness of the legs and thighs; the urine, which is scanty, and gelatinous in appearance, coagulates into a dense, firm, solid mass, * Made with one drachm of liq. plumb, acet. ^xij. of water, and as much oatmeal, moistened with the liquor, as may be nccessarv to form a poultice. (39) 306 ADDITIONAL APPENDIX. on being heated to about 180°.* Mitt, sanguis ad Ixyj. R Pulv. jalap, comp. 3ss pulv. aromatici gr. vj. M.—sumat statim. R Ext. col. comp. 9j. pil. aloes c myrrha, gr. x. M. ft.pil vj.—st. j. sing, noctibus. 2. Feels somewhat better; but the amendment, if any, is not very obvious. Perstat. R Sulph. sodas 3j- vin. ant. 3ij. tinct. digitalis 5j. aqua font, o'viij. M. —sumat coch. ij. ampla tertiis horis. 3. Several hard, dark evacuations have passed away ; the pulse very hard, frequent, quick, and irritable; tem- per very peevish; pyrexia considerable; complains of pain in the abdomen on pressure; dropsy nearly as at first note of this symptom. Urine still scanty, and coagulates on the application of heat. Sumat pulv. ja- lap, comp. 3j. Perstat usu misturx, et mitt, sanguis ad §xvj. 4. The violence of the symptoms somewhat abated; the tenderness on pressure, however, of the abdomen, still continues; the swelling diminishes; fluctuation still perceptible; anasarca of the legs and ancles much re- duced. Admov. hirud. no. xij. abdomini; aliter ut ante. 5. Did not apply the leeches, in consequence of the expense attending the purchase of them. The dropsical swellings subside rapidly ; the urine more plentiful, but still coagulates; the other symptoms as yesterday. Ad- mov. cucurbitula c ferro, et detrahantur abdom. san- guinis Ixij. et postea emp. vesicans. 6. All the symptoms relieved; the dropsical swell- ings, and tympany of the abdomen, have all nearly sub- sided. Perstat. * The most convenient way of ascertaining the degree of heat at which the urine coagulates, is to have glasses filled with water, heated to different temperatures, and immersing test- tubes, filled with the urine, into these. It may also be con- veniently done by filling a vessel with water, placing it over a lamp, and immersing in it a thermometer, and a test-tube filled with the urine; the thermometer will indicate the temperature, the moment coagulation takes place. ON DROPSIES, 3Q7 Prom this time all the symptoms rapidly improved. On the 19th, however, there was a slight return of the pyrexia, and with this state, the dropsical swellings be- gan to reappear. These symptoms were reduced by the abstraction of eight ounces of blood, and by the administration of digitalis and hyoscyamus, in half grain doses, three times a day. At this period he was also directed to use the camphorated mercurial ointment. By the end of the month, all the more urgent symptoms had nearly disappeared. On the 31st, the bowels being rather constipated, and the urine beginning to diminish, some pills, composed of extract of colocynth and soap, were directed to keep the bowels open; and he took small doses of the vinegar of colchicum. Jan. 7. He was attacked with high irritative fever; respiration very much hurried; pulse small, hard, and thready; great peevishness; thirst; skin hot and dry ; pains and dropsical symptoms returned; says he caught cold, through a broken glass in the window-frame of his room. Mitt, sanguis ad $x. R Aqua ammon. acet. |ij. vin. ant. 3ij. aqua font. |vj. M.—sumat coch. j. amp. 2dis horis. He died in a few days afterwards, and was interred before I was made acquainted with the event; and thus I had not an opportunity of making any examination of the diseased structures. Observations.—This case presents some phenomena worth noticing. This patient, at the first, was affected merely with symptoms of fever; there were no signs whatever of local inflammation.* The blood drawn upon each occasion buffed, and manifested the inflam- matory diathesis, in a very remarkable degree. There can be no question that the exhibition of mercury, un- der the circumstances of such constitutional excitement, contributed in no small degree to induce both local in- * I exclude the inflammatory ulcer »n the glans penis. i 308 ADDITIONAL APPENDIX. flammation and dropsy. When I first saw this case, I anticipated dropsy, from an active course of mercury. and I therefore determined to lower the excitement, be- fore subjecting him to the influence of a mineral which his disease demanded, but the Constitutional irritation forbade. Under the impression that I had sufficiently reduced the excitement, and corrected the habit, 1 ven- tured, on the 12th, to give small, and what I conceived unirritating doses of mercury. But the extreme sus- ceptibility of the nervous system soon convinced me that 1 had greatly overrated my endeavours; according- ly, on the 17th, the blue pill was suspended. On the 24th, the blue pill, combined with opium, was prescribed,* and, from the extreme susceptibility of both the nervous and circulating systems, was follow- ed by very serious consequences. It likewise unfortu- nately happened, that the patient took the medicine in double the quantity prescribed. On the 1st December, we find him affected with all the symptoms of highly acute, irritative fever, and fully formed dropsy. There can be little doubt of the exciting influence of mercury; and we can thus readily comprehend how diseases, in the first instance trifling and unimportant in their nature, are, by the injudicious use of mercury, converted into severe, and perhaps, ultimately irremediable organic disorders. Dr. Blackall, in his excellent work on Drop- sies, details the history of four cases of severe dropsy, after mercurial courses. " No one," he observes, " can contemplate these remarkable characters of the blood, * This circumstance shows the great advantage of being per- fectly acquainted with the history of the case. Had the gentleman who kindly supplied my place at the Dispensary been thorough- ly informed of my views with respect to mercury in this in- stance, I am well convinced it would have been the last reme- dy he would have resorted to, notwithstanding the formidable appearance of the syphilitic sore, and its efficacy in arresting the progress of such ulcers. i ON DROPSIES. 309 the dry cough, and pains in the side, the thickened membranes, and turbid fluid discovered on dissection, and particularly the spontaneous coagulation of the.fluid taken from the cellular membrane, without forming conclusions favourable to the doctrine of an inflamma- tion induced by mercurial courses, and of the great risk of that inflammation fixing internally."* It must be observed, that this young man was, how- ever, most unfavourably circumstanced. His habita- tion was a most miserable hovel, with scarcely a whole pane of glass in his room. Hence the windows were stuffed with old rags, which, falling out at night, left him exposed to all the deleterious influence of the cold night air. It is to an accident of this nature, that the relapse, which terminated fatally, should be attributed. CASE IV. Eliz. Plumridge :—Dispensary. 10th November, 1823. Applied with very severe dyspnoea, greatly increased by the least exertion; fits of coughing, and gasping for breath. The face be- comes flushed and purple, and even the effort of speak- ing aggravates the dyspnoea. Cannot lie down without danger of suffocation; the pulse hard, wiry, slow, 46 —52, and oppressed. Increased temperature of the skin; thirst; foul tongue; bowels regular; urine scanty. CEdema of the feet, so that she cannot wear her shoe up. Mitt, sanguis ad |x. R Supert. potassa §ss. theriaca q. s. ut ft. elect.—sumat coch. j. min. ter in die. R digitalis gr. vj. pulv. ant. gr. xij. ext. hyoscyami gr. x. M //. pil. no vj.—st. j. sing. noct. 17. The severity of the symptoms diminished; the pyrexia abated; the dyspnoea and cough, however, still * See page 71, of this volume. 310 ADDITIONAL APPENDIX. very severe; oedema now confined to one foot; pulse hard, but less oppressed; has increased in frequency, 64—69. Bowels rather purged; urine very plentiful; couipLius of slight rheumatic pains. Mitt, sanguis* ad$\i\], Perstat usu aliorum remediorum. Ht. item lin. anodyn. contra dolores rheumaticos. 19. All the symptoms much mitigated; the dyspnoea, and sense of suffocation on attempting the recumbent posture, still, however, very troublesome. Admov. hi- rud. no. x. sterno, et postea applic. vesicatorium : aliter ut ante. 26. Complains of vertigo, and some degree of ce- phalaea; the dyspnoea, and other symptoms of oppress- ed pulmonary action, very much relieved since the ap- plication of the leeches and blister. The frequency of the pulse diminishes again, it being about 40; the urine very plentiful; the oedema of the foot has entirely dis- appeared. Omitt. pilula digitalis. Perstat autem usu cremor. tart. 28. She complains that the electuary purges and gripes her; the urine diminished. Repet. elect, c addi- tione pulv. opii gr. vj. gum kino 3ss. adhibeatur ut ante. 1st December. A slight return of the dyspnoea; the pulse improves, and recovers its natural frequency ; is soft, and has lost that wiry, irritable feel, which has hitherto been remarkable. Repet. vesicatorium sterno: aliter ut ante. 8. Chronic form of rheumatism urgent; bowels con- stipated, otherwise the health tolerably good. Repet. liniment, et habt. pil. aperientes no. vj.—sumat ij. pro dose, urgente obstipatione. Omitt. electuarium. 24. The convalescence having been perfectly esta- blished, the following tonic electuary was directed. R * The blood drawn in these instances did not buff; but tht- serum was dense in its appearance. ON DROPSIES. 311 Tart.ferri 3j. pulv. colomba 3iij. cremor. tart. 3j. the- riaca q. s. ut ft. elect.—sumat circiter nucis mosch. magnitud. ter quaterve in die. She persevered in this plan for about a fortnight or three weeks, at the same time attending to the state of the bowels; and having experienced no return of the unfavourable ssmptoms, her name was removed from the books of the Dispensary, on 9th February, 1824. Observations.—It will be recollected that this wo- man, in the first instance, suffered from acute rheuma- tism, and on the subsidence of the acute stage, was at- tacked with symptoms of hydrothorax. These were met with active treatment, and were, at all events, par- tially suppressed. It is very probable, that a preterna- tural sensibility to the exciting causes of disease still remained. She was out one day in the woods of this neighbour- hood, searching for and collecting fuel, and I suppose was, through the exertion, overheated and fatigued. In this situation she got wet by a shower of rain, and al- most immediately after, suffered in the manner already described. The vigorous measures adopted soon sub- dued the violence of the symptoms, and she of course was left in a comparatively exhausted state.* Perhaps it may be objected that I carried the de- pleting system to an unnecessary and wanton length. considering her extreme age, and the active measures to which she had been so lately subjected. Case X. in Dr. Crampton's Report, however, decided me. " Tuite's case," he says, " is one of the most interest- ing in the collection, as he was twice subjected to me- dical treatment within a short space of time. In the * I met this old woman an evening or two" since, returning home from lavender-cutting, by which employment she earns her bread. She goes a distance of two miles daily to her work, and returns in the evening, and looks extremely well and healthy 312 ADDITIONAL APPENDIX. first instance, his attack of dropsy, as will be seen in the sequel, was met with repeated venesection, blisters, and other antiphlogistic remedies. The result was, that he was completely cured. " In the second instance, although his disease did not appear more formidable, the result was unfavourable. The same active plan of treatment was not adopted. Too much reliance was placed on cathartics and diure- tics ; and though there were less decisive m.irks of in- flammation, so far as could be collected from the symp- toms, yet the appearances after death show that there were not only old, but recent signs of inflammation."* Here then, even our errors, when candidly, and, I may add, thus honourably acknowledged, become use- ful practical guides, not only to ourselves, but even to others. Were I to have an opportunity of again treating Grace, I should, possessed of the advantages of my pre- sent experience, begin with opium earlier, and also in doses sufficiently powerful to control the excitability of the nervous system, which, I have no doubt, by its dis- turbance, contributed to aggravate the febrile symptoms. CASE V. Dispensary, Nov. 12, 1823. Sarah Burgess, aged 4£, a cook, applied labouring under general dropsy, with severe anasarca. The extremites, both upper and low- er, were swelled to an enormous size, and also the in- teguments of the face and abdomen. The distention so great, that the skin seems as if bursting; and on pressure, from this circumstance, the parts pit but little. The tension so great, that the slightest pressure produ- ces intolerable pain. Great difficulty of breathing; the temperature of the surface elevated ; pulse small, hard, and frequent (98 ;) but the difficulty of ascertaining the '* Dr. Crampton's Clinical Report, pp. 173, 174. ON DROPSIES. 313 state of the pulse, from the great distention of the cellu- lar membrane, renders any observations upon this symp- tom extremely equivocal. The abdomen was very much distended, and, on percussion, fluctuation was distinctly perceived. The urine scanty; the bowels torpid; tongue foul, dry, and furred. This woman had been afflicted with dropsy several times before; had been in several of the London hospi- tals on this account, and was never wholly free from some degree of the disease. An electuary, composed of the compound powder of jalap, was this day directed to be taken, in small and repeated doses. •* 14. At Dispensary hour, this woman's sister attend- ed, and stated that the patient was so ill as to be con- fined to bed, and therefore was unable to attend. On visiting her, I found her complaining of severe grip- ing pain of the abdomen. There was also pain of the abdomen increased on pressure, straining, tenes- mus, and an inability to pass any natural alvine eva- cuations. There was a constant desire of going to stool, but nothing was voided, except mucus, tinged with blood.* The urine, which was voided in very small quantity, on exposure to an elevated temperature, became a tough, viscid coagulum, scarcely a single drop remaining fluid. The same phenomenon took place on the addition of nitric acid. Indeed, the urine had a peculiar, thick, gelatinous appearance, which led me confidently to anticipate coagulation on the applica- tion of heat. Mitt, sanguis ad%x. et adhibeatur mis- tura oleosa^ ad irritationem intest. placand. * This bowel affection went through the whole of the family in which she lived as cook, and of which the master himself, a very respectable elderly gentleman, died, after a very tedious, lingering, and protracted illness. t Merely castor oil diffused through water, and suspended by means of mucilage, or yolk of eggs. (40) 314 ADDITIONAL APPENDIX. 15. The surgeon who attempted to practise the vene- section, was unable to open a vein, (although he tried in both arms,) in consequence of the distention of the cellular membrane with the dropsical fluid, and there- fore no blood was obtained. The bowels still feeling tender on pressure, and the obtaining blood from the system being apparently im- practicable, twelve leeches were directed to be applied to the abdomen, and a dose of Dover's powder to be taken at night. 16. The leeches bled freely; the tenderness of the abdomen somewhat diminished; pyrexia continues; griping and tenesmus as severe as at first; no natural faeces have passed ; no abatement of the dropsical symp- toms ; the tongue somewhat moister. Repet. mistura oleosa. 17. The griping pains still continue; the tender- ness on pressure rather increased; the dropsical symp- toms undiminished. On examining the tongue, I per- ceived that it was dry and parched, and evidently very different in its appearance from that of yesterday. This circumstance led me to conclude that she had been tak- ing wine, or some other exciting liquor ; and on strict inquiry, after some prevarication, it was acknowledged that she had taken, at the suggestion of some ignorant person, a little wine. She was ordered not to take any more wine, or other exciting liquor,.without permission. Admov cucwbitulse c ferro, et detrahantur sanguinis §x. cont. mistura. 18. The cupping-glasses were applied, but the pre- scribed quantity of blood could not be obtained; water flowed from the wounds inflicted by the scarificator. The griping, and tenderness on pressure, still continue. Every description of aliment or drink taken, passes un- altered through the bowels, almost immediately after its introduction into the stomach; the dropsical swell- ings somewhat diminished; fever abated; tongue more ON DROPSIES. 315 moist. R Rhei gr. vj. pulv. Doveri gr. iij. M. fiat pulvis ter in die sumendus—sumat item ext. hyoscy- ami gr. ij. hord somni, et admov. emplast. vesicans abdomini q. p. 20. The bowels still much affected, but the drop- sical swellings, especially of the upper extremities, ar6 diminished: the stools still consist of mucus. Cont. pulveres. 26. I have not had an opportunity of visiting this woman since the 20th. The dropsy has completely left the upper extremities; the pulse, on being examined, feels extremely hard and wiry ; elevation of temperature; tenderness of abdomen diminished, but the irritability of the bowels continues, though not so severely. The urine being passed with the evacuations from the bow- els, none could be collected for experiment; however, the hardness of the pulse, tenderness of abdomen, con- tinuance of the dysenteric symptoms, with the presence of the pyrexia, determined me, notwithstanding the apparent exhaustion, to practise a moderate general blood-letting. Mitt, sanguis ad 5yj. vel viij. 27. The gentleman who was directed to perform the venesection, did not make the attempt to draw blood, conceiving the effort useless; however, at my urgent solicitation, the attempt was made this day. 28. The venesection was effected yesterday, and about eight ounces of blood were drawn. The coagulum, oil separating, cupped and buffed, and was solid, and very hard; the blood generally highly inflamed; the fever abated; tongue moist; tenderness of bowels much di- minished ; but there is still considerable irritation. Inji- ciatur enema ex mucilag. amyli, c tinct. hyoscyami 3ss. 29. Tenderness of the abdomen, merely from the effects of the blister ; the evacuations from the bowels consist of small, crude, undigested lumps; the fever very much reduced, and the dropsical swellings have almost wholly subsided. Repet. pulveres rhei. 316 ADDITIONAL APPENDIX. 30. As at yesterday. Perstat. December 1. Passed a restless night; dysenteric symptoms, with fever, increased; pulse hard and fre- quent ; tongue, however, moist, and nearly natural in appearance; dropsical swellings returning. Mitt, san- guis ad 5*viij.—x.—sumat pulv. cretae comp. c opiogr. vj. bis in die. 2. About six or eight ounces of blood were obtained; it buffed, but did not indicate so much inflammation as the last. Passed a more tranquil night; fever much abated; dysenteric symptoms relieved, but the bowels are still irritable; tongue moist. Through some mis- conception, she did not take the anodyne absorbent powders. Sumat pulv. creta comp. c opio ut heri pra- script. 3. Pain in the epigastrium. Admov. vesicatorium part, dolent. 4. All the symptoms relieved; a little of the urine, which was procured this day, on exposure to heat be- came milky, but did not become solid throughout, as % related in a former experiment. Contr. pulveres c ad- ditione pulv. rhei gr. iij. sing, dosibus. 13. Recovery progressive, but extremely slow; on visiting this day, I found her sitting up in bed, eating- potatoes and butter,* and drinking a little wine and water. All the febrile, and dysenteric symptoms have disappeared, but the patient seems very weak and help- less. R Ext. col. comp. 3ss. saponis gr. x. M. ft. pil. viij.— st. ij. statim et]. sing, bihoriis ad alvum dedu- cendam. 14. Pills operated almost instantaneously, and brought away the potatoes unaltered ; considerable irritability of the bowels. Omitt. omnia medicamenta. 17. Gradually but slowly improving; skin rough * This circumstance is not introduced as an example for imitation, but as an imprudence to be deprecated. ok dropsies; 317 and harsh; pulse soft and good. R Ext. gent. gr. x. pulv. ant. gr. v. NL.ft. pil. no. iij. indies sumenda. 31. Skin has become more natural to the feeling, but she feels very languid and weak; bowels begin to re- sume their healthy vigour; the pills were omitted, and she was now directed to take a watery solution of the tartarized iron, in appropriate doses, at intervals during the day. This plan she pursued for a fortnight, taking occasionally, when necessary, an aperient pill, to act upon the bowels. About the 20th January, the convalescence being perfectly established, she had the compound infusion of gentian, with infusion of senna ; and on the 10th Fe- bruary she was discharged, perfectly cured. Since this period she has been in London, and has returned again, and is at the present moment in service in this town. Her sister, whom I accidentally met last night,* informed me that she finds herself much better now than ever she had been before. Observations.—The history of this case does not furnish any evidence of the existence of organic disease; nor indeed can the dysenteric affection be regarded as the cause of the dropsy. On the first application at the Dispensary, she was swelled to an enormous size, and it is a rational conclusion, that so severe a degree of general dropsy, could not have been a momentary opera- tion. Neither did she complain of any other particular ailment at first; and it was not till the 14th November, the third day of medical attendance, and perhaps an advanced period of her disease, that she complained of any visceral affections. There was, however, rather a severe degree of pyrexia observable from the first; there was also, as far as the circumstances of the patient would admit of judging, a hard, wiry pulse, with an accelerat- ed circulation. Such were the principal symptoms -. * 26th Mav. 318 ADDITIONAL APPENDIX. Had organic disease been the cause of the dropsical ac- cumulations, we should have been able to detect more decisive and unequivocal evidence of the existence of such disease. Her occupation as a cook frequently exposed her to extremes of temperature. These exposures, in all pro- bability, increased the inflammatory tendencies of the system; and possibly, at last, superinduced the febrile excitement. This excitement, no doubt, produced the dropsy; and probably also aggravated the intestinal ir- ritation,* when it came on. The extraordinary coagulability of the urine forms a peculiar feature of the complaint. It was principally this circumstance which determined me to bleed; not- withstanding the apparently hopeless condition of the patient, and the obscurity of the pulse as a guide. I have never hesitated, when the urine coagulates, to bleed in dropsies; and I have never yet had reason to believe the practice injudicious; and I cannot help expressing here my opinion, that the profession are highly indebted to Dr. Blackall, for so pointedly directing our attention to this condition of that discharge. I am not, indeed, prepared to admit that the sensible qualities of the urine form a principle upon which to found a practical division of dropsies; but I feel assured that the coagulability of the urine will almost invariably warrant the practice of blood-letting. The appearance of the blood drawn incontrovertibly proved, in this in- stance, the inflammatory tendency, and the propriety of the practice. On the 13th December, I directed the exhibition of active doses of the compound extract of colocynth, to * It should be stated, that this kind of irritation spread through the whole family, and proved fatal to the master of it; but yet it showed no contagious properties, as far as I have been able to ascertain. The affection, probably, depended on some local peculiarity of the atmosphere at the time. ON DROPSIES. 319 counteract the irritating and otherwise injurious effects of such indigestible food, in so debilitated a state of the digestive organs. I am particularly anxious to call the reader's attention to another remarkable circumstance in the history of this case, namely, the cure of so severe and unusual a degree of dropsy without the assistance of diuretics. The compound powder of jalap, prescribed on the first day of application, will hardly be urged as an exception to this general proposition. I have seen, and I believe have adduced in this report, several instances in which dropsy has arisen, in complication with a similar state of the system ; on correcting the habit, the dropsy has gradually, and it may be said, spontaneously disappear- ed. Surely, in such cases, there can be no inactivity of the absorbents; otherwise, the usual means of excit- ing them would necessarily form a part of the remedial measures, before perfect convalescence could be fully established. n I \ " *i &m mm *