Chapter M: BERTHE then remarks, that the greater number of instances of gangrene (4)

In this short account of the preventive treatment of cholera infantum, I have been less anxious to give a dissertation, embracing all that might be said on the subject, than to communicate those particular measures, which, according to my own experience, I have found most effectual. I will conclude the paper by the relation of a case, in which a strong predisposition to the disease was successfully counteracted. It will be proper, however, to premise, that the treatment of this case is by no means held out as an example to be generally followed with every infant, which may possibly become the subject of cholera. It is applicable in all its details only to those, in which, as in the present instance, there is every reason to apprehend, that the only alternative is between almost certain death, and the most careful prophylactic treatment.

CASE.--A gentleman of this city, whose wife had arrived at a period of life, when she could not expect to be the mother of many more children, consulted me respecting an infant daughter, their only surviving child. I was informed, that they had already lost eight children, all of whom, with one exception, had died of cholera. It may readily be imagined, that every feeling of parental anxiety was awakened for their babe; and that no degree of attention on their part was considered too great, which might contribute to its preservation. It was placed under my care, not to be cured, but that I might, if possible, devise some plan of management which would avert the disease they had so much reason to apprehend. I felt the responsibility of the trust, and endeavoured to find it to the best of my ability. Every opportunity which I could desire was afforded me; for the infant, from its birth was submitted to my direction; and both the disposition and ability existed, on the part of the parents, to carry implicitly into effect every measure which I might recommend.

As the mother was unable to furnish sufficient nourishment, the first step was to provide a healthy wet-nurse, who might be willing to submit to the necessary regulations in respect to diet.

I believed the children of these parents to possess a constitutional weakness in the alimentary canal; and, on inquiry, I was told, that they had been kept upon a vapid diet, under the impression that it would contribute to their health. In the present case, therefore, the principal object was to communicate strength to the stomach and bowels. With this view, the child was accustomed, from an early period of infancy, to a generous diet. When very young, portions of ginger tea were given to it daily; and as soon as it was old enough to suck the juice of meat, it was encouraged to do so. The nurse, during the warm season, was kept upon a nutritious diet, consisting principally of animal food, with the occasional use of ginger tea; and every description of recent fruit and fresh vegetable food was forbidden. Under this management, the first summer was passed without any symptom of the disease; but I looked forward to the second with no little anxiety, when the child would have to struggle with the irritation arising from dentition.

The same plan was continued during the second summer, and still more rigidly enforced. The child was now old enough to take animal food freely in addition to the breast. It was allowed as much salt fish, ham, beef-steak, essence of beef, &c. as it desired; ginger tea was given daily; a little sound old port wine was occasionally directed; and both the child and the nurse were restricted from every species of flatulent and indigestible aliment. So anxious, indeed, were the parents, and so careful to carry my directions into full effect, that they allowed no forbidden article of food to enter the house, and denied themselves their wonted comforts, lest possibly their child might be injured.

The gums were carefully attended to, and lanced whenever the operation appeared to be requisite. All those measures, which I have before mentioned as serviceable in obviating the effects of great heat, so far as they were applicable to the case, were adopted. The second summer was spent wholly in the country.

Very little medicine was required, and none was administered, except of the mildest description. Frequently, when summoned to visit the babe, I have found the mother trembling with fear, and anxious that something might be done; and often, under such circumstances, have I begged it off from a dose of physic, having determined to avoid a resort to every thing of the kind, unless real necessity should demand it.

By a strict adherence to the plan above detailed, the period of dentition was passed in safety; and it is with heartfelt pleasure I can say, that no symptom of cholera afterwards made its appearance.

ARTICLE VI.--_Case of Neuralgia cured by Acupuncturation._ Communicated by J. HUNTER EWING, M. D.

The attention of the medical public having been of late much excited on the subject of acupuncturation, I am induced to communicate the following case.

For eighteen months, Miss ---- had been afflicted, at intervals, with a severely painful affection of the nerves of the right cheek, immediately below the orbit of the eye, and extending to the angle of the lower jaw. On the 14th of January 1826, she was attacked more violently than usual, and the remedies, which had previously afforded some relief, now failed. Stimulating cataplasms, warm embrocations, laudanum, internally and externally, heat applied externally to the cheek by means of very hot flannels, produced not the slightest mitigation of the pain; and she continued to suffer excessively until the afternoon of the 15th; when acupuncturation being proposed, she consented to the operation with this remark,--"any thing to relieve me from this agony."

The needles were immediately procured, and three inserted about an inch from each other. Two in a line parallel with the inferior edge of the orbit of the eye, and half an inch below it; and a third below, and equidistant from the others. The first two were introduced to the depth of three-fourths of an inch; the last, a full inch. They were inserted very gradually and with a rotary motion.

The second needle was scarcely introduced, before the patient exclaimed, "the pain has entirely left me." When the third was introduced, she experienced a stiffness in the muscles of the cheek, and a creeping sensation, as if a spider's web had been drawn across the face; but no painful sensation whatever.

Such was the exhausted state of her system from the excessive pain she had suffered, that when thus relieved, she requested a pillow to rest her head on, and fell into a gentle slumber.

About two hours after the insertion of the needles, I again visited my patient, and found her still perfectly free from pain, and seated at a table reading. She thanked me for the relief I had been the means of affording her, and requested me not to withdraw the needles, lest the pain might return. Upon being apprised of the risk that might attend their being allowed to remain, she observed, that she would rather have a servant to watch her whilst she slept. The propriety of their removal being further urged, she at last consented. There was no return of pain.

The next morning, the patient remarked, that the stiffness of the cheek, and a numbness of the whole right side, continued through the night; and though she did not sleep very soundly, she was free from pain and rested well.

By the third day, the stiffness and numbness had passed away, and there was no return of pain. Several weeks have now passed, and she has had no relapse; although often since exposed to causes, which, heretofore, had always excited violent attacks. Previous to the operation, she seldom passed as many days without severe suffering.

Although I have performed this operation many times, and been present when others have performed it, I have never seen a case, in which its efficacy was so decided, or in which the relief afforded was more unquestionably attributable to the action of the needles.

ANALYTICAL REVIEWS.

ARTICLE VII.--_Researches into the Nature and Treatment of Dropsy in the Brain, Chest, Abdomen, Ovarium, and Skin, in which a more correct and consistent Pathology of these Diseases is attempted to be established, and a new and more successful method of treating them, recommended and explained._ By JOSEPH AYRE, M. D. &. London, 1825.

We have read the present work with the liveliest pleasure, and we dare hope with considerable benefit, and hasten to lay a review of its contents before our readers. Dr. AYRE is already advantageously known in this country, where his Essay on Marasmus has had an extensive circulation; but we are disposed to think, that, however he might be esteemed for the talent he displayed in his former composition, he is entitled to much more credit for his able researches into the nature and treatment of dropsy. We confess that we enter upon our editorial duties on the present occasion, with the two-fold intention of offering to our readers what we regard, on the whole, as a very correct view of the pathology of dropsy, and of showing to some of our medical friends, who shudder at the mere mention of what they denominate _hunch theories_, that the English physicians, or at least some of the most intelligent among them, so far from considering these theories as dangerous and unphilosophical, are beginning to entertain similar views with their Gallic brethren, in respect to the inflammatory nature of many diseases too long regarded as resulting from a state of debility, and classed by nosologists among the Cachexiæ.

By most writers upon the subject, dropsy has too long been considered as a _disease_,--constituted into a separate class, and divided into many species. Dr. AYRE entertains, however, a very different and, we believe, a much more correct view of the pathology of this complaint; regarding it as only one in a series of effects of a disease, and not always the last of that series. He remarks, that the true disease is to be sought for in that particular condition of the solids by which the effusion is produced; and that to appreciate justly the nature and treatment of dropsy, it is necessary to understand the nature of that condition, which constitutes the disease, and of which the serous and watery effusion is merely the result.

Of all the hypotheses that have been advanced to account for the nature of the morbid state, which gives rise to general and local dropsy, there are only three which our author regards as entitled to our notice. According to these, all dropsical accumulations arise either, 1st, From a want of tone or energy in the absorbent vessels, giving rise to a deficient absorption. 2nd, From an increased exhalation of the natural fluid, through a similar want of tone in the exhalents; and 3d, From a mechanical obstruction to the free return of blood by the veins, produced by tumours of various kinds, &c., by which a greater portion of it is forced into the exhalents, and a greater effusion of their proper fluids thereby occasioned. With these hypotheses, however, Dr. AYRE is not satisfied, and he endeavours, in the following manner, to show their insufficiency.

"1st. The opinion of a want of tone in the absorbents, as a
cause of dropsy, is contradicted by the fact, that in those
cases, in which it is assumed to prevail, it is found, that the
adipose matter, or fat of the body, is removed by the
absorbents; or, in other words, that emaciation takes place to
as great an extent, and as rapidly in this, as in other
diseases; and emaciation can only be effected by means of
absorption. Besides, in these cases of dropsy, mercury, when
rubbed upon the surface, or received internally, is absorbed as
readily, and affects the system as early as under other states
of the body. There is also no accumulation of the fluids in the
joints, or in the _bursæ mucosæ_ in these cases, which,
nevertheless would happen, if there was a general debility of
the absorbent system; and _ecchymoses_ or livid spots, though
easily induced in anasarcous limbs, are likewise easily removed
from them by the absorbents.

"2nd. The opinion of a want of tone or energy in the exhalants
involves in it one of the following conditions: namely, either,
1st, that the fluid of dropsy may escape mechanically from
them, and that the fluid thus _mechanically_ separated may be
identified in its sensible and chemical qualities with another
fluid which is confessedly secreted; or 2nd, that if the fluid
of dropsy be secreted, then that an _increase_ in the quantity
of a secretion may continue an indefinite period, under a
_decrease_ in the energy of its secreting vessels; conclusions
to which experience and analogy are alike opposed."

In answer to the third hypothesis, Dr. A. remarks, that such an obstruction as contemplated, has never been shown to exist.

"In the case of the liver, which is commonly considered, when
in a scirrhous or enlarged state, to be the seat of these
mechanical obstructions, and thus, to be the cause of abdominal
dropsy, we have no satisfactory instance yet shown to us, of
any such precise condition of that organ. There are, indeed,
numerous instances of abdominal dropsies, in those labouring
under a scirrhous or enlarged state of the liver; but there are
also, numerous examples of such states of the liver, as well as
of the spleen and other organs, without any such effusion; and
in many cases, when such effusion has taken place, it has been
carried off by the natural passages or by tapping, without any
return of the dropsy; and yet, without any visible change in
the structural condition of the liver."

Dr. A. further remarks, that if the cause were mechanical and existed in the liver, the effect should be constant; which, however, is not the case. Besides, were this mechanical cause necessary, how could we account for the appearance of abdominal dropsy, where there is no disease of the liver, or in other cavities, where no mechanical cause is asserted to be present, and where the remedies by which the cure is effected, have no relation to such causes? Again, if the discharge depended upon a mechanical cause, the water should in every case be of a uniform fluidity, and the progress of its accumulation likewise uniform; so that the operation of tapping should have no tendency to induce a more rapid refilling of the cavity. Yet, the contrary of all this is a subject of daily observation. In addition to this, Dr. A. calls the attention to the fact, that in experiments, in which obstruction has been artificially made, by tying the vena cava for example, the experimenter has committed an error, in reasoning from the lower animal to man--assuming, that as ascites had arisen in dogs, it would in like manner have occurred in human subjects.

"But there was an effect, here overlooked, which was to be
expected to take place in the abdomen of the dog, from the
injury done to the surrounding parts by the operation itself,
and which would be quite independent of any effect arising out
of the experiment. In the human subject, the effect would be
the highest form of inflammation, by which coagulable lymph or
pus would be poured upon the surface of the peritoneum. There
would, therefore, be inflammation excited in the abdomen of the
dog; but as the lower animals are less easily acted on than
man, the inflammation would in this case be in a lower degree.
But every degree of inflammation has its particular product.
The highest occasions a discharge of pus, whilst the lowest,
when seated in a serous membrane, is a larger portion of its
proper serous fluid. This, therefore, might be the product of
the inflammation, which was produced incidentally by the
experiment in the abdomen of the dog; and it would be just as
reasonable to regard the coagulable lymph in the human subject,
which would result from such an experiment, as an effect of the
mechanical obstruction, as to consider the fluid effusion in
the dog to be so."

In respect to those instances of diseases of the liver, connected with ascites, in which, in addition to its other morbid states, a partial occlusion of the vena portæ, by the effusion of coagulable lymph into it, is said to have existed, our author remarks, that they are very few in number, occurring, perhaps, in one out of several hundred cases of ascites with hepatic disease; and that we are justified, from analogy, to assume, that any obstruction given to the circulation by diseased vessels, would be quickly relieved by the enlargement of the anastomosing branches, and that no effusion of water into the abdomen would result from it. After referring to some cases, related by the late Mr. WILSON, in which the vena cava was completely obliterated, and no effusion took place; and some cases of morbid condition of the heart of an analogous kind, by which the course of the circulation became greatly obstructed, and yet, without being followed by effusion; our author concludes, that from these facts and others, to be presently noticed, it appears evident,

"That the dropsical effusion, in whatever part it may be
seated, does not arise from any want of tone in the exhalant or
absorbent system, or from a mechanical obstruction in the liver
or other viscus; but, that it proceeds from a morbid action in
the cellular or serous tissues, and that this action, as we
shall now proceed to show, is allied in its nature to
inflammation."

In support of this opinion, Dr. AYRE remarks, that all the phenomena belonging to cases of watery effusion, met with under one or other of the forms of inflammation, are common to those of dropsy. Thus the fluid, discharged under the cuticle in erysipelas or in inflammation induced by heat or a blister, or in cases of pemphigus, is a secretion, and resembles in all respects the fluid found in dropsy. In some cases of acknowledged inflammation, the fluid effused is found to vary greatly in its degree of tenuity, so as to be sometimes of quite a viscid nature. The same circumstance is met with in dropsy; the fluid of which varies sometimes in different forms of the disease, and at different periods in the same patient. With regard to the absence of pain, in ordinary cases of local or general dropsy, which, in the minds of many physicians, might seem to militate against this view of the subject,--since pain accompanies the inflammation of a blister, Dr. A. very justly says, that the difference is referrible to a different degree of sensibility of the parts affected; that, moreover, in pemphigus there is no pain, and that chronic inflammation of the serous membranes is little painful.

That the morbid action producing the effusion is only a modification of inflammation, our author thinks may be further shown by the fact that it obeys the same laws--being translated occasionally, like it, from one part of the body to another. On this subject, Dr. AYRE makes the very pertinent remark, that in these cases, the fluid alone has been thought to be translated; but that the metastasis, is without doubt, exclusively of the action which produces the serous discharge. Analogous also to what occurs in inflammation, especially of the erysipelatous kind, the action occasioning the effusion, as seen in anasarca, commences at a given point, and gradually extends from thence in a continuous course. It ought also to be noticed, that the results of common inflammation vary according to the intensity of the cause; the lowest degree of it, occasioning an increase in the quantity of the proper fluids of the part,--a higher degree, yielding for its product coagulable lymph, and a still higher one producing pus. All these several products of common inflammation, are more or less remedial of their cause; or in other words, are the immediate means of the cessation or abatement of the inflammation which produces them. This same power is likewise a property, though in a much less degree, of the hydropic effusion, when the inflammation which produces it, is idiopathic; or in other words, not created by a visceral or other disease, or some particular excitement of the general system, as is seen in cases of anasarca.

"And here," continues our author, "it may be proper to remark
upon a common error, committed by those, who, mistaking the
nature of the action which produces the serous effusion, look
in the _post mortem_ examination, for some of the common signs
of an inflammation having existed; and who conclude, upon not
finding such, that the water was derived from some mechanical
or other cause foreign to the true one. But in the higher forms
of abdominal inflammation, the products are pus or lymph, and
these are found upon the surface of the peritoneum, with
sometimes a thickening and discoloration or ulceration of its
substance; whilst in the lowest form of that increased action
to which the serous membranes are subject, the only product is
the serous fluid, and there can be, therefore, no visible
alteration produced by it in the structure of the serous
tissue."

"By the hydropic or serous inflammation, obeying the same laws
which govern the other degrees of common inflammation, it
follows, that upon a higher excitement being superinduced upon
it, the serous effusion should cease. This, therefore, is found
to happen in every case, where such higher excitement is
brought on. This increased inflammation is sometimes occasioned
by design or accident, and at other times, it occurs in the
natural and progressive course of some disease, formed within
the cavity, which is the seat of the dropsical effusion."

This is exemplified in the effects of the operation for the radical cure of hydrocele; or in the operation of tapping in some cases of ovarian dropsy; or even in some instances, of ascites from chronic inflammation of the liver, spleen, mesentery, &c. In all these cases, the serous membrane, which directly or indirectly was affected to a sufficient degree to occasion a serous effusion, takes on, from the extension of a visceral disease, or from some other cause, a higher degree of inflammation--lymph is thrown out, and the cavity becomes obliterated.

"Now from these, and similar examples, which have fallen under
my observations, I think it may be assumed, that ascites, when
proceeding from some visceral disease, (and the principle
applies to hydropic effusions from the pressure of disease in
other cavities,) does so by the gradual extension of the
chronic inflammation of the internal cellular or serous tissues
of the diseased organ, to its outer external coverings; and
that, commencing here as from a point, the serous or hydropic
inflammation is progressively propagated through the whole of
the serous membrane of the cavity. By the disease within the
cellular tissue of the diseased viscous increasing, a
corresponding increase, in these cases, will ensue of the
disease on the surface of the membrane investing it; until at
length a susceptibility to take on a higher action is induced,
which only requires any slight occasional cause to establish.
Under this condition of an increased excitement in the
peritoneal or other serous membrane, coagulable lymph is
discharged into its cellular tissue, and a thickening of it
takes place; until at length the operation of paracentesis,
which in the early stage of the disease was attended with only
inconsiderable inconvenience, becomes an adequate cause of a
still higher inflammation, which terminates perhaps in
suppuration; and, in the _post mortem_ examination the serous
fluid is found so mixed with coagulable lymph, and purulent
matter, as to give a whey or milk-like appearance to the mass.
The quantity of serous fluid, in these cases, is generally
small, when compared with what was accumulated in the
intervals of former tappings; for the vascular excitement
which occasions the discharge of coagulable lymph, is
destructive of that which pours out the serous fluid."

Dr. A. remarks, that, besides the particular facts deduced from observations on dropsy as a local disease, and which prove its relation to diseases of local excitement, there is a further support to be given to these views by various proofs that are afforded from observations upon the urine, of serous inflammation producing local dropsy, being frequently connected with one of a general kind. "So that the inflammatory state of the system becomes sometimes a cause of the effusion into a cavity, and at other times an effect of this state." After giving full credit to Drs. WELLS and BLACKALL for their researches into the state of the urine in dropsy, our author remarks, that there are certain conclusions deducible, which appear not to have been contemplated by those gentlemen, but which are strictly accordant with the pathological views he has endeavoured to establish in the present work.

"According to these facts, it appears, that when the disease of
dropsy is under a sub-acute form, and of the anasarcous kind,
it is usually idiopathic, and, often originating from cold; and
in this state, as well as in the symptomatic form, though in a
less degree, the urine is found to contain a portion of serum.
It is nearly peculiar to this disease, and denotes, according
to the quantity of it contained in the urine, the amount of
that excitement in the cellular tissue, and of the general
vascular system, which may be termed serous inflammation: for
it is met with most considerably in those forms of the disease,
in which these particular states of the body are most
apparent."

Serum is therefore found in greater abundance, when anasarca precedes the local dropsy, which, in Dr. A.'s opinion, denotes the operation of a general cause. This is found to be the case especially in anasarca after scarlet fever. In cases of anasarca, the skin, kidneys, and bowels are very defective in their operation. Serum is also found, though in a smaller quantity, in those cases in which the anasarca has followed the local dropsy; for the disease of the viscus, which is the cause of the inflammation in the serous membrane of the cavity, may produce an adequate degree of the vascular excitement which gives rise to a discharge in the cellular tissue. Our author sums up his observations on this subject, by remarking, that there appear to be four distinct conditions of the system by which the occurrence of serum in the urine is regulated.

"1. It is in the greatest quantity, where along with a copious
and continued effusion, there is a nearly corresponding
quickness in the absorption of the serous fluid, and which will
occur most commonly when the general excitement precedes, and
is cause of the local one.

"2. It is consequently, _cæteris paribus_, in a less quantity
where the general hydropic excitement of the system succeeds,
and is dependent on the local one.

"3. It is absent, or found only in a minute proportion, in all
those cases where the local increased excitement in the serous
membrane is only partially extended to the rest of the system,
and where the absorption from the part is inconsiderable; as
particularly happens in the encysted kinds, or,

"4. Where the effusion of the serous fluid has proved remedial
of the inflammation producing it; in which case the disease, as
it respects the presence of water in a part, may visibly
resemble another example, and yet be essentially different from
it, by the serous inflammation, which produced it in both,
having ceased, on its occurrence, in one of them."

Dr. A. discovers a further evidence of the relation which dropsy bears to diseases of local excitement, in the effects it produces on the general system. Thus, during the continued effusion of serum in anasarca, there is sometimes a large quantity absorbed and carried out of the body; by which a regular draught is made upon the nutrient principles of the blood, which must naturally create effects like those arising from the continued discharge of pus from a suppurating surface. In both cases the local disease, when extensive and of long duration, will necessarily occasion an exhaustion of the vital powers, by which that condition of the system termed cachexy will be induced.

"The exhausted or cachectical state, therefore, of the system,
which has been so variously accounted for, and so frequently
assigned as a principal cause of both local and general dropsy,
is a direct consequence of the agency of some power diminishing
the vital strength at its source; and in the case of a chronic
and long continued serous inflammation, it will proceed from
the daily abduction from the circulation of a portion of its
vital fluid: and whether it be pus or serum that is drawn from
the body; or whether it be from any permanent failure in the
supplies of nutriment to it, the effect will be the same, as if
a certain quantity of blood was daily abstracted from the
system."

Dr. A. continues to remark that, under these circumstances, a suppurating surface will readily become gangrenous, from any cause temporarily exciting it, and that, in like manner, a higher inflammation may sometimes supervene upon an oedematous limb, as in the former case, and terminate in gangrene.

"Hence, therefore, the tendency of dropsical parts to fall into
gangrene, and which has been urged, as an argument, in proof of
debility being the cause of the serous effusion, is only what
is common to other forms of local inflammation, under a similar
condition of the body."

From the view he has adopted of the nature of dropsy, Dr. AYRE thinks that the excitement of the parts, giving rise to the effusion, may be either 1st. Sub-acute or chronic. 2nd. Symptomatic or idiopathic. In other words, that it may arise from a local disease, or from the common causes of inflammation; and that these causes may be either general or particular. 3d. That the serous inflammation may be either local or general, giving rise to a general or local effusion.

After offering so copious an analysis of Dr. AYRE'S sentiments respecting the pathology of dropsy, it is unnecessary to enlarge very fully on the application of his theory to the particular forms of that disease. We shall, however, offer a rapid review, of some of his opinions, and next detail the method of treatment he proposes for the cure of these dangerous maladies. We commence with hydrocephalus, which he remarks has been divided into an acute and chronic form. This division, our author thinks, is correct in a certain sense; for the disease varies much in duration,--running its course, sometimes in a few days; and at other times continuing several weeks. Yet, he continues, the terms acute and chronic must be understood as restricted to that particular form of inflammation producing a serous effusion, and not as denoting the highest and lowest degrees of common inflammation. It is from the want of this distinction that much confusion has arisen in our speculations relative to the pathology of hydrocephalus.

Dr. AYRE calls our attention to the fact, that the forms of hydrocephalus denominated by Dr. GOLIS hyperacute and acute, do not differ from the sub-acute phrenitis of nosologists, in which pus and coagulable lymph are the proper products, with sometimes a serous effusion into the ventricles as an accidental effect; all of which forms of inflammation, the serous membranes of the brain, and of other cavities are liable to take on; and adds:

"Now, the true hydrocephalus internus stands distinguished from
these, in the nature of the inflammation of which it consists,
in the same way, precisely, that the serous inflammation of the
pleura, producing simple hydrothorax, is distinct from that
higher degree of vascular excitement, which occasions an
effusion of pus or lymph. Relatively to these, therefore, the
disease is in a chronic form; and consists, we may repeat, of
that lowest degree of inflammation to which serous membranes
are subject, and the effect of which is to increase the natural
secretion of the part, so as to cause, in regard to the brain,
an accumulation of that fluid in its cavities."

Dropsy of the brain is usually divided into three stages. In the first, continues our author, vascular excitement exists, as denoted by pain in the head increasing in acuteness with the increase of the disease; and in infants by a restless movement of the head upon the pillow, moaning, occasional screamings, sickness, retching, impatience of light and noise, contractions of the pupils, delirious terrors, &c. The second stage is indicated by signs of pressure on the brain by effused fluid, and by an absence of pain, excepting upon raising or moving the head, convulsions, permanent dilatation of the pupils, squinting, blindness, slow intermitting pulse, hemiplegia, and a peculiar placid expression of the countenance, &c. The third stage is made up of some of these symptoms, together with other ulterior ones which follow the vascular reaction. On this subject, Dr. A. offers the following remarks:

"With respect, however, to the division thus formed of this
disease, it is, I think, somewhat questionable, whether it be
pathologically correct; for strictly speaking, the true disease
is comprised between the incipient beginnings of the
inflammation, and its termination by the effusion; since the
symptoms which follow, and compose what are called the second
and third stages, are little more than the consequences of the
disease, and arise from the mechanical pressure of the water
upon the brain. The progress, therefore, of what may be
strictly considered the disease, should perhaps be considered
as terminating with the occurrence of the effusion, which is
often remedial of the excitement causing it; and the whole
disorder, to be thus made up of two distinct states, the first
consisting of symptoms, which commencing with the excitement,
terminate with the serous discharge; whilst the second is
composed of those of a secondary kind, and which are wholly
dependent for their origin and continuance, on a mechanical
pressure from the effused fluid."

Hydrocephalus may occur, either as an idiopathic or symptomatic affection. As the first, it may arise, where there exists a predisposition in the brain, from various injuries inflicted on the head by slight blows;--from all the general causes of inflammation--from the sudden drying up of long established discharges--the sudden repulsion of cutaneous eruptions, or the imperfect evolution of that or other sanative actions of the system, at the close of some febrile diseases, usually denominated defect of crisis. When, on the other hand, the disease is symptomatic, it may arise from a particular cause seated within the head, or in some distant part of the body. The former variety is not common among children, and when it does occur, it is the result of some chronic disease, as a tumour or a thickened state of the arachnoid or other membranes of the brain, resulting from a former inflammation. "Sometimes, adult patients wholly recover from chronic or sub-acute inflammation, which induced the structural disease, and this last becomes, at some future period, the occasional cause of the hydropic one." At other times, the chronic inflammation continues, and finally extends to the serous membrane, giving rise to the effusion.

"The most usual cause of the disease, however, particularly in
children, is an irritation which is sympathetically
communicated to the brain, from a disturbance in the
chylopoietic organs; and particularly from a functional
disorder of the liver. The cerebral disorder, to which a
derangement in the digestive functions thus gives rise, is only
one of those numerous effects which arise out of sympathies,
subsisting between these organs and different parts of the
system. In many cases, the same sympathetic irritation is
successively and variously directed to different parts of the
system. It will thus leave one organ or part, and suddenly move
to another; and through the operation of causes, which are not
always obvious, but which have a relation to some particular
predisposition, inherent or acquired. In this way, an
irritation may occasion an eruption upon the skin, and thence
be translated to the bronchial lining, producing a cough; and
next perhaps, to the serous tissue of the brain, exciting there
a turgescent or congestive state of the cerebral vessels, by
which symptoms are produced, through the pressure of the
congestive vessels, that simulate those of hydrocephalus; or
the true disease is brought on by an arterial re-action,
ensuing upon the congestion, which is resolved by a serous
effusion."

Dr. GOLIS, from observing the marked connexion "between the turgescent state of the brain from chylopoietic disturbance, and its serous inflammation, has concluded, that it essentially pertains to it;" consequently, that "whenever it occurs, it is a part of it;" that it should be considered as forming the first stage of the disease, and that in all instances, it precedes the excitement. He has, for the same reason, constituted all the symptoms of the chylopoietic disease into the first stage of hydrocephalus. Dr. AYRE shows, however, that this state of turgescence, is not essential to the disease, and is only a sympathetic effect, which in the majority of instances, requires no treatment, (at least a very subordinate one,) other than that of the primary affection. He concludes his remarks on hydrocephalus, with the following words.

"The cerebral turgescence and disturbance, therefore, in
whatever degree they may exist, are only, when sympathetically
produced, to be considered as morbid causes, whose presence,
where the predisposition prevails, may lead to a serous
inflammation of the tissues of the brain, but which do not
form, in any sense, parts of the disease itself; since, under
every degree of them, they are so frequently remediable, by
means which are alone available, for the removal of their
distant and sympathetic cause."

Of _Hydrothorax_, Dr. AYRE very justly remarks, that, as its name imports and as defined by Nosologists, it consists of symptoms, which strictly speaking, pertain only remotely to the true disease--arising, as they do, from a certain disturbance given to the lungs, by the pressure of water upon them. They are only the symptoms, therefore, of the effusion, and as the excitement sometimes terminates with the occurrence of the serous discharge, its existence, in many cases, is discoverable only by its effects--there existing no signs, which clearly point out the presence of that state, previous to the appearance of the effusion; and what are usually called, by writers on the subject, premonitory symptoms, being only those of an inferior degree of the effusion which has already commenced.

Like hydrocephalus, hydrothorax may be idiopathic or symptomatic; and proceed from a local or general cause--the nature of the inflammation being the same in both cases. It may likewise be divided into an acute and chronic form. When the disease is symptomatic, and arises from a local cause, it is generally chronic. When it arises secondarily from a disease of the lungs, our author thinks, that

"The mode by which this state is induced in the serous
membranes, is by the chronic inflammation that exists in the
diseased organ extending to them; and not by the same form of
inflammation being set up in them, by a certain sympathy or
consent of parts, which, from a loose analogy, has been thought
to subsist between similar structures."

All diseases of the thoracic organs, are not equally prone to occasion effusion; some of these also, are only dangerous to life, in proportion to their disposition in occasioning such an effusion; whilst in other cases, if it occurs at all, the effusion is only the sequel of a disease essentially fatal.

"To distinguish between these two conditions, is a desideratum
pathology. Modern writers on pathological anatomy have
prosecuted with considerable zeal and ability, their researches
into the nature of the diseases of the organs within the chest,
but they have done but little towards elucidating the true
relation, which subsists between the diseases of the several
viscera, and the serous effusions which take place into their
cavities; for, by limiting their views to the disease which the
_post mortem_ examination exhibited, they have overlooked those
intermediate actions or states of excitement which connect the
organic disease with such effusions."

Whenever the excitement, producing hydrothorax, is idiopathic and independent of an organic disease of the lungs, heart, &c. its remote causes may be either of a general or local kind; and are the same which produce, when applied in a higher degree, or under different states of the system, the other forms of inflammation. The effusion may take place in those cases in which, the individual being predisposed, the inflammation, owing to some peculiarity in the cause, does not reach beyond its lowest grade; or in those in which the inflammation being high, and treated too late, or by insufficient means, a chronic form succeeds to the acute one, which may produce a watery effusion; or some structural disease remains and eventually becomes a cause of the effusion. The occurrence of this effect, in those latter cases, is sometimes attributed to a debility, resulting from the large depletion required in consequence of the severity of the previous inflammation.

"That such opinions, however, are founded in error, may be
shown from this, that the effusion, thus imputed to debility,
does not occur sometimes, until some weeks or months after the
period when the bleeding was employed; and although the
debility is confessedly of a general kind, yet the effusion is
local, and is precisely in the very cavity where the disease
existed, which required the unjustly condemned evacuations. The
truth of the matter is, that in such cases, either the
depletory means have been employed in an insufficient degree,
or too late." "The imperfect recovery of such patients from
their first attack, and, which is attributed to the depletion,
arises from the disease which is left by it, and to the
injudicious means, perhaps, that are employed by the too
anxious attendants, with the view of restoring the strength."

Among the ordinary predisposing and exciting causes of the inflammation which produces hydrothorax, Dr. A. mentions a certain congestive or plethoric state of the circulation, which is brought on in some persons of particular habits, by indulging in the pleasures of the table, and taking little exercise. These cases are analogous to those occurring in the brain, and giving rise, by rupture, to a sanguineous apoplexy, or, by arterial reaction, inducing an effusion of serum.

Dr. A. next proceeds to the subject of _ascites_, the symptoms of which he remarks are at first so obscure, that the disease is sometimes with difficulty detected. The remote causes of ascites may be either symptomatic or idiopathic, and either local or general. When symptomatic, it may be seated in some diseased viscus, as the liver, spleen, or in the mesenteric glands, &c.

"To produce, however, a dropsical effusion into the abdomen
from this cause, it is necessary that the disease of this
viscus should be making progress; for, in its indolent state,
or, in other words, if inflammation be not present in it, it is
incapable from its mere bulk, as is commonly but erroneously
supposed, of producing this effect." "Nor does the serous
discharge always take place into the abdomen, in every case
where these organs are morbidly affected, but only where their
peritoneal covering participates in the disease; for the
chronic inflammation in those cases, where it occasions
ascites, does so by extending from the cellular tissue of the
internal structure of the organ, to the serous tissue investing
in it." "When ascites is an idiopathic affection, it may
proceed from all the common causes of inflammation. The most
frequent cause is cold, and which may act either locally or
generally. When in the latter mode, the ascites is usually
combined with anasarca, and the disorder generally comes on
suddenly, and has a rapid progress. The vascular system is
excited, and there is more than usual thirst; the blood when
drawn exhibits the buffy appearance; and the urine, when
subjected to heat, is found to coagulate strongly, from the
large quantity of serum contained in it. In some of the severer
cases, the effusion into the abdomen takes place very suddenly,
and yet, by a copious bleeding the disease may be at once
arrested, and the water be afterwards absorbed."

Unlike what occurs in hydrothorax and hydrocephalus, the effusion in the present form of dropsy is of inconsiderable importance, compared to the visceral disease which is its remote cause. When, however, the accumulation becomes very considerable, the pressure of the fluid may affect the organs, and more particularly the peritoneal lining, which from the irritation induced in it, may take on a higher grade of inflammation, terminating in effusion of coagulable lymph or pus, and in death. The necessity which arises of tapping, where the effusion is very considerable, proves sometimes a farther cause, perhaps, of aggravating the disease of the affected viscus, and either of renewing or extending the hydropic excitement, or of converting it into a higher or more destructive form of inflammation.

By most writers on dropsy, anasarca has been maintained to originate, in all instances, in debility, and to be curable only by a tonic and invigorating plan. It is true that some writers, especially among the ancients, (for we can hardly class PORTAL among the moderns,) have spoken of the disease as arising occasionally from a plethoric state of the circulation, and enforced the necessity, under these circumstances, of venesection. This view of the pathology of anasarca, although leading in many instances to a successful practice, was, however, vague and often unsatisfactory. To the late Dr. RUSH, and to Dr. PARRY, much credit is certainly due for their labours on this subject; but so far as we are informed, it was not until within a few years, that the subject was cleared of part of the obscurity in which is was involved, and that the disease, at least the active sort, has been referred to an irritation of the cellular tissue. Following up this opinion, and generalizing still more than the French pathologists, our author asserts that anasarca invariably consists in an inflammation of the cellular membrane of the body, with a serous effusion as its result. The accumulation, he continues, may be either idiopathic or symptomatic, and either general or local; occurring only under two forms, the one being of greater intensity that the other. In general, the disease derives all its importance from the nature of the remote cause.

"When it is idiopathic and proceeding from cold, it is usually
unimportant, for though the progress of the swelling be rapid,
and the appearance of the disease formidable, yet it readily
subsides under proper treatment, as the effusion proves in
these cases, either partially or fully corrective of its cause;
and little more, under such circumstances, is required in its
treatment, than to promote the absorption of the water. In some
cases of general anasarca, however, the disease is more severe;
for sometimes the action of the heart and arteries is
increased, the urine becomes loaded with serum, and there is
thirst and other indications of general vascular excitement,
similar to the state which was noticed, as producing effusion
into the brain, or the other cavities of the body."

In some cases, the serous effusion appears to be translated from one part to another. Our author very justly adds, however, that this translation is not of the serous fluid, but only of the serous inflammation giving rise to the effusion. It usually takes place from one portion of the cellular membrane to another; but sometimes from this membrane to the serous tissue of the brain, chest, or abdomen.

Oedema of the feet and ankles is often symptomatic of chylopoietic disturbance, and particularly in young women, in whom the menstrual function is obstructed. In these cases, as well as in the oedema following gout or rheumatism, the swelling usually commences with considerable pain and stiffness of the parts, and hardness of the swelling.

"But the most common form of anasarca is that which is
symptomatic of some visceral disease; and which, as it
ordinarily appears, arises from a state of the system that
answers to the hydropic diathesis of systematic authors."

This form of the disease begins in the lower extremities, and is rarely attended with strong signs of local excitement so obvious in anasarca of the idiopathic kind. Its occurrence has been referred to various causes. When combined with ascites, it is supposed to arise from pressure of the iliac veins by the fluid accumulated in the abdomen,--an opinion which our author combats by repeating, in great measure, the arguments we have already noticed.

"But here let me observe, that the denial of ascites producing
an anasarcous state of the legs, from the water compressing the
iliac veins, must not be understood as implying, that a
mechanical compression of a vein will not in other cases
produce an effect of this kind. A pressure made on the brachial
vein and its branches by scirrhous glands in the axilla, is a
common cause of this state. The remote cause is here, indeed,
of a mechanical kind, but not so the proximate cause of the
effusion. By the resistance given, in this case, to the blood's
return by the principal veins of the limb, a reaction is
occasioned in the extremities of the arteries leading into the
corresponding extreme branches of the veins, and which reaction
is in this, as in a multitude of other occasions of congestive
fulness in these vessels, a sanative effort of nature to
overcome the primary obstruction."

The disease has often been referred, when occurring under these circumstances, to a local and general debility; and this opinion is thought to be supported by the facts that the swelling is increased by a depending position of the limb, and diminished by a horizontal one--by the occurrence of an inflammatory state of the parts being incompatible with such a degree of debility, and lastly by the absence of preternatural heat on the surface of an oedematous part. To these pretended arguments, Dr. A. opposes, that the effusion cannot be attributed purely to debility; because the effects are in no correspondence with the assigned cause,--the debility being, in some instances of chronic and acute disease, very considerable, and the effusion small, and vice versa;--because anasarcous limbs will occur in the strongest individuals when the limbs have remained a long time in an erect posture,--because there is in certain fatal chronic diseases, a tendency in the lower limbs to take on an inflammatory action, often of an erysipelatous kind,--and because the fact of oedema increasing by an erect posture and diminishing in the horizontal one is readily explained by the greater congestion of the vessels induced in the limb by such a position, as it occurs in the higher grades of inflammation.

"And with respect to the temperature of the surface of
oedematous parts not being preternaturally raised, the
objection, if of any force, must apply to all, for all have
this peculiarity, and yet some cases of oedema confessedly
arise from inflammation; differing not, in this respect, from
several other morbid states, as those for instance, of chronic
rheumatism, and which are indubitably, as indicated by the
nature of their causes and remedies, of a truly inflammatory
kind."

Dr. AYRE, therefore, regards all these cases as secondary to a serous inflammation seated in a cavity; and lastly as arising from some disturbance in the digestive functions, by which this and other distant irritations are produced through the operation of that law of the animal economy, denominated sympathy.

Having thus offered, in the preceding pages, an analysis of Dr. AYRE'S views of the pathology of the principal forms of dropsy, we must be allowed, before proceeding to the treatment of the disease, to make a few remarks. It appears to us that Dr. A. has treated the subject in a very able manner, and contributed greatly to remove many objections, that could be adduced against the opinion of the inflammatory nature of some of the more obscure cases of dropsy. We cannot help thinking, however, that he is too exclusive in his theories, and that he has rejected too positively the idea of a passive dropsy; in other words, of a dropsy independent of inflammation. Some cases of the disease which follow extensive losses of blood, (profuse uterine hemorrhages, for example) and which are cured by tonics and an invigorating diet, without the aid of diuretics, cannot always, though they may sometimes, be accounted for by admitting the existence of inflammation. Such instances have fallen under our own observations, and could not be explained by supposing that the effusion had relieved the inflammation; since there had not existed, at least as far as we could ascertain, any local inflammation. In one case it followed abortion, attended with profuse hemorrhage, and produced, not by disease, but by an accident.