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canse the ordinary antiphlogistic treat-ment enables us so completely to controlthem. I think so highly of Mr. Wardrop’sknowledge and judgment, and rely so

implicitly on all that he relates, that Idoubt mv own conclusion when I find itat variance with his experience, andtherefore advise vou to examine the mat-ter for yourselves. Let me observe,however, that although the puncture, re-garded as an operation, may be spokenof lightly, and certainly is accomplishedwithout difficulty, it is not so trivial as toinduce us to do it, unless with decidedexpectation of benefit. It is often difficultto fix the eye for any operation, and the

pain and irritability of severe inflamma-tion do not make this easier; often, too,the eyelids are swelled. Instances haveoccurred, where the instrument has beencarried as far as the pupil, in which thelens and iris have’been pushed forciblyagainst it, and cataract has been pro-duced ; an event which, indeed, is charge-able to anskilfulness, but its possibilitymust be taken into account in estimatingan operation proposed for so great a num-ber of affections. The puncture has notbeen injurious in any case where I havepractised it.

LECTURES

ON THE

THEORY AND PRACTICE OF PHYSIC,

BY DR. CLUTTERBUCK.

Theatre, General Dispensary, Aldersgate-street.

LECTURE XXV.

Of the treatment of Dropsy in general.

Gentlemen,THE treatment of dropsy is as various

as the causes inducing it, and may treunderstood, in some degree, from whathas been already stated. In the firstplace, the treatment will differ essentially,according as the disease is known to de-

pend upon increased exhalation, or upondiminished absorption; and, therefore, weought always to endeavour to ascertainthis point. If, however, we should beunable to do this, then we must be con- Itent to act empirically; that is, we must I

have recourse to such means as formerl experience has shown to be useful.I The most important object in the treat., ment of dropsy, is the tracing its con-

l nexion with inflammation ; so that wheret you find this to be still sub-isting, thet removal of it is the first and chief pointto be attended to ; and, for this purpose,, antiphlogistic remedies of various kindsmust be resorted to; and, among theI rest, bloodletting is frequently required.I Many practitioners have a great dread of, bleeding in dropsy, from believing theI disease to be founded essentially in de4i.t lity, and that bleeding itself is capableof inducing the disease, and is, therefore,not likely to prove a remedy for it. Such, an apprehension, however, is for themost part without foundation; for expe.I rience has sufficiently proved, that blood-letting is not only safe, but often of thegreatest service, so as to be absolutely. curative, in numerous instances ot dropsy,when connected with inflammation. But7 although there is no doubt of the pro-; priety of bleeding in the circumstancesmentioned, provided there is still a tolera.t ble share of general strength remaining,it is never necessary to take blood in

large quantities.We must bear in mind, that the disease

generally takes place under circumstancesthat are unfavourable to large bleeding.! The bleedings should be always small inquantity, seldom exceeding four or fiveounces at a time; this quantity is com.

monly well borne by the patient. It atonce lessens the general febrile symp-toms, dnd diminishes the topical inflamma-tion. The appearance of the blood drawn,in a majority of instances, justifies theuse of the lancet; for it is, in general,buffed, and contracted. But althoughbleeding to a large extent is neither ne.

cessary nor proper, a repetition of’ it isoften called for. We may take away bloodto the extent mentioned, every two orthree days; so that five or six bleedingsmay be performed in the space of two orthree weeks. The practice has this ad-vantage, that even where the disease isaccompanied with much disorganizationof parts, the treatment still relieves,although it may not be able to effect acure. This treatment is equally applica-ble wherever the disease is situated;whether in the abdomen, in the chest, orin the craninm. I scarcely need observe.that the other parts of the treatmentshould be in strict accordance with this;for it would be both useless and injuriousto employ stimulants, for the purpose ofI exciting the absorbents to greater actionin such cases.

The dig italis is of advantage in drop3ies

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of the kiud now mentioned, particularlyin dropsies of the chest ; probably be- pcatiae these so frequently depend uponinflammation. This medicine has a dou-ble advantage here, acting both as a

sedative and as a diuretic. The cream oftartar, likewise, is well adapted to this

state; as are also nitre and purgatives, es-pecially the saline ones. Mercury, as faras it is capable of taking off inflammationof a chronic kind, may sometimes curedropsy, by removing the cause.

If the dropsy has arisen from long-con-tinued febrile disorder of any kind, littlecan be done by art, further than the en-deavouring to remove the cause of thefebrile state, when this is practicable.To stimulate in such cases, can only havethe effect of bringing back, or agyavat-ing, the primary cause of the disease.

Ifthe disease arise from debility simply,as from heamorrhage, or inanition, little canbe done medicinally. Tonics are of littleother use, than to give appetite, wherethis is deficient. Time, and a sufficientsupply of food, are in general all that isrequired for the restoration of the gene-ral strength : and when this object is

’accomplished, the dropsy will sponta-neously disappear.

If dropsy arise from pressure uponveins or lymphatics, we should endeavourto obviate this as far as possible. Themeaos of effecting it, will readily snggestthemselves wben the cause producingthe compression is ascertained.

If the disease arise from paralysis ofthe absorbents, as in cases of anasarca

accompanying hemiplegia, stimulants and (

friction may be applied, but are not likelyto effect much, as they have no power to tremove the cause. <

t

Having thus looked to the cause, and t

endeavoured as far as possible to obviale t

it, your attention may be then properlydirected to the removal of the effect, that l

is, the effused fluids; attempts of this s

kind, however, cannot always be judi- a

ciollsly made, as the means of accom- a

plishing the purpose are not at all times n

without danger. Dropsy is not necessa- n

rily fatal, but may subsist for many years,with little inconvenience to the patient c

In cases, therefore, where the life of the <

patient is of more than ordinary impor- d

tance, and where it is not immediately e

endangered by the disease, we are scarce- slly warranted in putting it to the risk t(that necessarily attends an operation for cthe removal of the fluid. Where again ttthe disease has been of long standing, tiand has been found to be not incompa- n,

tible with a tolerable share of comfort to wthe patient, it would hardly be worth n)

while to encounter the risk of an opera-tion, for the advantage would not be inproportion to the danger incurred. I re-member the case of a woman who hadlaboured under ascites for fifteen years,with little other inconvenience than whatarose from the weight and bulk of theaccumulated fluid. At her urgent request,the water was drawn off by tapping;peritoneal inflammation ensued, and shedied in a few days. It is an additionalreason against such operations, that therelief afforded is seldom more than tem-porary, a fresh accumulation generallytaking place.

e With the exceptions I have now stated,it may be proper to endeavour to removeethe fluid, when, by pressure or other-wise, it interferes materially with any

important function, or is productive of, much distress to the patient.] Now, there are two ways of getting ridof the fluid in dropsy. The first is direct,that is, discharging the fluid by an ope.t ration, as by tapping, puncture, or scari-fication; the second is indirect, throughthe medinm of the absorbents, which are; employed as the agents for the purpose.. I shall speak of each of these in turn; but

first, of the direct removal of the fluid byoperation.

The operation of tapping is sometimes. dangerous, on account of the risk of in-flammation supervening ; and this ismore especially to be dreaded in the largercavities.

In dropsy of the brain, the letting outthe fluid suddenly, is attended with itnme-diate danger to life, and is, in fact, not to.be jnstified. It puts the organ into sonew a condition, as can hardly be con-ceived to b2 compatible with life ; whilethere is the further danger of inflamma-tion following. In a very few instances,the fluid has been discharged through asmall orifice, made by a needle, and thepatient has not appeared to suffer in con-sequence; but no permanent cure, as faras I know, has been effected in this way ;and I consider the practice, (if not whollyunjustifiable) as having little to recom-mend it.When the water is collected in the

channel of the spine, the danger of eva-cnating it, is not much less. We cannotdraw off the fluid from this part withoutendangering the life of the patient; thespinal marrow being scarcely less essentialto life,than the brain itself. In most of thesecases, there is at the same time water inthe brain; and there being a communica-tion with that in the spinal canal, we can-not draw off the fluid from the latter,without influencing the brain also. As amatter of experience, I may observe, that

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it has been done in a few instances, incases of what is called spina bifida, by avery small puncture, with no immediateill consequence ; but then the risk is run,without any great chance of ultimatesuccess, or even of material advantage.Even in hydrothorax, the operation of

tapping has little to recommend it, and itis, in fact, very rarely employed. The

advantages arising from the operation arenot commensurate with the danger of thesucceeding inflammation ; added to which,is the improbability of doing permanentgood, on account of the diseased state oforgans that is so generally present in thosecases. Undoubtedly, there are instancesin which it might be proper, as where thechest is obviously enlarged, and where thedistress of the patient is very great. Insuch cases, it may be necessary for theimmediate relief of the patient. What Ihave now said, applies with equal, or

greater force, to dropsy of the peracar-d:um.

In ascites, the immediate danger of theoperation is less, while the advantagesresulting are often sufficient to warrantits performance. But even here there is

always more or less risk of superveninginflammation, and which can never be ab-solutely guarded against ; while theopera.tion is probably not absolutely curativein one case out of fifty. Hence the ne-

cessity of the considerations I beforementioned, as proper to guide your deci-sion. There is another danger here whichmust not be overlooked, arising from thesudden abstraction of the fluid, which issometimes followed by fatal syncope.This is obviated by making pressure onthe abdomen as the fluid escapes. It hasbeen attempted to prevent a return of thedisease after tapping in ascites, by inject-ing red wine as an astringent. A case ofthis sort is recorded in the PhilosophicalTransactions, in which claret wine wasthrown in for the purpose, and with suc-cess ; for the patient escaped, and thedisease did not recur. This practice wasadopted in another instance by the samepractitioner, but proved fatal by the stic-ceeding inflammation. In cases of ovariandropsy, tapping is less objectionable, as itis not so liable to be followed by inflam-mation. The chance of cure, however,is even less than in ascites.When the dropsy is situated in the

cellular membrane, immediately under theskin, the fluid is sometimes evacuated bypnncture or scarification. This may in

general be done on the trunk of the body,and in the upper extremities, with safety,and occasionally with advantage. But inthe lower extremities, especially about thefeet and ancles, and also in the scrotum,

there is great danger of gangrene follow-ing the operation ; and the danger of thisis much greater in bad habits of body, inpersons who have led a life of excess, andin old subjects.The other mode by which we attempt

the removal of the dropsical fluid, isthrough the medium of the absorbents.This would be the best mode, if we hadadequate means of directly exciting thesevessels. But unfortunately, our powerover them is very limited. We cannetstimulate the absorbents without at thesame time acting upon the exhulents, so asto increase exhalation. Mercury, indeed,is supposed to have such a power, andhas been often used for the purpose. Butit is quite certain that mercury excites thesanguiferous system, in at least an eqnaldegree with the absorbents. As a matterof experience, we find that the adminis-tration of general stimulants is far fromsuccessful ; which is not to be wonderedat, considering how large a proportion ofcases of dropsy originate in inflammation.If we endeavour to excite the absoi-bentsby local means, such as friction, heat, orother stimulants, the same difficulty oc-cnrs. We cannot stimulate the absorbents,without at the same time exciting the ex-hateots ; so that little is gained.But although we caunot ad vanl ageously

influence the absorbents in a direct way,we can do so indirectly; namely, by in-creasing some of the watery secretions;by which, a want of fluid is cr eated in thesystem; and this want, it is the businessof the absorbents to supply ; accordingly,they often drink up eagerly whateverfluid is presented to them, and so makegood the deficiency. Thus we alwaysfind, that under the use of purgatives,diuretics, and sudorifics, tturst zirises;

and if fluid is taken into the stomach, it isquickly absorbed by the lacteals. In likemanner, the lymphatic absorbents, andthose which open into the different cavi-ties, take up the fluid presented to them.This mode of treating dropsy, though

sometimes successful, is far from beinggenerally so ; because, in the first place,it is no easy matter to produce a stifficieiltdischarge of watery fluids by any of thesecretions ; and in the next, because theabsorption of the effused fluids will notalways or necessarily follow. Anotherreason is, that if we succeed in removingthe accumulated fluid, we only remove aneffect, and not the cause ; so that a freshaccumulation generally ensues, and evenfaster than before. The means, however,which we possess for producing such in-creased discharges, are either diuretics,purgatives, sudorifics, or epispastics. Theseare of different degrees of utility.

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1. Diuretics. The kidneys are the mostnatural outlets for the dropsical fluid, astheir function is naturaliy that of dis-

charging watery fluid from the system.Unfortunately, however, onr means ofexciting the kidneys are not very power-ful, and are at all times uncertain in theireffect ; and, which is still worse, they aremost apt to fail in those very cases whichmost require their use; namely, in drop-sies. This uncertainty holds with regardto the whole tribe of diui-eties ; so thatthere is little ground for choice amongthem; and the best thing you can do is totry them in succession, or variously com-bined ; taking your chance for success.

The principal diuretics that have beenused in the cure of dropsy, are the squill,diluted acids (particularly the nitric acid),supertartrate of potash, the carbonated al.kalies, the neutral salts, particularly nitre,and acetate of potash ; which last was

supposed to be so efficacious, as to haveacquired the name of the diuretic salt; butI much doubt its being entitled to thatdistinction. Alcohol, largely diluted, isa powertul diuretic, but is seldom properon account of its stimulant and othereffects. Cantharides have been recom-meuded by some, as a diuretic ; hut thisproperty is denied them by others. Asfar as my own experience goes, I havenot seen any satisfactory proof of theiracting in this way. The tobacco has beenrecommended by Dr. Fowler of Stafford,(a very good anthority), who used it withvery favourable results. But it has notbeen much employed; perhaps on accountof its nauseating effects, and the extremedepression which it occasions.

The digitalis merits more particularnotice, on account of its verv powerful,and often asefal, effects. No diuretic willbear a comparison, in point of efficacy,with the digitalis. It often occasions amost copious discharge of urine, to theamount of several quarts in the space oftwenty four hours, followed by a rapidabsorption of the dropsical fluid. Indeedwere the effects of this i emedy as certainas they are powerful, it would be an in-valuable remedy. But unfortunately, likeall the others, it is liable to fail us, andthat without our being able to assign thecause of the failure. We should not,however, too hastily abandon a remedyof such great occasional efficacy ; for byvarying the dose or preparation, or bylaying it aside for a time and again re-suming it, we shall sometimes succeed,though we might at first have failedwith it.

It has been generally believed, that

the infusion of the plaut, either fresh ordried, is more effectual as a diuretic, thaneither the powder or the tincture. Ifsuch be the fact, it is one that does notreadily admit of an explanation. All Ican venture to say upon the subject is,that the infusion, prepared according tothe pharmacop&oelig;ia, is an exceedinglyefficacious form, hot which requires to bewell regulated in regard to its dose.Half an ounce of the infusion may beconsidered as an ample dose, even forstrong subjects ; and, for weak ones, thisquantity is much too large to be continuedwith safety. I have often seen a singledrachm productive of much distress tothe patient ; and yet there are many,who can bear a couple of ounces, withlittle or no effect. But you should never

presume this to be the case, withoutactllal trial, however strong the patientmay be. The dose, whatever it is, shouldbe repeated three or tour times withinthe twenty-four hours, and not oftener ;for the operation of this medicine is slow ;and, exhibited in moderate doses, theeffects are not perceptible immediately,seldom in less than 24 or even 48 hours.We should, therefore, guard against anaccumulated effect, by occasionally inter-mitting its use, and not pushing it on tillthe desired eftect takes place, or the

pulse be greatly reduced ; tor in this case,the latter doses which have not yet comeinto operation, may occasion too violentan effect; small doses often succeed,where large ones fail. The effects some-times take place alter the medicine hasbeen laid aside, for perhaps two or threedays; and it is worthy ot notice, that whenonce it has begun to act in a favomabteway, a small quantity will serve to keepup the effect. In this respect, dlg,talisdiffers from most other medicines ; whichcommonly become less active by repe-tition.

In consequence of the great uncer-tainty in the use of diuretics we are ob-liged to have recourse to cathurtics, which,though more harassing to the system,have the advantage of greater certaintyin their operation. The great extent ofthe intestinal canal presents a large sur-face for secretion, and much fluid maybe thus evacuated from the system ; aneffect, in which the accessory organs, theliver and spleen, no doubt concur. Theresult, often, is a rapid absorption of theeffused fluids. Unfortnnately, with theexception of the supertartrate of potass,the more violent or drastic purgativesare the only ones to be relied upon ; andindeed but few of these ; such, namely,as used to be called hydragogues, from

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their producing copious watery stools.Jalap and gamboge are of this descrip-tion ; but the buckthorn berry is far moreefficacious, in the dose of an onnce or twoof the syrup, as directed in the pharma-copoeia. T he elaterium, however, ex-ceeds all others in point of efficacy, as apurgative, for the cure of dropsy. Asin gle dose of it will often dischargemany pints of fluid, and be followed bya rapid absorption of fluid from the partsin which it has been effused. On accountof the violent operation of this remedy,we should be very careful respecting thedose. Half a grain will often produceboth vomiting and purging; this quan-itity should, therefore, be seldom admi-nistered, except in robust subjects. A

quarter of a grain, and even one-eighth,is in many cases sufficient for the pur-pose. You will often find the elateriumrecommended in books, in the quantityof two or three grains, or even more;and that without any caution. Those whohave thus spoken of it, must have usedit in a very imperfect state; which youought to be on your guard against. Thesafest way of employing the elaterium indropsy, is to give it in the dose of a quar-ter of a grain, and to repeat it once, oreven twice, at intervals of two or threehours. This may be done daily, or every

. other day for a few times ; giving, in theintermediate days, infusion of gentian, orsomething equivalent to this.

Sudorifics have occasionally been em-ployed in dropsy, and sometimes with

advantage. The quantity of fluid, how-ever, evacuated by such means, is not

large ; but sudorifics may do good inother ways ; as by taking off an inflam-matory disposition, and determining tothe surface, where there is always defi-cient exhalation. The Dover’s powder isthe sudorific best adapted to the purpose.

Epispastics are seldom useful as eva-

cuants, though they may be so in otherways. Applied to the lower extremities,they are not without danger, by theinflammation they excite, especially inbad habits.

I may repeat what I before stated, thatalthongh dropsy is seldom cnred, it is notso much owing to our inability to get ridof the effused fluid, as from the incurablenature of the primary disease, of whichthe dropsy is but a symptom.

FOREIGN DEPARTMENT.

ARCHIVES GENERALES DE MEDECINE.

Observations on some points of PathologicalAnatomy and Pathology. By P. H,BERARD, M. D.

Partial Dilatation of the Heart.THE title aneurism of the heart has beenapplied to simple dilatation of the cavi.ties of this organ, whether accompaniedby greater thinness than natural or morethan usual thickness of its parietes.-Authors, however, have scarcely takenany notice of those aneurismal. pouches,situated on the aides of the heart, andcommunicating with some one of its cavi.ties iu the same way as aneurisms of thearteries communicate with the vessels

upon which they occur. This disease,which has been styled partial dilatationof the heart, has only been met with bya small number of observers. Corvisartgives but one case of it: the tumour wassituated on the upper and lateral part ofthe left ventricle; it almost equalled theheart in size, and its interior comnmni-cated with that of the heart by a smooth,round, and rather narrow opening. Dr.Haillie states, that he once saw the stim-mit of the left ventricle changed into a

pouch large enough to hold a small

! orange. This pouch, whose walls were

i thin, was lined with an opaque, whitemembrane ; it contained a very small

quantity of coagulated blood.In the two cases which I have seen, the

apex of the heart was possessed by a largetumour, which appeared to be separatedfrom the summit of the ventricles by akind of external narrowing, or circularstricture. The point of the right ventri-cle was applied against the base of thetumour, bnt did not open into its cavity.The left ventricle communicated with it

by a rounded orifice ; the interior of theaneurismal pouch was filled with distinctlyorganized clots; lastly, the heart adheredto the pericardium.

The first case I observed was the fol-lowing :-On opening the body of a female, fifty

years of age, by no means emaciated,and whose lower limbs presented no ap-pearance of infiltration, the lungs werefound adhering by a laminated cellulartissue to almost every point of the costal