Chapter M: BERTHE then remarks, that the greater number of instances of gangrene (5)

In the second and fifth volumes of the _Archives Générales de Médecine_, Dr. BOUILLAUD has related many cases of partial and general dropsy, which undoubtedly originated in obstruction to the venous circulation, from adhesion of the parietes of the principal veins. It is true that Dr. A. is compelled to admit this among the causes of dropsy; but faithful to his theory, he supposed the supervention of an arterial reaction resulting in an effusion of serum. It does not appear to us, however, that this arterial reaction is admissible in all cases of the sort, and we prefer on the whole the explanation of the mechanism of the effusion, originally given, by DONALD MONRO, and lately by Drs. BOUILLAUD and BROUSSAIS, who refer it to an obstruction in the venous circulation and to a consequent deficient venous absorption. By admitting this explanation, it is readily perceived, that we admit a passive dropsy, and we think the view well exemplified by a case which occurred last summer. The individual had recently recovered from a violent attack of disease, and was left much debilitated. Induced by this circumstance to travel to the north, he had occasion to notice that when seated long in a stage with his feet depending on the veins compressed, oedema invariably came on, and that it as invariably went off the next day if he did not ride. This occurred so often as to lead us to think there could not always be an arterial reaction occasioning the effusion, and that this effect arose from the mere obstruction to the venous circulation.

In making these remarks we are not actuated by the desire of detracting from the merits of Dr. A.'s views of the pathology of dropsy; convinced as we are, that the great majority of cases of the disease, which are thought by many physicians to arise from debility, do not owe their origin to this condition of the system, but to an increased excitement of the membranes or cellular tissue. Were it otherwise, how could we account for the fact, that dropsy is generally _local_, whilst the _debility_ to which it is in most instances referred, is general?

But whilst maintaining the correctness of many of Dr. A.'s views, we are inclined to the opinion, that he may do some injury to the doctrine he is advocating, by invariably making use of the word _inflammation_, to express that condition of the vessels, giving rise to an excessive secretion of serous fluid. We are ready to admit, and we dare hope, that few will refuse to do so, that _inflammation_, strictly speaking, will occasion such an effect; yet, it often happens, that effusion will occur in cases, where no inflammation can be detected. In such instances, the vessels are evidently in a state of increased excitement; or in other words, in a state of irritation, but not of inflammation, which always implies congestion. This latter morbid condition, may supervene on the irritation, and occasion a suppression of the serous effusion, and the formation of coagulable lymph or pus. It is true, it may be said, that both these states (irritation and inflammation) being an increase of the life of the part, and requiring the same treatment, may be designated by the same name. Nevertheless, to prevent confusion, and the quibbling of some of the opponents of the theory of inflammation in dropsy, we are inclined to believe, that it is better to substitute the word irritation, whenever there is merely an increased secretion, and reserve the word inflammation, to designate those cases, in which there are decided marks of local excitement and congestion, attended or not with general fever.

Dr. AYRE, adopting the opinion of Dr. PARRY, regards some cases of local dropsy as an effect of a general hydropic diathesis, or of a general inflammatory action of the vascular system, occasioning a local excitement, ending in dropsy. This is a natural consequence of the views, entertained by many physicians in Europe and this country, that fever produces local inflammation. We must confess, however, that all Dr. A. has said on the subject, is not calculated to carry conviction to our minds. Thus, one of his reasons for regarding some cases, as arising from this general vascular excitement is, that they are produced by what he considers as a general cause,--as cold, for example. But cold produces local diseases, occasioning, and not preceded by, a febrile excitement; and if it can, and does occasion anasarca, who will pretend to assert, from its being a _general_ cause, that this anasarca is a general disease? Does not cold occasion also ascites, which, in many cases, is regarded by every one as a local disease, sometimes terminating in anasarca? If so, why shall we regard anasarca, ending in ascites, as a general disease? The cases are analogous, and the action in both should not be explained differently. If the action of such a cause were really general, and extended to all parts of the body, then the effects should also be general, and the dropsy should be universal, which is very far from being always the case.

2nd. It is also said in support of this opinion, that where anasarca is idiopathic, it is attended with fever, but that this latter does not exist, when the disease follows ascites. This difference appears to us to be very readily explained by the fact, that the disease in the former case, is more acute, and that the heart sympathises more actively with the irritated cellular tissue, than in the second case, when the disease is milder, or more gradual in its progress.

3d. It is also maintained, that when anasarca is idiopathic, there exists a large quantity of serum in the urine; and this is brought forward in order to distinguish these cases from local dropsies. But it is also admitted, that serum is found in the urine in cases of anasarca following ascites. Consequently, if there be none in cases of simple ascites, and if it only appears when anasarca supervenes, the only conclusion that may be drawn from these facts, is, that anasarca is the only form of dropsy, in which serum is absorbed, and passed off by the kidneys; and if there be a greater quantity discharged when anasarca is primary, it is only because the disease is more violent, and generally more extensive. But, surely all this is far from proving, that primary anasarca is a general disease, and owes its origin to a primary arterial excitement of the whole system. When fever exists first, and terminates in dropsy, who has proved, that there existed no local irritation producing the fever, and that the hydropic irritation has not supervened by metastasis. This takes place in scarlatina and other eruptive diseases, which Dr. A. would surely not be justified in calling general diseases. Dropsy follows the suppression of cutaneous diseases, unattended with fever; consequently, when there happens to be a febrile excitement, we are at a loss to know, why we should call this latter to our aid, in our explanation of the dropsical effusion, and not account for it on the same principle, as we did in the former cases; namely, by metastasis. If febrile symptoms are sufficient to make us regard a disease as general, then there is no local disease, except when apyretic.

We now proceed to notice the mode of treatment, recommended by our author, for the different forms of dropsy. From what we have seen, it is natural to conclude, that as Dr. AYRE regards the proximate cause of the several forms of the effusion, or in other words, the _disease_, to be the same under all its conditions, he will be of opinion, that "the same general principles of treatment, are alike applicable to all--subject only to such modifications, as arise from differences in the nature and intensity of the remote cause, and those general or local relations of the parts implicated in the serous effusion, with the diseases of the organs, which incidentally produce it." Founding upon these views the indications of cure, he states them to be; 1st. To remove the visceral, or such other disease or state, which, when present, proves a remote cause of the effusion; 2nd. To remove the morbidly increased action in the serous membrane or tissue, which is its proximate cause. 3d. To promote the absorption of the effused fluid.

Agreeably to Dr. A. the treatment of hydrocephalus internus, is divisible into three general heads:

"The first, consisting of means to correct, with its causes,
that turgescent state of the brain, which may produce the
arterial re-action and effusion; the second, of those which
shall subdue the excitement, when formed; the third, to correct
or relieve, as far as it is practicable, the effects of the
effusion, and procure, if possible, its absorption."

With respect to the general causes, tending to produce that congestive state of the brain, precursory to its inflammation, he remarks, that they are of three kinds; 1st. Those acting through the general system, and consisting of an irritation, from some obstructed or required evacuation; 2nd. A local disease, seated in the head, or a local injury inflicted on it; 3d. Chylopoietic disturbance, acting sympathetically upon the brain. When the first of these causes appears to have been instrumental, in occasioning this condition of the brain, it is plain that it must be removed, and the obstructed emunctory corrected,--the suppressed evacuation promoted, or a new and artificial one substituted. When there exists any structural disease within the head, or a relic of a former state of excitement, a serous inflammation may be reasonably apprehended, and to avert it, the most rigid and undeviating attention must be paid to regimen, whilst cupping and leeching must be employed, and a seton fixed in the neck.

"For the object of the treatment, in these cases, is not to
remove, but to avert the inflammation, and which, from the
strong disposition to it, conferred by the organic disease, can
only be effected by avoiding, not merely the causes of
inflammation, but likewise, all those agents, which are
calculated, in any way, to increase the momentum of the
circulation." "Beyond those, the common precautions against
morbid irritations, little else can be done."

When the turgescent state of the brain, arises from a disturbance in the digestive organs, it will be remedied, by means directed to this cause. Our author locates the primary seat of this disturbance, in most cases, in the liver; though he admits, it may occasionally be in the stomach and intestines. He places great reliance for correcting and increasing the secretion of bile, on small doses of calomel,--purging off the contents of the intestines by aperient medicines; and recommends, at the same time, the application of cups and leeches to the temples, as a measure of precaution. He very properly lays considerable stress on the necessity of combating this secondary affection of the head;

"For though the means applied, to correct the disorder in the
digestive organs, may be sufficient to remove the turgescent
state of the brain, which arose from it, yet, those means will
have little or no control over the excitement, which that
turgescent state has created; and still less can they avail in
subduing an excitement, that may even survive its remote cause,
and continue independently of it. By overlooking these facts,
much distrust and disappointment have arisen with many, who
confided in the opinion, delivered by some writers, of the
uniform prevalency of chylopoietic disturbance, as a cause of
this disease, and of the sufficiency of calomel to remove it."

When the inflammation exists, and is a sequel of some pre-existing structural disease in the brain or membranes, all that can be reasonably expected, is to _palliate_ it by the antiphlogistic plan; but when it is idiopathic it may readily be cured, by the same remedies, graduated to the age and strength of the patient and to the violence of the attack. Dr. A. seems to rely principally on cups and leeches;--not excluding, in some cases, bleeding from the arm. Blisters to the summit of the head and afterwards a cold evaporating lotion to the temples, are also recommended. As soon as, by these means, an impression is made on the disease, mild diaphoretic medicines, assisted by the tepid bath, or the pediluvium, maybe prescribed;--the bowels are to be kept open by small doses of calomel, followed after two hours by a draught of some aperient medicine,--the antiphlogistic regimen should be rigidly enforced, and light and noise carefully excluded.

"Many practitioners give the mild preparations of mercury, and
particularly calomel, freely in this disease, under a notion of
its having some specific power in subduing it; but it never
should be so used, excepting in cases where the disease is
symptomatic of some functional disturbance in the liver and
other chylopoietic organs, where it is calculated, in
conjunction with the local bleeding, &c. to afford the most
important service."

With a view of pointing out some characteristic sign, by which to distinguish those cases in which the affection of the bowels is primary from those in which it is secondary, he remarks--

"The condition of the stools at the period when a child is
labouring under the disease, will afford to such persons but an
imperfect notion of its true nature; for the disturbance of the
brain will often create a disorder in the secretions, both of
the liver and the other chylopoietic organs, producing green
looking stools; and there is often a congestive state of the
brain for a short time preceding the full development of the
idiopathic excitement, which may, in like manner, by reacting
upon the liver, create a disorder there. In cases, however,
which are symptomatic of this cause, the chylopoietic
disturbance will be found to have existed several days or even
weeks; and the origin of the disorder, in like manner, may be
commonly traced to some irregularity of diet, or other obvious
causes, and frequently in infants to those which are connected
with premature weaning; and sometimes even the cerebral
disorder itself will have been only the last of a series of
effects in the system, to which such disturbance had given
rise."

Agreeably to Dr. A., it is not proper to discontinue those means, immediately upon the occurrence of what appears to be symptoms of effusion, since, frequently, these symptoms, as it respects the effusion, will immediately manifest their fictitious character, and disappear under a treatment no wise adapted to such a state, and with a rapidity, too, which equally betrays their true nature. He notices, though we believe not in its proper place, a modification of the disease in which the effusion takes place in the cellular membrane of the substance of the brain, and thinks this species more likely to be recovered from than when the water accumulates in the ventricles. He concludes this section by remarking, that

"Of the means to be employed to promote the absorption of the
water, under these or other circumstances of its accumulation
in the brain, little satisfactory can be said. The treatment
must be founded on the use of such means as shall avert the
risk of renewing an inflammation in the organ. To this end,
occasional blistering the head will be proper; the diet must be
spare, and the several secretions, particularly those of the
kidneys, must be cautiously promoted."

We next turn to the treatment of hydrothorax and ascites. As the existence of hydrothorax in its early stage is difficult to ascertain, and as what have been called premonitory symptoms are only those proper to the mildest forms of the disease, and not of that condition of the parts which gives rise to the effusion, the treatment is somewhat difficult, and, in too many instances, our remedies are directed, not to the disease itself, but to one of its effects. Faithful to his view of the pathology of dropsy, Dr. A. remarks, that the plan of treatment to be pursued at an early stage of symptomatic hydrothorax, must consist in the use of those means which shall subdue the chronic excitement of the serous membrane, as well as the chronic inflammation of the diseased organ. To attain this end, the antiphlogistic and revulsive plans, graduated to the age and strength of the patient, and to the violence of the disease are recommended. In general the frequent application of leeches are held by Dr. A. as preferable to venesection, unless the patient be plethoric, and the disease arise from a local congestion within the chest, which, according to him, is often a cause of serous inflammation of the thoracic tissue, independently of any previous disease. Dr. AYRE calls attention to the fact, that topical bleeding is particularly adapted to correct that chronic inflammation of the serous membranes, which causes an effusion from them, and which is neither the result of any inflammatory excitement of the general system, nor of a nature to produce it; and that when properly conducted, it has the advantage of acting only slightly on the general system, and therefore only slightly on the general strength, and very considerably on the local disease. Together with leeches, blisters are to be used, and after the chronic action existing in the serous membrane is subdued by these means, a seton fixed in the integuments of the chest will be found of great utility.

The same treatment will be found equally serviceable, not only to correct the chronic excitement existing in the peritoneal membrane and giving rise to ascites, but very commonly to cure or palliate the visceral disease producing it. In respect to the very common practice of resorting to mercury in this complaint, our author makes the following judicious remarks.

"With too many practitioners, it is the practice to employ
mercury freely in every case of abdominal dropsy, under the
vague notion of there existing some mechanical obstruction in
the liver or other viscus, as a cause of it; and under the
equally vague notion, that mercury so employed will remove it.
The practice, however, to speak of it in the mildest terms, is
founded on erroneous views of the pathology of these diseases;
and employed, therefore, as it is by some, on all the occasions
in which they meet with them, must be frequently very
injurious. For, independently of the injury to be inflicted by
it, when given freely in some of the forms of liver disease,
there is an effect produced by it on the urine, when given to a
person in health, resembling that which arises from the
specific excitement of dropsy. Under a salivation, the urine
becomes charged with serum. Any condition of the system,
therefore, approaching even to a state of salivation, must be
injurious, by the tendency it must have to increase that morbid
state of the body, which is nearest allied to the hydropic one.
Hence the mercurial salivation has been numbered amongst the
remote causes of dropsy; and the resemblance between the
dropsical and mercurial excitement, thus established by the
common resemblance of the urine in these states, goes far to
prove this connexion; and it is not improbable, that the
mercurial inflammation, when considerable, may survive its
specific cause, and degenerate at length into the purely
hydropic state. When, however, mercury is given in minute
doses, so that these its specific morbid effects are not
produced, it is capable of becoming highly useful, as we shall
presently have occasion to notice."

In conjunction with bleeding and other means just noticed, drastic purges have an important influence in subduing the disease; not merely by removing the water, but likewise by contributing to subdue the chronic excitement which occasions its effusion. This latter effect Dr. A. very justly refers to the counteraction and irritation these medicines excite on the mucous membrane of the bowels, by which the excitement of the serous tissue or of the diseased viscus is removed. He remarks that drastic purgatives are sometimes inadmissible in ascites, when an affection of the liver or mesentery is its remote cause, and there is a tendency to a spontaneous diarrhoea, which even the mildest purgatives would increase. "In the case of the mesentery, such a mode of treating dropsy would speedily destroy the patient." Dr. A. ought, perhaps, to have explained the real cause of the danger attending the practice, and not referred it merely to the tendency to diarrhoea, which itself can only be an effect of a morbid condition of the bowels. The fact is, that most cases of hepatitis, and all cases of mesenteric disease, are attended, whether as cause or effect we care not, with inflammation of the stomach or bowels, which purgatives can only tend to aggravate. In general, the practice of administering drastic purgatives is more serviceable in hydrothorax, and especially in anasarca, or in _idiopathic_ serous inflammation of the peritoneum. Dr. A. prefers the gamboge to all other medicines of the same class, and gives it to the amount of four or five grains in a single dose, with the same quantity of some aromatic powder, and triturated with a few crystals of the supertartrate of potassa; or in urgent cases of hydrothorax, he prescribes ten or twelve grains, divided into four doses, one of which is to be given every three hours. When the strength admits of it, the purgative may be given every four or five days.

Dr. A. next notices diuretics.

"The sensible operation of these medicines," he says, "as is
well known, is to promote the secretion of the kidneys. There
appears to me, however, to be farther effects produced by them
upon the system, or particular parts of the system, which is
not referrible to the mere evacuation of a certain quantity of
fluid from the body; and these effects, it is probable, consist
in promoting the natural discharges by this and, perhaps, the
other emunctories, whose partial suppression may either produce
this disease, or serve materially to continue it; and likewise
in occasioning a derivation of blood to the kidneys, and
therefore to a part distant from the morbid one; and that thus,
whilst they are contributing materially to the removal of the
fluid, they are serving like the purgative, an important end,
in assisting to subdue the cause of it. The medicines which I
am accustomed almost entirely to rely on in this disease, are
the powder of dried squill and digitalis, given in combination
in the form of pills, and in doses, which, from their
smallness, will probably excite no little surprise in the minds
of some of my readers. The dose of the squill is something less
than a grain, and of the digitalis only a sixth part of a
grain, given uninterruptedly every third or fourth hour."

To render these medicines more effectual, a third or half a grain of calomel may be given nightly, and an infusion of dandelion, or some other popular diuretic, may be taken _ad libitum_. Our author speaks in terms of merited disapprobation of the practice pursued by some physicians, of allowing their patients daily, potions of gin punch, with the view of aiding the operation of the diuretic medicine, and supporting their strength. He shows, that, although by these means the water may be promptly evacuated, the disease is not cured, and the effusion is soon renewed with redoubled violence and danger to the patient.

In the idiopathic form of hydropic inflammation, attacking the serous membranes of the chest and abdomen, and which, agreeably to our author, may be strictly local, or consist in a general specific excitement of the system, leading to a general watery effusion, the lancet is particularly advantageous, and should be had recourse to. The pulse is generally hard, the blood exhibits a buffy appearance, and the urine coagulates when subjected to heat. Leeches, in pretty large numbers, must also be used, as well as all the remedies already enumerated. But as in these cases, which according to Dr. AYRE are more common among females than males, and among the younger than those of middle and advanced age, the disease is of a more acute nature, a greater reliance is to be placed on an active antiphlogistic plan; and if this be steadfastly persevered in, comparatively little difficulty will be experienced in effecting a discharge of the water.

When hydrothorax occurs after scarlatina, and is combined with anasarca, its course is generally rapid, and the cure difficult; partaking, as it often does, of the two-fold state of debility and excitement. When detected early, the lancet must be promptly used. Cups and leaches, followed by the warm bath, blisters, and cathartics, must also be resorted to.

"Diuretics, which are so beneficial in the less acute forms of
dropsy, are commonly too inert and slow in this, unless given
in doses to act immediately upon the vascular system, when the
infusion of digitalis, as given by many practitioners in all
the other states of the disease, may be resorted to; since the
treatment here is not so much to remove the water, as to
prevent, if possible, its farther effusion; for when a
discharge suddenly takes place into the chest after scarlet
fever, it will generally prove fatal, even though the quantity
collected be inconsiderable, and only such as would occasion,
if gradually effused, a moderate degree of inconvenience to the
lungs."

In respect to tapping, our author remarks, that the circumstances calling for this operation are, where, from the very considerable accumulation of water, and the consequent distension it occasions, a permanent and morbid stimulus is given to the peritoneal membrane, by which its serous inflammation is perpetuated or increased; or where so much pain and irritation are produced, as to risk inducing a similar disease in the chest, and of bringing on likewise an ulcerative form of inflammation in the peritoneal lining of the abdomen.

"Whilst the objections to its employment consist in the danger
which is incurred, where there is much visceral disease, of its
causing a destructive form of inflammation in the peritoneum;
and the probability of its occasioning, under the most
favourable condition of the disease, a more rapid renewal of
the serous accumulation."

Our limits not allowing us to enter on the treatment of ovarian dropsy, we proceed to offer a few remarks on the means recommended by Dr. A. for the cure of anasarca. As in the treatment of every other form of dropsy, it is necessary, in attempting the cure of anasarca, to advert to the nature and causes of the disease.

"If it be idiopathic, and unconnected with any dropsy of a
circumscribed cavity, and the pulse at the same time be soft,
and the urine free from serum, it may be treated solely with
the view of procuring the absorption of the effused fluid, as
in such cases, the watery discharge in all probability will
have removed, in a considerable degree, the excitement which
caused it."

It is in such cases that recoveries take place under almost any plan of treatment, and that bark and other tonics have been found beneficial. Their utility, however, in these cases is very limited, consisting only in aiding the removal of the effects of the disease, and keeping up the strength of the system, whilst the absorbents perform their function, and remove the fluid. Dr. A. recommends, in these cases, puncturing and bandages; but he very justly adds, that they must not be employed, whenever there remains any inflammation in the parts, as they would then tend to aggravate it.

"To oedematous swellings, in which the serous local
inflammation, whether symptomatic or idiopathic, still
subsists, I am accustomed to direct the application of leeches
and cold evaporating lotions, observing not to commence the use
of the latter, until twelve hours after the leeches have been
used, that inflammation may not be produced in the wound."
"When anasarca arises from a general excited state of the
system, as denoted by the pulse, and by the serous quality of
the urine, venesection becomes necessary, combined with the use
of leeches, applied to the extremities, or to those parts of
the body, in which the serous tissues are most affected, along
with the active use of the general means already alluded to."

In anasarca, an error is sometimes committed, especially by young practitioners, of estimating the degree of danger, and the necessity for active treatment, by the single consideration of the extent of the oedematous swelling. This, however, should be guarded against, as the swelling may be very considerable, and the disease subsided, or of little consequence; whilst, in other instances, the reverse may be the case. In the first instance, where the disease is not seen early, the treatment must sometimes be limited to those means which promote the absorption of the water, and neither venesection nor leeches will be required. In such cases, the practitioner must be guided by the state of the pulse and urine; the presence or absence of vascular excitement; the history given of the case up to the period when visited, and particularly by the progress of the swelling.

"When the dropsy of the skin is considerable and long
protracted, and symptomatic of some visceral disease, as it
most commonly is in these cases, and is attended by a serous
state of the urine, and a general failure of the strength, the
cachetical state of the system may be considered as
established, and the treatment is then beset with difficulties.
For the general means, which are useful in the earlier states
of the disease, and when the vital strength is entire, become
injurious in this, by the tendency they have, aided by the
effects of the visceral disease, to diminish farther the vigour
of the system; whilst, at the same time, the treatment, which
is suited to support the declining strength, can contribute
nothing towards lessening the constitutional and local
diseases, but will frequently increase the morbidly excited
state of the circulation, which, analogous to what occurs in
diabetes, will continue and increase under the most decided
marks of general constitutional weakness. Pending the
continuance of that inflammatory state of the system, in which
the urine is charged with serum, the debility will be mainly
derived from that drain of its nutrient parts, which is thus
established in the body, assisted by the weakening effects of
the organic disease. If blood be drawn, it will be found, in
many of these cases, to exhibit the usual signs of
inflammation; and the treatment of the tonic kind, when
employed to support the strength, will be found to act
unfavourably.

"The plan to be pursued must consist in the use of such means
as shall assist the powers of digestion and assimilation; so
that, by a highly nourishing but plain diet, the drain from the
system may be somewhat counteracted; and, at the same time, the
cause of the effusion is to be corrected by the use of local
depletion and blistering, and by the temperate employment of
those general means, which are useful in the less aggravated
forms of the disease."

The diet of patients, in the symptomatic forms of dropsy, should be plain and unirritating; and in the idiopathic states, the antiphlogistic regimen should be rigidly enforced; particularly an abstinence from all fermented liquors, until the inflammatory period of the disease be removed. The clothing should be moderately warm, and selected of that kind, best suited to promote the insensible perspiration of the surface.

Before taking leave of Dr. AYRE, we cannot omit adverting, in a very few words, to a circumstance noticed in his preface, and which we think of some importance. He remarks, that if, in the prosecution of his task, he has had no acknowledgments to make to any individual as his guide and authority, he is nevertheless indebted for many important facts to the writings of the late Dr. WELLS, and of Drs. BLACKALL, ABERCROMBIE, and DUNCAN, jun. and particularly to the system of pathology of Dr. PARRY. He further remarks, that he entertained and taught for many years, the views advocated in this work, and that, after the manuscript had been sent to press, he had seen a copy of an abridged edition of the elaborate Dictionnaire des Sciences Medicales, in which the doctrine of dropsy, maintained in the larger work, is relinquished; whilst others are given in their place, conformable, in the main, with those which it is the object of his treatise to establish. Now it would appear, from these expressions, that Dr. AYRE wishes to inculcate the idea, that the English writers, whom he has cited, were the only ones who had published anything valuable, and conformable to his doctrine; and that prior to 1823, the year of the publication of the Dictionary above mentioned, the French entertained very different views of the pathology of the disease. We think it our duty, however, to rectify our author in this respect, and to show to our readers, that, even allowing full credit to Drs. WELLS, BLACKALL, ABERCROMBIE, &c. for their researches into the nature and treatment of dropsy, the American, French, and Italian pathologists are entitled to a much larger share than is allowed to them in the present work. A few references will be sufficient. Many years ago, our celebrated RUSH taught, that general dropsies "depend on a certain morbid excitement of the arteries;" and that hydrocephalus, "in its first stage, is the effect of causes, which produce a less degree of that morbid action in the brain which constitutes phrenitis." In 1812, Dr. BRESCHET, of Paris, published an excellent dissertation on active dropsies. In the early writings of BROUSSAIS, though more particularly in the propositions prefixed to his _Examen_, the opinion is maintained, that all active dropsies depend on irritability, either primary or secondary, of the serous and cellular tissues,--a theory more closely allied to Dr. A.'s, than all that is contained in the writings of Drs. WELLS, PARRY, &c. But what, perhaps, is more to our purpose, Dr. GEROMINI, of Cremona, published a work, in 1816, on the origin and cure of dropsy, in which he compares the dropsical accumulation to that of serum produced by the inflammation of a blister, or by fire; and in which he also maintains, that a slight inflammation occasions a flow of limpid serous fluid, whilst a higher degree gives rise to the formation of pus. From these circumstances, he concludes, that the hydropic fluid, which contains little albumen, is the product of a lower grade of inflammation. In the same work, he finally asserts, that in more than 200 individuals who had died of dropsy, he invariably found marks of inflammation or its effects; views which our readers will readily discover to be nearly allied to those supported by Dr. A. In making these remarks, however, we do not wish to be understood as asserting, that the theory advanced by our author did not originate also with him. We have too favourable an opinion of his honesty, to accuse him of plagiarism. Our sole intention has been to render unto each the degree of praise to which he is entitled, and, by pointing out this coincidence of opinion, to derive a further proof of the correctness of most of the pathological views, so ably defended in the present work.

ARTICLE VIII.--_An Essay on Venereal Diseases, and the Uses and Abuses of Mercury in their Treatment._ By RICHARD CARMICHAEL, M.R.I.A. _With Practical Notes, &c._ by G. EMERSON, M. D. Philadelphia, J. Harding, 1825; pp. 360.

One of the most important improvements in practice, which modern experience has established, is the reformed method of treating venereal diseases.

To the labours of several distinguished military physicians and surgeons of Great Britain, we are chiefly indebted for the facts and researches connected with this interesting subject. And although we may have much to learn in regard to the true nature of these complaints; yet the plan adopted by Mr. CARMICHAEL, of determining their distinct pathological characteristics, and applying the remedies accordingly, is the only one likely to subvert the empirical routine of prescribing mercury on all occasions, a practice which derives such strong support both from the indolence and prejudices of the profession.

In this country, many eminent practitioners have contributed to restrain the abuse of mercury; and it is believed, that Professor CHAPMAN has for many years, in his lectures, disseminated the most enlightened doctrines on this point. Dr. HARRIS and other surgeons of the navy have made a fair trial of the non-mercurial treatment, and with the most satisfactory results.

The great object, so desirable of attainment, is to form a correct discrimination between the diseases, which may be cured or benefited by the exhibition of mercury, and those which do not require this medicine, or become aggravated by its use; for it seldom fails to do injury, when its advantages are not very obvious.

Mr. CARMICHAEL has taken the most conspicuous part in this investigation for the last fifteen years, and from the extensive theatre, in which his inquiries were conducted, has had the best opportunities of arriving at the truth. He, therefore, who undertakes the management of these affections, may be justly pronounced culpable, if he neglect to make himself acquainted with the experience of this eminent surgeon.

In this enlarged and improved edition of his work, several subjects have not been treated of so copiously by the author, as was requisite to render it acceptable as a book of reference; but the judicious notes of Dr. EMERSON, whose attention has been profitably directed to the investigation of venereal diseases, have well supplied the deficiency.

A brief outline is here presented of the contents.

The author describes the various symptoms in plain and intelligible terms; rejecting such unmeaning appellations as syphiloidal, pseudo-syphilis, &c. as designating no particular phenomena, and therefore of no use in describing a disease.

He thinks there is a plurality of venereal poisons, and has divided the disease into four classes, from their different primary and secondary symptoms; making the eruptions on the skin the most certain criterion of distinguishing them from each other. These classes are:--the papular venereal disease; the pustular; The phagedenic; and the scaly venereal disease. The latter is the true syphilis.

First, the Papular. This is the most common disease, and the most easily cured. Its primary symptoms are, a simple ulcer without induration, without elevated edges, and without phagedena. Sometimes there is a patchy excoriation of the glans penis, attended with a purulent discharge. This disease and gonorrhoea are caused by the same poison. The constitutional symptoms are:--fever; pain in the head, shoulders, and larger joints, pain in the chest; dyspnoea; a papular eruption on the forehead, chest, and back, sometimes extending in a more scattered way over the extremities. It is often attended with iritis. It never gives rise to nodes. The sore throat is different from that of syphilis; the latter having deep excavated ulcers. If buboes accompany it, they are mostly of an indolent nature. The eruptions do not all appear at once; but follow each other. When on the decline, they are of a pale red or copper colour, not scaly, as in syphilis, but papular; disappearing and recurring repeatedly, and ending in desquamation.

_Remedies._--Venesection; cathartics; antiphlogistic regimen; antimonials, combined with decoction of sarsaparilla. Alterative does of calomel and antimonials, when the eruption declines.

The local treatment consists in astringent washes and simple dressings.

Iritis is to be cured by venesection, cathartics, mercury, blisters, and belladonna.

This disease will yield to the powers of the constitution. Mercury is always injurious in the early stage.

Second, Pustular venereal disease.

Primary ulcer of a reddish-brown colour; borders closely on the phagedenic character. The edges raised and well defined; not excavated, but on a level with or above the surrounding skin. In the commencement, a small itchy pustula; distinguished from the ulcer attending the papular disease by its well defined and elevated edges, and by the absence of the smooth fungous surface of the former; from the phagedenic by its well defined margin and its corroded-like surface, and the absence of acute pain; and from chancre by the absence of the callous edges and base. These ulcers are of a chronic nature, showing little disposition to spread. The ulcers from buboes partake of the same character, the edges being hard and the ulcer disposed to burrow. These edges Mr. C. removes with the knife. The disease is rendered extremely obstinate, where full courses of mercury have been given. The more closely the eruption approaches the papular, the more mild and manageable will be the disease.

_Constitutional symptoms._--The eruption is pustular, and often exhibits simultaneously new pustules; also scabbing ulcers, the crusts of which fall off, and leave discoloured patches of skin after healing. For these ulcers of the skin, the best remedies are, sulphur fumigations, nitro-muriatic acid baths, and ointment of tar and sulphur.

_Remedies._--Rest; gentle astringents; mild ointments; antimonials and sarsaparilla:--for the constitutional symptoms; venesection; cathartics; antimonials; sarsaparilla.

Mercury is decidedly injurious, until the disease is on the wane, when alterative doses may accelerate the cure.

Third, Phagedenic venereal disease.

The primary ulcer has a corroded appearance. It exhibits neither granulations nor induration. It spreads sometimes rapidly, sometimes slowly; healing in one part, while ulcerating in another. It is mostly situated on the glans and prepuce, and often attended with hemorrhage. In this disease, buboes most frequently appear.

The sloughing ulcer occurs also in this disease. Mercury is extremely pernicious, always rendering the disease more inveterate and rapid in its progress.

_Constitutional symptoms._--High fever precedes the eruption, but abates afterwards. Nocturnal headachs; tenderness of the scalp; slight dyspnoea; tenderness of the sternum on pressure; soreness of the chest; an eruption of tubercles, or pustules, or spots of a pustular tendency, which quickly degenerate into ulcers, with thick crusts, that heal from the centre, while they extend from the circumference, with phagedenic borders. The crusts are often of a conical figure. The ulceration of the throat is of the most formidable nature. It commences in the form of a small white aphthous sore; which usually attacks the velum or posterior part of the pharynx, mostly the latter. It extends rapidly, destroying the parts, and at last attacks the bones. It often attacks the larynx, after which, the patient seldom recovers. The affection of the bones of the nose is never joined with the papular eruption, nor with the scaly syphilitic lepra; but in every case with the pustular description, and when scales and ulcers were present. At the time of the eruption, pains in the knees, wrists, and ankles occur, attended with swelling and redness. He has never seen nodes in the disease, except in cases where mercury had been given. Full courses of mercury introduce the disease into the deep seated parts; for the bones are seldom or never affected in this disease, unless mercury has been given.

_Remedies for the primary symptoms._--Absolute rest; venesection; nauseating doses of antimonials; warm poultices and fomentations; opium; hyosciamus and cicuta in sufficient doses to lessen pain and irritation. For the sloughing ulcer, stimulating applications are often useful; such as Venice turpentine or balsam copaibæ, mixed with olive oil.

_For the secondary symptoms:_--Venesection; antimonials; sarsaparilla; Dover's powder. Mercury increases the ravages of the disease, except when on the wane, when it may be given in alterative doses, with safety and advantage. For the pain in the head, a blister to the nape of the neck. If the eruption appear scaly, then mercury is likely to be useful. If the throat and skin are affected, muriate of mercury in solution, and decoction of sarsaparilla. If the ulcer in the throat be small, touch it with the oxymel æruginis, or solution of nitrate of silver, grs. v a x to an ounce of water; but if there exist extensive ulcerations, fumigations with red sulphuret of mercury ought to be employed.

Fourth, Scaly Venereal Disease, or Syphilis.--Primary ulcer of a circular form, excavated, without granulations, with matter adhering to the surface, and with a thickened edge and base. The hardening is very circumscribed, not diffusing itself gradually or imperceptibly into the surrounding parts, but terminating rather abruptly. Its progress is slow, sometimes assuming a tawny appearance.

_Constitutional symptoms._--Sometimes the skin, at other times the throat, is first affected. There is headach, restlessness, and fever. The scaly eruption appears, but does not relieve the fever, as in the other diseases. This eruption commences with a small hard reddish protuberance; and as it advances, the sides are raised, and centre depressed or flat, and covered with thin white scales. It terminates in ulcerated blotches. This eruption appears on the forehead, breast, back of the neck, and groin; often in large copper coloured blotches, in parts near the hair. The ulcers of the throat mostly affect the tonsils, and come on without much previous pain or swelling; although there soon appears a considerable excavation of the tonsil, attended with evident loss of substance. The ulcer is foul, with thick white matter adherent to it, which cannot be washed away. The bones then become affected, those nearest the surface being most liable to attack; such as the tibia, sternum, clavicle, and cranium.

The remedies for syphilis are full courses of mercury, for both primary and secondary symptoms; except where a tendency to phthisis, or a delicate constitution forbids them. He thinks syphilis a rare disease now, compared with what it was formerly.

ARTICLE IX.--_Remarks on some Means employed to destroy Tænia, and expel them from the Human Body._--By LOUIS FRANK. M. D. Privy Counsellor of her Majesty, Maria Louisa, Duchess of Parma. [Lond. Med. Rep. April 1825.]

The symptoms produced by the presence of tape worm in the human body, are exceedingly distressing, and the sufferings of the patient are increased, by the obstinacy, with which these animals resist the operation of the most disgusting, and even painful and dangerous remedies. Improvements in the mode of attacking and expelling them, therefore, should be gladly received, and widely made known.

The numerous reports which we have received, concerning oil of turpentine as a remedy for tænia solium, have already given to that remedy the highest character; but many cases have been only partially relieved by it. The ol. tereb. seems to be capable of causing the separation and expulsion of portions of the animal; but while the head remains unexpelled, it is supposed to be capable of reproducing the joints, to a degree not yet ascertained. If we may believe medical writers, the tænia has been observed of the enormous length of 700 feet. It is probable that the reproduction, after the loss of large numbers of joints, is often very rapidly effected; as was the case in a patient treated at the Carey Street Dispensary, mentioned in their report for Aug. 1813,[18] This person always discharged very considerable quantities of joints or fragments, after the use of oil of turpentine; after which he remained free from the complaint for a few months, until the tænia recovered a troublesome magnitude; when it was again easily reduced to less uncomfortable dimensions.

We are not able to state positively, how long the oil of turpentine has been in use as a remedy for tænia. The Carey Street Report for Feb. 1810, informs us, that a mechanic in Durham, having been very successful in the treatment of tænia by means of this article, the circumstance was communicated by Dr. SOUTHEY, of that place, to Dr. LAIRD of London; and it was accordingly prescribed in doses of [Symbol: ounce]ss. to [Symbol: ounce]ij. at several of the London charities. It had been found, says the report, that ol. tereb. might be thus given, as safely as so much gin, and frequently caused the expulsion in two hours: Dr. KNOX says it has been in use in Germany for fifty years for the expulsion of tænia.

The experience of Dr. KNOX, concerning tænia, at the Cape of Good Hope, is the most extraordinary that we are acquainted with. Dr. SPARMAN, the traveller, had observed, that worms were exceedingly common in the northern parts of the colony; but Dr. KNOX, who was there in 1819, did not notice any special prevalence of verminous disorders, "previous to Oct. 1819, when the _tape worm became so general among the troops, as to resemble an epidemic_."[19]

Most of these troops had been employed on a short campaign to the east of the great fish river. They had been compelled to live on very bad beef and mutton, driven and starved half to death; and Dr. KNOX thinks he has proved, that the tænia in these cases did "arise from the use of unwholesome animal food; from the flesh of animals, which had been diseased." Two out of five of the troops, who had been thus employed and fed, were affected with worms. Of a detachment of 86 vigorous, healthy young men, 36 were found, on inquiry, to have _tape_ worm. Those who remained in the colony did not suffer so much, as those who had been out on the campaign, the ratio being as one to four; whereas of the others, it was two to five. Dr. KNOX had ample experience of the utility of turpentine during this singular prevalence of tænia. Concerning the 36 men above mentioned, he says, "the cure of all, who chose to adopt the means, was easily effected by small doses of the spts. of turpentine, after the failure of purgatives and various other remedies."

He considers ol. tereb. as the _most efficacious remedy_. He does not approve of large doses, because of headach, vertigo, and delirium, which have been produced by them in "many patients."

"I have generally found," says he, "that from one to two drachms of ol. tereb., given in a little water, morning and evening, for three successive days, were sufficient to destroy the tænia solium, (even in the most obstinate cases,) and cause it to leave the intestines, without the aid of any purgative medicine." He advises, however, to give a little castor oil each day about noon.

It has been a very common observation in regard to the dose of turpentine, that the patient suffers more cephalic distress when it is given in small quantity, than in a large dose. The writer of this has been obliged to desist from the exhibition of oil turpentine, in doses of [Symbol: dram]ij twice a day, in consequence of a vertigo so considerable, as to alarm and distress his patient very much. Perhaps there might have been in this case some peculiar liability to nervous excitation, which in another patient would not have been worthy of much notice. Dr. KNOX'S opinion is of great weight.

The celebrated remedy of CHABERT, Dr. KNOX thinks, owes its efficacy to the ol. terebinth. combined with it.

Dr. FRANK, whose name stands at the head of this article, was informed by the celebrated helminthologist, Dr. BREMSER, at Vienna, in 1814, that he had for ten years preferred the use of CHABERT'S remedy, and with invariable success.

CHABERT was a veterinary surgeon of Alfort, who used the animal oil of Dippel in many diseases of animals, as well as those of men. This oil he often gave for the purpose of removing tænia in his animals. He often combined it with spt. terebinth. and gave equal parts of these substances, in doses of [Symbol: dram]i.[20] The London Medical Repository states, that CHABERT'S remedy is prepared from

Ol. Corn. Cerv. Foetid. 1 part.
Ol. Terebinth, 3 parts.

These are well mixed, and left at rest four days; they are then distilled in a sand bath, till three-fourths of the liquor has passed over. It must be kept tightly stopped, out of the light.[21]

The great objection to CHABERT'S remedy is its disgusting flavour; which is the more obnoxious, because the remedy must be continued for a length of time. Dr. FRANK cured two persons affected with tænia solium, after considerable perseverance with it: he cured two other persons with a preparation as follows:

Ol. Terebinth. [Symbol: ounce]ss
Æther Sulphuric. [Symbol: dram]ij
Pulv. G. Arab. [Symbol: ounce]ss
Aq. Flor. Chamam. distil. [Symbol: ounce]xvj _m._

Two spoonfuls morning and evening.

Four of these mixtures were sufficient to cure the patients, who remained well two years afterwards.

A fifth patient, unable to take the last named medicines, was cured by the boluses subjoined:

Sem. Santonic. pulv. [Symbol: ounce]ss
Pulv. Jalap.
Ferri Sulphat. aa [Symbol: dram]i
Ol. Corn. Cervi, gtt. viij.
Syrup. q.s.
Make 20 boluses.

One to be taken morning and evening. These 20 boluses being repeated three times, the patient found himself perfectly well. In the above 5 cases, the tænia was discharged in fragments.

Dr. FRANK does not say much concerning the bark of pomegranate root, which has come into vogue lately as a remedy for tænia. He refers to the Med. Chirurg. Transact. Vol. XII. for accounts by some English physicians, and remarks, that Dr. GOMEZ, the Portuguese physician, had cured 14 cases with this bark.

Dr. POLLOCK (vide Ed. Med. and Surg. Journal, Oct. 1819) treated a child, aged 14 months, with the decoction of bark of pomegranate root, so far back as the year 1811. This infant, under the use of the medicine, discharged at several times upwards of 30 feet of tænia solium, and was cured. We learn also from the Med. Repository,[22] that MM. DESLANDES, SOURYA, and BOURGEOISE, have employed pomegranate with great success; that the decoction generally expelled the worm in two hours; that it sometimes occasioned vomiting and griping pains; and that it has been a common remedy for tape worm, in the East Indies, and among the blacks of St. Domingo.