-No. 12. LONDON, SATURDAY, SEPT. 24, 1825.

FROM

LECTURESON THE

PRINCIPLES AND PRACTICE

OF PHYSIC,

BY DR. ARMSTRONG.

Theatre of Anatomy, Webb Street.

Dropsical Affections.THE following is an abstract of Dr.

ARMSTRONG’S concluding Lecture onthe nature and treatment of Dropsi-cal Affections :-Dr. ARMSTRONG observed, that drop-

ey is seated in various parts of thebody ; sometimes in the brain, in thetheca vertebralis, in the bags of thepleura, in the cavity of the belly,within the pericardium, within thetunica vaginalis, very often in thecellular connecting membrane of thebody, and occasionally it is encysted,as occurs in what is commonly calledovarian dropsy.

Dropsy, however, is nothing but asymptom ; it is not a disorder or a’disease of itself, but the sign of a dis-order or of a disease. CULLEN givesthe names of Hydrothorax, Ascites,Anasarca, and soon, to certain varie- ’,ties, without the slightest reference ’,to, the conditions on which they 4e-pend ; but although dropsy be a

eymptom, it is dependent on variouscauses.

rauses.

Dropsy may arise from four diffe-rent causes; first, from inflammation,acute, subacute, or chronic. Thus itoriginates from acute inflammationwithin the brain, leading towhat iscalled hydrocephalus internus, or effu-sion into the ventricles of the brain ;

the frequently leads of the pericar-dium frequently leads to what is call-

ed hydrops pericardii, or dropsy ofthe pericardium ; the acute inflam- _

mation of the pleura frequently teadsto dropsy of the chest, or hydrotho-rax ; acute inflammation of the peri-toneum sometimes leads to dropsy ofthe belly, or ascites ; acute inflamma-tion of the tunica vagiualis sometimesleads to hydrocele ; so, in like manner,chronic inflammation of these partsleads to dropsy. In fact, dropsy ismore frequently the concomitant, ortermination, of chronic inflammationthan of any other canse. When

dropsy arises from acute or subacuteinflammation, it is generally attendedby pain* and fever, a furred tongue,high coloured urine, in which there issometimes albuminous matter, and theblood abstracted moslv shows the

biiffy coat; but when dropsy arisesIrom chronic inflammation, lever isgenerally absent, or, if present, hasa slow insidious character.In the second place, it arises from an

obstruction to the transmission or

free return of the blood ; in that wayvenous congestion, whether acute orchronic, sometimes leads to dropsy.Night-watching sometimes thus leadsto the same result ; the heart’s ac-tion is weakened, with the other partsof the muscular system, the retnrn ofthe venous blood is consequently re.tarded, the minute vessels are dis.

tended, and an effusion of the mor&fluid part of the blood, called serum,takes place in the cellular connectingmembrane of the lower extremities.It is partly in this way that dropsyfrequently arises from bronchitis inold persons ; the bronchial affectionimpedes the respiration, and the diffi-culty of breathing, by retarding thereturn of venous blood, causes a ful-ness in the branches of the pulmo-nary vessels, and an etfusion ot serummay be the consequence. It fre-fluently arises, too, from the obstruc-tion caused by a sudden iuflitnmation

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of the external and internal veins, asfor example, of the vena portze, or ofthe crnral veins, and consequently anexternal,or internal, effusion succeeds.Some French writers have illustratedthis form of dropsy, and Dr. DAVIS,the able lecturer on midwifery in this’school, has written a most excellentpaper on the subject in the Medico-Chirurgical Transactions, as it relatesto what has been called phlegmasiadolens.’ It is a form of dropsy whichmost frequently arises in child-bed,but not always confined to the child-bed state, as Dr. A. had seen cases

occur in women who had never beenpregnant. On the same principle,tumours may occasion dropsy, by ob-structing the return of blood and

leading to an effusion of serum fromthe capillary vessels. The influenceof this cause of dropsy may be provedby direct experiment. Tie a ligatureround the arm ; let it remain theresome time, the blood is preventedfrom returning, and a cellular dropsyis the consequence. Some such expe-riments have been made on dogs,which proved the same facts. Itwould appear, however, that a sud-den interruption is not necessary toproduce dropsy thus, since cases areon record where no such effect fol-lowed the slow obliteration of thevein, the anastomosing branches

having so enlarged as to carry on thecirculation. It must have been per-ceived, liowever, that inflammation isfrequently mixed up with this cause,though the more immediate one ofthe dropsy be obstruction. Organicaffections of the heart, Dr.ARMSTRONGobserved, were among the most com-mon causes which led to dropsythrough simple obstruction, as mightbe illustrated in many cases of hydro-thorax and some of ascites.

In the third place, dropsy occasion-’ally arises from sanguineous or aque-ous plethora, or repletion. Individualswho take large quantities of food,who allow their bowels to become

torpid, who leave off their former ac-tive habits and become sedentary, inthis way now and then become drop-sical from an excess of blood, leadingto obstruction and effusion, occasion-ally without, but more often with in-flammatory symptoms. It occurs some-times after the ce8sation of the men-

strnal discharge ; many women getplethoric at that period, and ulti-

mately become dropsicat ; some ofthem exhibit no distinct sign of in.flammation, though it must be con-

fessed, that in most of such cases in-flammation is conjoined. When thisform of dropsy is conjoined with in-flammation, the indications of it arepresent, and the blood exhibits the

buffy coat. In the sanguineous ple-thora, the blood drawn generallyshows a superabundance of red par-ticles. Aqueous plethora arises sud-denly, as in weak convalescents, whodrink incautiously a large quantity ofcold water, which lessening the heart’saction and chiiling the surface, thereturn of the coltiinn of the venousblood is retarded and effusion is theconsequence, when liquids have beentoo copiously taken. Individuals maysometimes be saved from this form ofdropsy by a greatly increased secre-tion from the kidneys, which act as apump in lessening the quantity ofblood, when profusion occurs, by in-creased secretion. Experiments havebeen made on dogs, by HALES andothers, who produced dropsy in themby bleeding and making them after-wards drink largely ot water, andDr. ARMSTRONG had known some ofthe disciples of Sangrado producedropsy in their patients by similarmeans.

In the fourth place, dropsy arisesfrom a morbid condition of the fluids,and a laxity of the solids. An exampleof this form of dropsy sometimes oc-curs in chlorotic girls. The surfacebecomes pale, the muscular fibre fee-ble, the tongue furred, the stools

clay coloured, the form wastes, andthe legs begin to swell. There is, insuch a case, a complete change in theblood, it becomes more thin than na-tural, and exhibits a smaller numberofred particles than usual when drawn.Sometimes, indeed, it scarcely stainslinen, being thinner than claret. Thesame effects are sometimes producedby copious bloodletting and sparediet, a remarkable instance of Which,Dr. A. detailed, where his patientdied, and no trace of inflammationcould be discovered after death. Thisform of dropsy is often accompaniedhy organic disease, and sometimes bychronic inflammation.

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Some forms .of dropsy, Dr. ARM-STRONG remarked, do not always comeunder the heads already described;such, perhaps, is ovaiian dropsy, adisease, the pathology of w6ich wasnot spfficiently knowp, though he sus-pected it was most freqnently owingto an insidious inflammation seatedabont the ovary. This dropsy is en-cysted, and frequently there are manyof these cysts, each occasionally con-taining a different fluid from the other.

Diagnosis.

The varieties of dropsy have i-eceiv-ead different names. When dropsy issituated within the bags of the pleura,it is called hydrothorax ; when theeffusion is in both bags of the pleura,it is attended universally with a dif-ficulty of breathing; bnt Dr. A. had,fonnd, that when the iluid is poured,out into one of the bags of the pleurabnty, there is often no difficulty ofbreathing : he mentioned an instanceof an old man who had been accns-tomed to ascend a long tlight of steps_:daily to light a lamp,on a pier in oneof the sea ports, and who had no dif-ficulty ’of breathing. He died sud-

tleuly, and on examination, it wasfound that one side of the chest wasfilled with Quid, and that the otherwas, quite. empty. He had known,he said, several instances of the samekind, though, generally speaking, thebreathing is difficnlt, especially ontaking exercise. The patient is antto be seized with sudden fits of difB.culty of breathing, the sleep is disturb.ed by frightful dreams; palpitationsof the heart often attend, the mineis generally,scanty and high coloured;it ts often accompanied by anasarcousswelling of the lower extremities, andoccasionally, the parent has a distinctsense pf fluctuation in the chest, acase of which the Doctor related.

Upon, the whole, he considered theapplication of LAENNEC’S inttrnmentone of the safest guides in detectingthe presence of hydrothorax, and re-lated a case of organic disease of theheart, where he gave it as his opinion,from the application of this instru-ment, that the heart was conjointlydiseased, with an effusion into bothbags of the plectra. The patient died,

and dissection confirmed the accuracyof the opinion. Dr. A., however,thought, that LAENNEC disregarded toomuch the attendant symptoms, which.should always be carerol1v consideredin forming the diagnosis.Sometimes fluid is eflused into the

pericardium, and then it h called hy-drops pericardii. In this affection.the patient is generally easier whenbent forwards, and is very short ofbreath, or threatened with syncope oitexertion. There ia often uneasinessin the region of the heart, with palpi-tation, aud pain occaionally shootingdown the left arm. It is sometimes,however, very difficalt to distinguishdropsy of the pericardium from dropsyof the chest, both of which sometimesexist together.

.

When dropsy is situated in the hellp,it is called. ascites ; the abdomeu be-comes rounder and rounder, till atlast it is extremely large ; the simtassumes a shining appearance, and the.veins are seen rambling across it moredistended than natural. In the pro-gress of ascites, the face generallybecomes pale and peaky. The upperand lower extremities become moreor less emaciated,’ and if the hand beput on one side of the abdomen, andthe other side be struck with the end&of the fingers, a distinct fluctuationmay be felt, which is the most cha-racteristic sign.When dropsy is situated in the ovary,

the tnmour arises at first onlv on oneside, and then gradually enlarges, ap-pearing at first about the size of anorange, and continues to increase.The general health suffers but littleand that forms a diannosis in the ad-vanced stages between asoites andovarian dropsy. Dr. A. drew thediagnosis between ascites and preg-nancy, principally by contrasting theorigin and progress of each, and thestate of the patient’s general health ;but he said, where any donbt existedfor want of sufficicnt evidence, thepractitioner should defer the opera-tion of paracentesis, till after the usualterm of gestation. He related somedoubtfnl cases, one of which provedfatal, under the hands of an eminentpractitioner, who violated this ruts.

Auasarfa is a soft inelastic ,,wellingof the cellular membrane, which pit.%

, upon pressure. The only case of

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dropsy of the cellular membrane thatcan be confounded with any otheraffection, is that of dropsy of the in-teguments of the abdomen for dropsy ofthe ravity of the abdomen. The diag-nosis, however, is easy; if the fist bepressed against the anarsarcous swell.ing of the alidominal integuments, itwill be imbedded in a pit, which willnot be the case in ascites.

Treatment of Dropsy.The treatment of dropsy is very va-

rious, according to its causes. Whenit depends upon an acute, subacute,or chronic inflammation, it may befrequently removed. If the inflam-mation be acute or subacute, it willbe denoted by the state of the pulse,by the heat of the surface beinghigher than natural, by a furredtongue, by the urine being scanty andhigh coloured, and sometimes uponthe application of heat, or of the nitricacid, the water yields a deposition ofalbumen, but not always; and gene-rally there is pain in the part, whichis the seat of the inflammation. If theinflammation be chronic, pain is oftenabsent, but an accurate observer maygenerally detect the signs of the ob-scure inflammation wherever it be seated. Bleeding. purging. aud a

spare diet, with rest and qnietude,are the main remedies for this formof dropsy, and Dr. A. has seen indi-viduats relieved with great rapidityby these means. Even when com-bined with organic disease, this formof dropsy may sometimes be relieved ;a case of which he related, where aninflammatory dropsy was accompa-nied by organic disease of the heart.Digitalis, squills, and colchicum, are sometimes powerful assistants in thismodification of dropsy, especiallywhen, the inflammation having reced-ed, the effusion remains as a mere

sequela. ;_ In that form of dropsy, which de-pends upon an impediment to thetransmission or return of the blood,mild aperients and occasional altera-tives, generullv have a good effect,and when the liver is affected, verysmall doses of calomel, combined withsqiiills and digitalis, often succeeri inthe removal of the effusion, aided bythe repeated application of leeches to

the abdomen. The first object is todiscover the nature and the seat of the

obstructing cause, and whether or notit be connected with inflammation.The next point is to attempt its re-moval, where it is uncombined withany organic affection; but when or-ganic affection does exist, as a gene.ral rule of treatment, the practiceought not to be so active as in theother case, many lives being shorten.ed by young practitioners doing toomuch in organic affections.When dropsy arises from sangiii-

neous repletion, it is best removed bybleeding, purging, and a spare diet;and that dropsy dependent upon anaqueous repletion, is best removed bythe use of the warm bath, by aperientmedicines, and by acting upon thekidneys through diuretics. There aleno medicines, however, more uncer-tain in their operation than diuretics.Recently dried squills in powder, andfresh digitalis, are the best, assistedby the alkalies, and a properly ma-naged temperature.When dropsy arises from a morbid

condition of the fluids, with a laxityof the soiids, the practitioner mustendeavonr to find out the cause ofthis condition of the body, which willbe often found in the combined dis-order of the skin, and of the internalmucous membranes, with a torpid

state of the liver and colon. Whatthe medical attendant has to do, is toovercome the dryness of the skin bythe use of the warm bath every secondday, to place the patient in a fresh at-mosphere, to stimulate the liver by asmall occasional dose of calomel, orblue pill, or to act gently on the bow.els by the mildest laxatives ; to pre-scribe a light diet, and if there be

pain, observed Dr. A., ou pressureover any part of the belly, to applyi leeches till itbe removed, and the pa-tient will have the fairest chance ofrecovery.With respect to ovarian dropsy,his experience has induced him, in

confirmed cases, to conenr with theopinion of Dr. W. HUNTER, " thatthose patients have the best chance

of living the longest, for whom the

least is done." This is certainly a very

good remark, he repeated, iii confirm-ed cases, though, in incipieut ones,he was satisfied that it was best to

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treat them as if they proceeded from Islow inflammation, which was oftenthe fact. This was a point which had not been attended to in the commence-ment of what has been called ovariandropsy, a disease which, when fully

’

formed, sometimes required the usnatoperation as a temporary palliativefor excessive pressure.

In ascites it sometimes becomes ne.cessary to relieve the patient hy anoperation. The rule which should

guide the practitioner in the perform-ance of it is this : when the distension

becomes so great as evidently to im-pede the respiration, the operation isnecessary, but not before. Wheneveran operation of any kind is mentioned,it shonld be proposed with the great-est delicacy, and especially in a caseof this kind. The medical attendantshould speak of it to the patient as avery trifling operation, merely as a

puncture through the skin to let outthe fluid, and thus to give very greatand instantaneous relief ; but to thefriends, the real nature of the opera-tion should be explained, since it is

only a palliative in general, and sincein performing it there is the possibi-lity of au immediate haemorrhage, andof an ultimate inflammation. Thereare two precautions which should beobserved previous to the operation ;the one is, not to confound the dropsyof the integuments with that of thecavity of the abdomen ; and the se-cond is, to have a very distinct senseof fluctuation from a sufficient collec-tion of fluid, some persons having per-formed the operation too early owinyto the great distension of flatus. IIIthe latter cases the intestines, pushedagainst the inside of the abdominalinteguments by the air, have beenmateriatty injured in the operation.There are two places at which theabdomen may be pnnctured by thetrochar, the one midway between theanterior and superior suinous processof the ilium and umbilicus, and theotlier midway between the symphysispubis and umbilicus. The objectionto the tirst situation is, that when theabdomen is immensely distended therecti musclee. are sometimes displaced,and the epigastric artery is carriedmore towards the side of the abdomenthan usual,. and it has happened inperforming the operation, at that

point, this artery has been wounded.The latter situation is, therefore, pre-ferable midway between the pnbes andumbilicus, in the linea alba, the onlyobjection there being the tendinousstructure of the part. The patientbeing seated in an elbow chair, andhaving a bandage previously placedround the abdomen, by way of com-manding pressure after the fluid flowsont, to prevent syncope, the trocharshould be introduced till the feelingof resistance ceases,and then it shouldbe withdrawn immediately. The fluidhaving been drawn off, the patientshould be treated, tor the first twenty-four hours, as if a capital operationhad been performed, in order to pne-vent the occurrence of peritoneal in-flammation.There is no donbt, said Dr. ARM-

STKONG, that the operation of tappingmight be frequently performed withbenefit for collections of water in thechest, and as we have now a precisemode of ascertaining whether or notfiuid be in the chest, throngh the ap-ptication of LAENNEC’S instrument,there is no reason why the operationshould not be performed in urgentcases, for sometimes the inflammationceases which produced the effusion,and nothing remains to impede re-

spiration bnt the pressure of thefluid on the lungs. In regard to ope-rations for letting out flnid in otherparts of the body, medical men shouldbe caittiolis how they make puncturesin anasarcous swellings below theknec, since they are apt, in somesubjects, to rnn into gangrene.

Prognosis.The prognosis in dropsy should be

founded entirely upon the cause.-That form of dropsy depending uponinflammation may often be removedby proper treatment ; that form de-

pendent on obstruction may also hein many cases removed, but is apt toreturn, where there is organic disease.I Those, forms of drop.y depending uponsanguineous and aqueous plethora areoften cnred. Dropsy arising from themorbid condition ot the fluids, with

laxity of the solids, may be cured.provided there be no organic disease,which, however, is often present insuch instances. In short, in every

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ease, the cause of that condition calleddropsy must be investigated, and theprognosis deduced from that, and thestate of the patient in other respects.

Dr. ARMSTRONG concluded thiscourse of Lectures by expressing hisregret, that the dangerous ilinesswhich he -had in October IS24, andthe great debility which it left forsome time afterwards, should have

compelled him to compress the lec-,--tures on chronic affections into a

smaller compass than usual, ttoughhe trusted that he had exhibited idlthe more important particnlars andprinciples with respect to their patho-logy and treatment. His health beingconfirmed, it was his intention to sim-plify his arrangement with referenceto acute affections, which would en-able him considerably to extend hislectnres on chronic affections, andalso to give a series of lectures, in thebeginning of the course, on the phy-siological and pathological method ofascertaining the existence and seat ofacute and,chronic- affections.(The conclusion of this course of

Lectures called forth the enthusiasticplaudits of a numerous class of stu-dents.]

LECTURESON

PHRENOLOGY,BY

DR. SPURZHEIM.

LECTURE 18.

LADIES AND GENTLEMEN,I come to-day to a very important

application of phrenology, nanlely, to

Education.Look at man in general, and see

what a wretched state he is in, berequires to be treated almost as a

child, and yet writers have told us,that the world wishes for education.Many books have been written on

education, whole libraries have beencompiled, various jnstitutions esta-

blished, yet very little improvementhas taken place. Can man be per-fected by cdttcation, or can lie not!It is cer tain that the improvement isaot propairtionate to the troitble which

some individuals have taken. There-fore I repeat, can man be.perfectedor not ? Or sltall he remain eternallywhat he is? In speaking of the per-fectioii of man, I do not mean to saythat man can, by any power whatever,acquire any one of the fundamentalpowers of the mind, because the num-ber of them is determinate; but thequestton is, whether these powers canbecome more or less active, and wue-tlier they can he directed in a waylikely to be most useful to the indiri-diial ? Commonly, in speaking of edu-cation, it is divided into two parts, phy-sical and moral. Since we admit thatthe moral, part of man, or, in otherwords, the mental part, depends uponthe organization, and since we do notadmit of any intlnence independent ofthe cerebral organizatiou, I do notlike this division, and therefore shallunt speak nt’it:

However, I shall speak of education under two heads. I shall nrstexamine how far it is possible togive more or less activity to thefundamental powers with which manis endowed, since we admit in phte-nology that man has received fromthe hands of the Creator a certainnumber of pors, and that these

powers aie manifested under certainconditions. Now we see that manypowers are more active than others,and that, in a general way, the ani-mal powers are more active than thepowers proper to man. Is it possi-ble to give more or less activity tothe individual powers? that will be

the first question.I shall, seconclly, examine how far

it is possible to direct these powers ? What shall we do if we find per-sons born more-active than others?There are various conditions whicttmust be observed. Man is a created

being, and lie must be btudied in the

same way as all other created beings,by observation. Nature makes no ex-ception to her general laws, althoughwe wish to make exceptions muchmore frequently than is necessary.Atthotfgh the subject may appear deli-cate, I shall insist upon it. Man mustbe ianproved in many respects, as allother created beings. Are we notsure to have good cattle, a good breedof any description, by attending to

certain conditions ; but are we Bare ot