H

WO-

*

John OZvaTv/auL %

OBSERVATIONS

On fome of the

D I S E A S E S

Of the Parts of the

HUMAN BODY.

Chiefly taken from the DhTe&ions of M o R bid Bodies.

By SAMUEL CLOSSY, M. D.

LONDON:

Printed for G.Kjarsly, in Ludgate-ftreet. MDCCLXIII.

182i)*.

^it^ci-

PREFACE.

KNOWLEDGE being the perception of the agreement or difsgreement of Ideas, -that knowledge is more compleat by how much more thofe Ideas are conformable to the Types they are taken from. But Ideas are either General or Parti- cular : and general Ideas being formed of par- ticular Ideas ; by leaving .out the difference, and preferving the reft, particular Ideas are more conformable to their objects than gene- ral Ideas, and knowledge drawn from parti- ticular Ideas more exaft than knowledge taken from general Ideas ; and our knowledge of Subftances and their afte&ions acquired from particular Ideas more exact than fuch know- ledge from Ideas made general by abftracting. Perfect it cannot be, forafmuch as our Ideas of Subftances with the nominal comprehend not the real effence of the object; therefore from the nature of the human mind, and its operations and powers, there can be no uni-

a 2 verfal

iv PREFACE.

verfal propofitions made about fuch fubjects admitting unexceptionable proof.

Now as all human knowledge is derived at firft from fenfation, and improved and en* larged by the operations of reafon and reflec- tion, fo our knowledge of the affections of the Human Syftem is acquired by feeing the fymptoms and directing Bodies, and both are improved by reafon and reflection.

We muft therefore commence with obfeiv yations and experiments, and draw general conclufions therefrom by the method of induc- tion : It is true indeed the arguing from ex- periments and obfervations by induction is by no means fuflicient for general conclufions ; yet it is the heft way the nature of the fubject will admit of, and may be held as fo much the ftronger, by how much the induction is more general ; by this means we proceed from effects to their caufes, and from particular caufes to more general ones, till the argument; end in die moit general; then we affume thefe caufes fo difcovered, and by them explain the phenomena of the fymptoms, and prove the explanations j and this is the method which I have endeavoured to follow in thefe obfer- vations, where examples of the fame kind uou'.d admit.

Bv

PREFACE. v

By the word Difeafe, I underftand ftich an affection of the whole animal fyftern wherein the functions of its feveral parts are difturbed, or fuch an affection of any part that difturbs its function 5 and fo a fever is fuch an affection of the whole fyftern, wherein the functions of its feveral parts are difturbed; and a jaundice* fuch an affection of the Liver as difturbs its function.

By the word Symptom I underftand a pre- ternatural affection refulting from a Difeafe, ei- ther of the whole fyftern or any part thereof; fo the heat in a fever, or the high-coloured Urine in the jaundice, are preternatural affeo tions refulting from the difeafes of the fever and jaundice.

The caufes of difeafes are whatever pro- duces the difeafes, and may be termed either material or immaterial ; of the immaterial caufes are the paflions of the mind, which may either difturb the uniform motion of the whole fyftern, or any part thereof. A fudden fright has fufpended, and even totally flopped the motion of the whole fyftern ; and the paflion of fliame has diffufed the Blood through the Neck and Face. Of the material caufes are the febrile matter, which being in the Blood

a 3 xaifes

vi ■ PREFACE.

raifes the fever, whether it be by irritation, or obftrudtion, or an inftitution of nature to de- purate the Blood -, and the acrid or infpiffated Bile are caufes material of the jaundice.

But caufes alfo are either antecedent or im- mediate -, of the antecedent are the Air, Diet, Exercife, Secretions, Sleep, and Paffions of the Mind; all which, by preternatural quality, quantity, or motion, may introduce affedtions preternatural in the Fibres or Fluids, which are caufes immediate.

Immediate material caufes are difcoverable ei- ther by reafon or diffedtion; and fo when a fudden profufe haemorrhage cures that fort of blindnefs termed gutta ferena, we infer that the caufe of the blindnefs was a fwelling of the Retina, whereby the medullary Fibres of the Tunic fuffered compreffion by intumefcence of the Veffels; and a tumor or water com- preffing the optick Nerve within the Skull, or a wafting of the Nerve, is found to be the caufe of the fame fort of blindnefs, not by rea- fon, but difTedtion. The inveftigation pf caufes by meer reafon is, I believe, what comes un- der the denomination of Theory or /Etiology of diieafes, and is rather to be held as the moil eafy and intelligible manner of conceiving

how

PREFACE. vir

how fymptoms are produced, than what the

caufes really are.

©

While I was endeavouring to trace fuch caufes of difeafes, as can be difcovered by dif- fedtion, in St. George's hofpital in London* and Stevens's hofpital in Dublin, by the invi- tation and permiflion of the late Dr. Stevens* in the years 1752, 1753* 1754, 1755, 1756V and keeping an exact regifter thereof; together their antecedents at the time, with fuch re- flections as the phenomena feemed to me to fugged, I thought I obferved fome things lightly paffed over by authors* and others where their experience was defective. The fyftems are furely of exceeding ufe, as they fhew us what to look for in due order and method 3 and indeed Galen himfelf fays, we ought to have fome plan of univerfal theorems, and exercife ourfelves in particular examples * *• yet the concifenefs to be obferved in drawing np fy- ftems will fcaree admit of fuch diffufive de- fcription as the importance of the fubject re- quires, or as is fufficient to convey exact ideas.

But in all this attendence 1 had no opportu- nity of feeing what might be the caufe of the

* De meth. medend. lib. 9,

a 4 lymp-

vni PREFACE.

fymptoms of fenfe, intellectual powers, and motion, when the caufes are fuch as can be ob- jected t© the fenfes -, and being at a lofs about thefe things, Mr. Butler of Stevens's permitted me to fee if among his patients, wounded in the Head, if I could find any thing relating to the fubject. Now in thofe obfervations though I did not fucceed to my defire, for among other defects I did not fee what fymptoms fol- lowed from the Cerebellum in being com- preffed, broken, or other wife affected, yet as what I there faw may carry with it fome de- gree of illuftration of the affections of the Head, arifing from internal caufes, and be ufeful to the youngerj furgeons, I have drawn them to- gether, agreeable to the plan laid down in fome other of thefe fections, which, with the reft of the cafes, fhould the reafoning be erroneous, may ferve in part thofe whofe tafte for fuch fubjects may incline them, and leifure afford opportunity, to draw up more elaborate fyftems.

For while I was thinking over, and duly di- gesting, what I had obferved of fome other af- fections, whofe caufes are gathered from rea- foning chiefly, and going on obferving at Mer- cer's, finding myfeif under a neceflity of in- termitting thefe difquifitions, and probably for a considerable time, I have chofen the follow- ing*

PREFACE. k

ing, as of more general ufe, till freedom of thought, and a more eafy fituation, fhall afford time and power to proceed on (o defirous a bufinefs.

It is true indeed our knowledge of fuch caufes as are found by diffeftions, is not of fuch general ufe as of thofe objected to imagination and reafon chiefly ; for all epidemick and in- tercurrent Fevers, Fluxions of different fpecies, and Hyfterical difeafes, come under this head, which are by much the greater part of the fubjefts under the care of Phylicians ; yet they are not to be rejected becaufe they are incur* able; for, by our intelligence herein, wre leave the lick, whom we cannot reftore, no worfe than we find him -, nay it is even more than this, for there is fcarce any difeaie of the parts, or even of the whole fyftem, that will not ad- mit of fome relief, which every humane man will endeavour to adminifter ; but we are alfo inftructed in the confequences of difeafes whofe progrefs and effects might be checked when incipient.

I faid above, mould the reafoning be erro- neous > for though I am certain that a free com- munication with the external air is by no means effential to the formation of Pus ; the Pus in the

upper

x PREFACE.

upper and lower Venter, (in theformer of which I have feen it where there has not even been a fiffure of the Skull evident to fenfe ; and in the latter I have feen it in the very center of the Liver, where there could not be fufpected even the lead imjrority depofi-ted from the Blood into the part which might inrlamc it) is an inconteffible proof of this proportion ; and I have likewTi fe feen it deep in the Mufcles of the Loins and Thighs, where the external caufes which gave origin to it did not even break the Skin.

But that pure Blood, extravafated without communication with the external air, fhould put on fuch a modification of parts, whereby it may come under the denomination of Pus, I cannot fay that I am fo exactly fettled in : for having advifed with very good judges among the furgeons while I was reviewing thefe ob- fervations, and whofe experience in thefe mat- ters is more extenfive than mine, I find they are inclined to think that it is rather the refultof an inflammation j though at the fame time they do not affirm the impoffibility of the change. Now fince the fettling of this propofition does not feem to interfere with the practice, we fliall let it lie over, till common general expe- rience, (which with reafonable men will always 7 . be

PREFACE. xi

be the flandard of truth in thefe fubjects) fhall approve or reject it.

I mould probably make fome apology for the too liberal ufe of the word Sleep. Sleep in due reftriction is fuch an affection of the whole man, as is infervient to refection and nutrition, being an inftitution of nature to that end -y whereas the train of fymptoms arifing by com- preffion, or other ill dilpofition of the Brain, is by mechanical affection ; but I have ufed the word to convey the whole company of fymp- toms, by exciting the idea of fleep -, nay, tru- ly, for endeavouring to illuftrate or prove pro- portions by fo few facts as have fallen within my experience, exclufive of the narrownefs of my genius in drawing deductions, were I not afraid of Cato the fenior's cenfure, ReBe qui- dem, mi domine vir, fi mo do Amphydlionum dc- creto conftriStus evulgas hcec.

CON-

CONTENTS.

SECT. I.

Of the Head.

OBS. I. Lethargy and Paralyfis from contufed In-

teguments. i

OBS. II. Lethargy from Extravafation on the Dura

Mater. g

OBS. III. Lethargy and Extravafation between the

Membranes. 4

OBS. IV. Lethargy from Extravafation below the

Pia Mater 1 and among the Membranes. 7 OBS. V. Lethargy from a Depreffion of the Skull

and Corruption of the Brain. - . 9

OBS. VI. Lethargy and Paralyfis from a Concuffion

with Extravafation. 10

OBS. VII. Lethargy from the Brain broken and

putrified. 1 4

OBS. VIII. Lethargy with Fungous Excrefcences.

l5 OBS. IX. Eplepfy from the Dura Mater ah feeding.

*7 SECT.

CONTENTS,

SECT. II.

Of the Neck and Cius t.

OBS. I. Quincy from a Swelling of the Larynx. 35 OBS. II. Afihma from an Induration of the Lungs.

39 OBS. III. Dropfy in one Cavity of the Cheft. 45

GBS. IV. Dropfy in both Cavities. 48

OBS. V. Htemoptoe. $5

OBS. VI. Dropfy anafarcous from Lofs of Blood.

61

OBS. VII. Empyema and Apoftem of the Lungs* 62

OBS. VIII. 66

S EC T. Ill Of the Live r.

OBS. I. Suppuration in the Liver. 68

OBS. II. Apoflem of the Liver. 70

OBS. III. Symptoms and Effecls of the Stone in the Gall Bladder. 77

OBS. IV. Vomiting from an Induration of the Pan- creas. 8 1 OBS. V. Abfcefs in the Lungs from another in the Loins. 86

SECT. IV.

Of the Drops y.

OBS. I. A'1. a f area from an Uterine Hemorrhage. 89 OBS. II. Anafarca from Olfirufiion in the Skin. 9 1 OBS. III. Af cites from Qbftruftionsin the Skin. 92

OBS.

CONTENTS.

rOBS, IV. Afcites from Objlrucjions in the Kidnies,

93 OBS. V. Afcites from ObflruElions in the Liver. 94 OBS. VI. 96

OBS. VII. Afcites from an obfirucled Spleen. 100

SECT. V.

Of the Intestines. OBS. L Dyfentery from an Apoflem in the Reel urn.

OBS. II. Iliac PaJJion from Adherence of the In- teftines. 1 1 8

OBS. III. Iliac Paffion by Involution. 120

OBS. IV. Suppreffion of the Contents of the Inteftines, from Weaknefs of their Fibres, 123

OBS.V. Flat Worms. 128

OBS. VI. Round Worms, 130

OBS. VII. j3j

SECT. VI.

Of the Kidnies and Bladder.

OBS. I Total Suppreffion of Urine from Weaknefs in

the Bladder. 133

OBS. II. Total Suppreffion from Weaknefs in the

Bladder. 135

OBS. III. Total Retention from a Stone in the Bulb

of the Urethra. 137

OBS. IV. Total Retention from an Inflammation in

the Kidnies. 142

OBS. V. Strangury from folding Urine. 144

OBS. VI. Strangury from fcalding Urine, 147

OBS.

CONTENTS.

OBS. VII. Stone in the Bladder. 149

OBS. VIII. Stone in the Bladder. 151

OBS. IX. Stone in the Bladder. 152

OBS. X. Stone in the Bladder, 153

OBS. XI. Stone in the Bladder. 156

OBS. XII. 157

OBS. XIII. 158

OBS. XIV. Stones in the Kidnies. 161

OBS. XV. Stones in the Kidnies and Bladder. 162

OBS. XVI. 166

OBS. XVII. Stone in the Bladder. 167

OBSER-

— -■ —

OBSERVATIONS

O N

Different Diseases.

SECT- I

Of the Head.

OBSERVATION I.

Lethargy and Paralyjis fro7n coiitufed biteguments.

IN fummer 1752, a young woman was brought to Steevens's, who re- ceived a ftroke with a fkellet on the left Parietal Bone, bruifing the Integu- ments twelve days before. The whole Head was fwelled, and together with the Neck covered with an eruption like that in the mealies in the two or

A three

a Of the HEAD.

three firft days of that difeafe. She could not fland eredt, but }f left to herfelf, would reel, and tumble, and fleep. In the place of contusion two fedions were made, ■ at right angles to each other down to the bone ; and the angles being raifed and removed, no frafture could be traced. The wound was fuffered to bleed and fuppurate; in fome days it digefted and healed, and fhe perfectly recovered.

If from an external violent caufe, therefore, a Drowfinefs and Paralyuck affection a rife, attended with an Eryfipelas over the Head and Neck ; we may fometimes conceive the former rather as pro- ceeding from a compreffing of the Brain, by being overcharged from the obftruclion of the external Membranes o5f the Head, than as fymptoms of pref- igure from extravafation in the internal Membranes, and efpecially if no traces of fracture appear to the fcalper. This eryfipelacous appearance has been ob- ferved by Henry Francis le Dran *, a man of great circumfpedtion, fagacity, and experience, who af- ligns it to the- wound of the Membrane of the Skuli, or other aponeurotick expanfion, and that it may be held as a fymptom of violence done to thefe Mem- branes.

* Obf. 15. and Operations, London, 1749. 370.

OB-

Of the HEAD. 3

OBSERVATION II.

Lethargy from Extravafation on the Dura Mater.

In April 1752, was brought to Steevens's a man about forty. Eighteen days before he was thrown by a horfe againft a wall that ftruck him oblique on the left Parietal Bone. The Integu- ments being lightly contufed, he was fomewhere dreffed fuperficially, and thought to be fecure. The feventeenth day from the accident, the day before he came to the hofpital, he grew drowfy, and a general resolution of the whole fy- ftem of the Mufcles fucceeded. The eighteenth day he flept profoundly, and fnored without fenfe or voluntary mo- tion ; the Integuments being raifed, no fradture appeared. It was determined however by the Surgeons to trepan him 3 which being accordingly done, as foon as the piece in the crown of the Trephine was removed, and even be- fore, the matter flowed out, and conti- nued to difcharge from between the Dura Mater and Skull. In the evening he awaked, and the matter being all dif- A 2 charged,

4 Of the HEAD.

charged in a few days, he recovered both his underftanding and motion.

Blood extravafated, therefore, will put on the form of Matter, that is to fay, it will corrupt without con- tact with the external air; and if it increafcs in quan- tity, will, by its preiTure only on the Brain, incom- mode the functions of the Organ : For as the Dura Mater, by the experiments of Haller *, is deftitute of feeling and motion by irritation in common with the Membranes of the two inferior Venters, it could not be that the want of fenfe and motion in the whole fy- item did arife from the quality of the extravafated and flagnant fluid, acting on the Membrane, but did by its pre fibre only ftop the propagation of that which be- ing communicated to the Fibres of the Mufcles, puts them into motion, and to the Fibres of the interior parts communicates motion, which from habit is not attended to by the thinking thing that is within us •, and Blood may be extravafated many days on the Dura Mater without any damage to the Membrane. The fafety therefore of deferring the Trephine, as in the preceding, may be indubitably fettled, for it would have been ufelefs there, though the fymp- toms were the fame.

OBSERVATION III.

Lethargy from Exiravafaiioii fotwi the Membranes.

The 2 5 th of October 1755, a boy of fourteen, on the left fide of the head,

* On Irritability, &c. p. iS. Loud. i~ ;.

received

Of the HEAD. 5

received a kick from a horfe which cut up the Integuments to the very bone. He lay for fome time quite motionlefs; when he came to himfeli they conduct- ed him to fome place where he was dreffed {imply, and feemed tolerably well to the feventh of November, when he became drowfy and ftupid, and was brought to Steevens's, being thirteen days from the accident. The day fol- lowing he fell into a deep fleep, and his right arm became quite paralytick. The Integuments being removed no fracture appeared, but being trepanned on both fides of the Coronal Suture, from the Foramen in the Frontal Bone came out an inconfiderable quantity of Pus, and from the Parietal Foramen nothing. The next day he flept deeper than be- fore, and his Pulfe was quick and de~ preffed. On the fixteenth day from the accident his Face was inflated, his ftools and urine came off involuntarily. The Dura Mater being cut through in both Foramina, fome Pus came up from the Pia Mater. In the evening of this day he died,

A 3 The

6 Of the HEAD.

The day after the Integuments of the whole Skull being removed, the tendon of the Frontal Mufcles with the Peri- cranium appeared quite feparated from the Bone down to the orbits of the Eyes. The Skull being fawed and raifed with as much of the Dura Mater as lined it, the Pia Mater and Brain were exhibited to view. A fmall effufion of Pus was fpread fuperhcially on the Pia Mater, and fome Blood Veffels paf- ling to the longitudinal Sinus divided, and the Membrane every where thick- ened. On removing the Membrane and feparating the Hemifpheres, fome part of the Pus was obferved covering the Corpus Callofum, yet the Brain did not feem injured in its organical conftitution. Now the Dura Mater being removed from the part of the Skull fawed off, there appeared near the holes of the Trephine a fifTure of the Inner Table which croffed the Su- ture, paffing obliquely to the External Table, fcarce difcernable to the eye, and without any injury perceptible to the External Table : nor was the^e any

Pu?

Of the HEAD. j

Pus or Blood between the Dura Mater and Bone.

The application of the Trephine, therefore, is not fo likely to fucceed, if the extravafation is between the Membranes as if above the Dura Mater only ; for Blood and Pus may diffufe themfelves too far on the Pia Mater to be emitted by trepanning ; and if the V:fTels on the Pia Mater bleed below the Mem- brane, the Blood may fall between the Hemifpheres, and there corrupting deftroy the Brain. Now from the fmall quantity of the expanded matter, which could make but a flight imprefTion, having fo much fpace for its expanfion, it is probable the Brain fuf- fered in its organical ftruclure, fo that its medul- lary texture was broken like jelly in a glafs, tho' the change, as not tranfparent. was not evident to fenfe, for the fifiure internal fignified the Impetus of the Vibration, communicated by the Pulfe of the Cra- nium, was loft in the Brain \ which has been like- wife obferved by the judicious Monf. Je Dran *.

OBSERVATION IV.

Lethargy from Extravafation below the Pia Mater ^ and among the Mem- branes.

A man about thirty, on the fecond of March 1755, received aftroke with

* Obf. 17. Lond. 1740,

A 4 a

8 Of the HEAD.

a pole on the left Parietal Bone, which fractured the Skull to fplinters, and wounded the Membrane. On the eighth he was brought to Steevens's : the wound being cleanfed and the fplinters removed, the Trephine was applied on the 12th, being drowfy, indolent, pale and difpirited. When the piece, taken out by the Trephine, was examined, the Inner Table ap- peared feparate from the external : the motion of the Dura Mater was ftrong in the hole ; the lethargy continued. On the fifteenth the Dura Mater was cut through, but no Blood iffued from beneath. On the feventeenth in the morning he died.

The Cranium being removed. Pus was expanded on the Dura Mater around the hole of the Trephine, to the breadth of the palm of one's hand, and the Dura Mater being removed, an equal furface of Pus was diffu'fed en the Pia Mater. Now at one place under the ftroke and the fra&ure, the Pia Mater appeared black, and on flitting

the

Of the HEAD, 9

the Membrane a clot of Blood was difco-

vered which had formed for itfelf a cavity

in the fubftance of the Brain5 as large as

a pullet's egg, but not corrupted.

Blood, therefore, extravafated from the Pia' Matter, may not only ditfuie itfelf fo far as to fall between the Hemifpheres, but force its way into the fubftance of the Brain, and there accumulate.

OBSERVATION V.

Lethargy from a Depreffion of the Skull and Corruption of the Brain.

A man about 40, on the fourth of April 1755, had a portion of the Frontal Bone, on the left fide, de- preffed with the ftroke of a fpade, which depreffion was fhaped like a notch. On the fixth he was brought to Steevens's. The feventh and eighth he was ftupid and drowfy with fre- quent convulsions. On the ninth he raved. The Trephine being applied, the depreiTed part raifed and fplinters of the Inner Table removed, Pus and Blood came from beneath the Bone: To the 1 6th of the month he continu- ed in a deep fleep without convulfiqns;

and

io Of the HEAD.

and being the twelfth from the inju- ry, he had tremors and fweats, and then died.

The Cranium being removed, the Membranes were lacerated and the Brain, of the fize of a cubic inch, was corrupt underneath.

Convulfions may be therefore caufed by the fplinters of the Internal Table pricking the Brain, and may fometimes indicate the exiftence of fplinters pointing toward and piercing the part •> for by the ex- periments of the celebrated Haller, the Membranes are conftitnted void of fenfe or perceptive powers -, and in the preceding, where the Membranes were divided to fearch for extravafated Blood or Pus, I obferved neither exprefiion of pain, or motion fuch as arifes from irritation without pain ; though the want of either fenfe or motion in thefe cafes, is by no means an argument of their want of either in a ftate of health -, for the Brain is fo affected in all wounds of the Head, that probably it may not convey to the mind the idea of continuity folving in its Mem- branes at thofe times.

OBSERVATION VI.

'Lethargy and Paralyfts from a Ccn- cujfion with Extravafation.

A very fat man about forty (coach- man to commiffioner Burke) on the

tenth

Of the HEAD. M

tenth of May 1755, fell down back- ward in the liable under a coach horfe ; the horfe, frighted and ftarting, fet his foot on the mans head at the left fide of the Frontal bone, and rammed it to the ground; the Integuments being lightly bruifed, he was treated in the country as if only contufed, yet he was not fo well but they fent him to Steevens's on the 2 if!:, being the eleventh day from the accident ; he fevered flightly in the even- ing with horrors and thirft, but in two hours the fever intermitted, and returned in like manner on the 2 2d, 23d and 24th; then a flight Paraly- fis of the left Thigh fucceeded, and when about to {it down he plumped into the chair, as if a Paraly fis of the whole fyftem of Mufcles had caufed it. On the 25th he was drowfy, the lower Mandible convulfed. On the 26th, he raved: the Trephine was applied immediately under the bruif- ed Integuments; Pus appeared in the Diploe, a little on the Dura Mater, and a fmall quantity came up from the Pia Mater, when the Dura Mater

was

12 Of the HEAD.

was cut through/ The Lethargy per- fifted. On the 28th of the Month, and the eighteenth day from the ac- cident in the evening he died.

When the Integuments were re- moving the following day, the Pus appeared every where expanded on the Frontal Bone under the Pericra- nium, which was fliaken from the Bone. The Cranium removed, ex- hibited the whole furface of the Dura Mater, on the left fide, covered with Pus. The Dura Mater, being cut and removed, (hewed the Pia Mater in like manner overfpread ; and in the part of the Skull which remain- ed on the Spine, diametrically oppo- site to the hole of the Trephine, be- tween the Membranes, a confiderable quantity of clotted Blood was accu- mulated and flatted by their preflure; but the Skull itfelf, either in the part fawed off or that which remained on the Spine, was no where injured.

Hence we may &e how (Irong the vibration of the Shell is fometimes from a return of the ftroke, (6 as to be able to (hake off the Pericranium and

5 Dura

Of the HE A D. \\

Dura Mater on both fides the Bone, for it is by the ftrength and quicknefs of the Vibration, that this feparation is effected, and that the vefTels between the Bone and Membrane, and between the Mem- branes, being divided, the Blood diftils, from whence the Pus, overfpreading the Membranes, arifes; and from hence we may likewife deduce how dangerous a fign it is, when a drowfinefs and Paralyfis continues after dividing the Membranes, and the Skull is no where injured, or but (lightly fiflured, as in Obf. III.

Moreover in a concuftlon with extravafation, the extravafation may happen on the fide oppofite to that where theftroke is firffc given. Now as the Paralyfis of the left thigh was fir ft obferved, being the fame on which the Head received the firft (hock, we may fay fometimes that if the Paralyfis be of the fame fide with the contufion, an extravafation is on the oppofite ; for the Paralyfis of the left thigh was firft obferved and more evident, and the clot, by whofe preflfure it was caufed, much thicker than the fuperficies of Pus on the left fide ; which to my knowledge hath not hither- to been obferved ; not indeed is the obfervation of any great uie ; for the ftrength of the Pulfes of the Skull going and returning, has very probably fo fhaken the Brain, that its medullary tracts preferve not that pofition and diftance among themfeives which may be fervient to the due functions of the Organ ; nay even were it otherwife, that the Brain preferved its Organical ftructure9 yet as there is no indubitable mark for the Trephine to fix on, the letting out the Matter or Blood is thereby impracticable, even were it between the Dura Mater and Bone.

OB-

i4 Of the HEAD.

OBSERVATION VII.

Lethargy from the Brain^ broken and putrifxd.

In July 1752, came a youth about eighteen to Steevens's, who had fallen from a horfe perpendicularly fourteen days before ; and from the time of the fall he was drowfy, filer t and inert; he rarely opened his eyelids, and when he did, the Eyes feemed quite mo- tionlefs, the bruifed Integuments re- moved, no fradlure appeared. The Trephine being applied on the Crown, near the Sagittal Suture, no Blood came from the Membane nor Pus ; the Membrane being cut through, no- thing came from beneath ; the Le- thargy continued. On the third from his arrival, and the 17 th from the fall, he convulfed. On the 1 8 th he died lethargick.

When the Cranium and Membranes were removed, among which there was no Pus or extravafated Blood, the Brain was found broken at its bafe,

and

Of the HEAD. 15

and putrified, but without extrava- fated Blood about it ; or in the Mem- branes near it.

The fuddennefs and continuance, then, ofthefymp- toms of the fame tenor, and their degree, may fome- times fignify a rupture in the Brain, and it alio appears, that a drowfinefs may arife from the Brain being broken without preflu re by extravafation : So the ef- fect of the Pulfe of the Shell, returning by the Im- petus on the oppofite fide, may not only feparate the Membranes from the Bone and extravafate Blood thereby, but the very Brain itfelf may be likewife broken : The Impetus was firft received on the Crown, and the Bafe of the Skull, returning the Vi- bration, effected this rupture by fuddenly propa- gating its additional Momentum through it.

Nor, from all the foregoing cafes, can it be de- termined on what day the drowfinefs will fucceed from the fall, or other impuKe •, for in Obfervation the fecond, it came on the 17th; in , the third, on the 13th ; in the fourth, on the tenth ; in the fifth, on the 3d ; in the fixth, on the 15th, and in the feventh, on the id -, it being according to the effect of the impulfe, or intenfuy of the preflu re, the Brain receives from the extravafation, or rupture.

OBSERVATION VIII.

Lethargy with Fungous Excrefcences.

In November T753, a boy about ten years old was brought to St George's

in

16 Of the HEAD.

in London 5 who received a blow with a pole in Hyde-park that fractur- ed the Skull : In fome days after he was trepanned on both fides the Sagit- tal Suture, (the fra&ure croffing the Suture) and the Membranes cut thro'. Now the Brain puffed out of the Fo- ramina to an inch or more at every drefling, and was constantly cut away, and thus continued till he died. He ilent likewife with an obfeure deli- rium the whole time.

It fhould feem, then, as if the Brain had a mo- tion independent of its Membranes, as all orga- nical and animated parts have: for it could hardly be the motion of the Pia Mater, which is fo weak a Membrane, that by repeated Syftole did exprefs this Fungus ; and for the Dura Mater from its adherence to the Skull at the Sutures, and in the intermediate fpaces by vefTels paffing between the Bone and Membrane, it feems totally incapable of Syftole. And in all the fore- going cafes, the vifible motion of the Dura Mater did not feem to be the motion of the Mem- brane only, but of fomething whofe impulfe to the finger was ftronger than the motion of the Mem- brane could be ; which you will readily perceive by paffing your finger through the hole of the Trephine, and prefTing the Membrane firmly.

Buc

Of the HEAD. 17

But herein I do not confider the caufe of its motion, whether it arife from a i welling of the Cortex in ex- piration, or exifts in the part as an Organ in action, independant of the motion of the Heart.

Moreover whether theie excrefcences of the Brain correipond in proportion to a fuppuration in other foft parts, to which Monf. le Dran * feems to com- pare them, or whether owing to the mere inteftine motion or agitation of the parr, I do not affirm. I once law an inflamed tefticle which abfceded, fhoot out a fungus in a manner not very difllmilar. Now if it is the nature of Glandular Bodies abiceding fo to do, it may be fome fort of argument that the Brain is of the Glandular kind.

OBSERVATION IX.

Epilepjy f?~om the Dura Mate?" ah- feeding.

In the year 1752, a man about 30 was brought to Steevens's, who had epi- leptick fits returning feveral times a day for three years. On examining the Head, there appeared a fulnefs on the left Parietal bone, which had remain- ed from a ftroke of a faplin about the time of the commencement of the fits.

* Obf. 24. Lond. 1740.

B The

18 Of the HEAD.

The Integuments being raifed, it was difcovered to be afwelling in the Bone; the Trephine being applied in the place, in the operation the Bone was found cellulous and fpungy with Pus in the midfl ; to the Bone the Dura Mater firmly adhered. In fome Days after he died in a Lethargy.

The Cranium with the Dura Ma- ter being removed, there was a circu- lar afperity on the infide the Bone, about the iize of a crown, and feve- ral abfeefles in the Membrane about the fize of peas adjacent to the hole.

A Bone therefore may fuffer by contufion an ex- travafation in its Diploe. The extravafated Blood, by corrupting, may effect an abfeefs in the Bone, as in the foft parts when fo affected : which cor- rupted Matter will foften and fwell the Bone, and produce the difeafe termed by the Arabians * Spina Ventofa •, probably as the Bone in this difeafe feems inflated, and being obferved oftener in the Spine than other Bones, this was made an univerfal Name for fuch Diftemper in any Bone. If this difeafe hap- pens to a Bone of the Head, an inflammation may be raifed in the Membrane underneath, which ter- minating in one or more apoftems, may induce an in-

* Avicenna, lib. 4. Fen. 4. Trac, 4. Cap. 8.

curable

Of the HEAD. 19

curable Epilepfy, adrowfinefs and death; and this may rather be occafioned by the Pus or Ichor of thefe apoftems, or by the vapour expiring toward the Brain, and thereby difturbing it, than any fpafm of the Membranes, for the reafons laid down in the preceding ; which have been alfo noted by the noble Hungarian Kovats Tatai*: Becaufe, when the Brain is irritated with fharp Matter, the whole ani- mal falls into convulfions -, and the Pia Mater, be- ing connected by VefTels to the longitudinal Sinus, and in the intermediate fpaces by velTels between the Dura Mater and it, and its want of irritation and fenfe, is equally incapable of fpafms, held fometimes as caufes of the fits.

We may likewife note what ferious attention an extravafation in, or a diftemper of, the Bones of the Head merits, and how ufeful the Trephine turned, till you get to the midft of the Bone, may be, when early applied in fuch affections : for thus you let out the extravafated Blood, Matter or Ichor, which otherwife will foak through the Inner Table to the Membrane. A fimilar cafe you will find in the Ob- fervations of Le Dran -f\

In the obfervations related, we have feen apo- plectick fymptoms arifefrom extravafations of Blood and Pus between the Dura Mater and fkull, as in the fecond-, between the Membranes, as in the third and fixth -, from the extravafated Blood forcing into the medullary fubftance of the Brain, as in the fourth -9 and that paralytick fymptoms arife from the fame

* De Epilepsia Ultratrajefti 1670. f Obf. 27.

B 2 caufes j

20 Of the HEAT)'.

caufes •, and that they are all fatal unlefs the Blood has an exit, and the Brain and its Membranes are free from permanent impreffions, as we have feen in the fecond cafe. Whereby we conclude how ufeful and juflthofe rules of the Surgeons are, when they repeatedly and diffufivdy bleed in all wounds and concuffions of the Head, to prevent thofe fatal ef- fufions, and abforb that which may have extrava- fated while fluid, before it can run into clots by ftagnation. And in all thefe we may remark that where the Brain is the part affected, the powers of the underflanding are likewiie affected; which may lead us fometimes into the part precifely affected in paralytick diforders, as they have their caufes exig- ent in the Brain, Medulla Oblongata, or Spine.

And that fimilar extravafations happen from in- ternal caufes, as when the veffels are eroded by (harp Lymph flowing in their Tunics, tranfudation from rare veffels, or rupture from plenitude, we have the authority of the Royal Society to prove. For Cole * teils us, that an hyfterical lady, who had been liable to Hemorrhages of the Nofe, on a neglect of bleeding, her ufual remedy, and an ill-timed ufe of Aftringents, was taken with a violent pain in her Head and a faukering fpeech, and fo died immedi- ately. On opening the Head next day, he found the veffels in the Membranes of the Brain, the Pia Mater efpecially, on the right fide of the Head, being the part fhe complained of, turgid with Blood, and the Membranes being cut, emitted from

* Tranf. Phil. vol. 3. 29.

beneath

Of the HEAD. i\

beneath a great quantity of bloody Lymph, and in the fubftance cf the Brain an ounce and half of gru- mous Blood, which had formed for itfelr a cavity. The famous Anatomift Marcellus Malpighius, as we are told by Lancifius, being fazed with a Ver- tigo, a lofs offpeech, a contortion of the Mouth, and pally of the right Cide, was taken off with an apo- plexy. In the right Ventricle of the Brain were found near two ounces of extravafated Blood, with more than half as much of yellow Phlegm in the left Ventricle. And * Adams found in the left Ven- tricle of a woman, who died of an apoplexy, near five ounces of clotted Blood, the whole right fide of the Trunk and extremities being firft feized with the palfy.

Moreover that the fame fymptoms may fome- times arife from the Serum or Lymph fweating trom the Membranes, and by its preffure, whether it ex- ift among the Membranes or in the Ventricles, hin- dering the due function of the organ, or the propa- gation of the Will along the medullary tracts to the Fibres of the Mufcles or interior nervous Membranes or parts, we have the authority of Wepfer f to de- pend on, who was one of the mod learned and in- genious Phyficiansof thofe times: He tells us that Jacob Reutinger, a full man, about fifty, and given to excefTes, fome weeks before he died had fo vio- lent a pain in his Head that he was quite diilra&ed ; about three weeks before he died he became totally blind, made urine involuntarily, grew paralytick, firft in his right and then in his left Leg j at length

* Tranf. Phil. vol. 5. 210. \ 0bf. 4. de Apop. Sea-

phufi, 1675.

B 3 fell

22 Of the HEAD.

fell down in a violent apoplexy, in which continuing four days he expired. On raifing the Skull and wounding the Dura Mater, the water jetted up, leaving a more than natural fpace between the Mem- branes-, the like was obferved between the Pia Ma- ter and Brain •, the Brain had imbibed it plentifully ; all the Ventricles were full, even the canal of the Spine itfelf. And that Urfula Frigen, in her 37th year, and during her being with child, had vio- lent pains in her Head with a Vertigo ; in her fourth month (he fell down in a violent fit of apo- plexy, deftitute of fenfe and voluntary motion, in which (he continued three days, then fenfibly came to herfelf, except that her right Leg and Arm re- mained paralytick, and her Underftanding weak- ened : In her nine month fhe became melancholy ; and from the time of her lying-in, till her 4^th year, continued unequally fo, and died of a plrurify : On removing the Skull, the Dura Mater feemed raifed up as if by vapour, its Arteries turgid ; under the Pia Mater all parts were immerfed and foaked in Lymph; the Ventricles full; the vefTels of this Membrane turgid ; Lymph round the Medulla Ob- longata •, and lome too flowed out of the Spine ; in the right Plexus Choroides feveral Hydatids, of which fome were larger than a pea ; in the left Ven- tricle there were likewife feveral, one of which was greater than an hazel nut ; the Cerebellum flaccid ; the Spinal Marrow fmaller by much than it ought. And * Conradus Bruner tells us that Chriftopher

* Obferv. Celebrium. Amfterdaro, 1724.

Weiler,

Of the HEAD. 23

Weiler, in his 64th year, an incefTant drinker, a fmith by trade, fell down dead in an apoplexy, as he was at dinner in his (hop ; the whole fpace between the Membranes was rilled with Serum ; all the veffels and cavities, even the fourth Ventricle, and the whole Bale of the Skull were inundated, to- gether with the Canal of the Spine, in which too there was a Cavity filled with Lymph. Such are fome of the material caufes of the fymptoms of fenfe, intellectual powers, and voluntary motion.

As to the diftinction of apoplexies from thefe different caufes ; thole from Sanguineous «extrava- fations, or fudden fwellings of the Membranes give very little notice, the Brain being fuddenly comprelled by the fwelling, the fymptoms inftantly follow. By extravafation the Brain is at at once overwhelm- ed, and all voluntary motion almoft, if not alto- gether fuppreffed j but thofe from Serous exfuda- tions, being formed by degrees, moftly fignify themfelves by head-achs, vertigoes, drowfinefs, numbnefs, and even refolution of fome of the Muf- cles and fatuity *. And they alfo follow the errors of incefTant and intemperate drinking, obftructions to the difcharges of perfpiration and urine, or the drying of an old ulcer whofe Ichor has diffufed it- felf in the Cortex, Membranes or Ventricles.

Sometimes apoplexies have been known to arife from caufes not evident to fenfe by dilfedion. A remarkable example of which is related by Willis +: He found in an elderly gentlewoman, who was fud-

* Sir Edmond King, Tranf. Phil. vol. 3. 157. f De anima brmornm, Oxon. 1672, p. 389.

B 4 denly

V

J

24. Of the HEAD.

denly taken off with this diforder, neither fwelling of the Membranes, Cortex, extravafated Blood, Lymph, or ill conformation of Brain or Membranes, nor any morbid difpofition or preternatural appear- ance in either of the other Veneers. So that he af- figns as the immediate caufe fome heterogeneous materials depofited out of the Blood in the Brain, which acted by extinguishing the ipirits: and (to me) not without reafon too-, tor if a drop from the poifon-fangs of the Rattle-Snake * killed in a mi- nute withfymptoms not very diffimilar, or the bite of the creature called by Galen Phalangium, or Tur- tur Marinus, or Scorpio Terrenus, can propagate its deadly effects in an inftant, I fee no reafon but fuch an humour might be fometimes generated in the Blood and depofited in the Brain, and tho* fmall in quantity yet great in Power 'as Galen fays f) have a fimilar effect. Whether that effect mould arife from a want of that which is conveyed through the nervous Fibres and Membranes of the fyftem, as in the cafe of extinction •, or from a fudden and uni- verfal fpafm of the fame parts into which they might be thrown by the action of that humour on the ethe- real medium of the medullary Tracts and Fibres of the Nerves ; at leaft I fee no contradiction in it.

Now, if thefeand fuch obfervations are duly con- fidered, we may readily infer how ufeful and effec- tual instantaneous and copious bleeding may be in fudden apoplexies J from internal caufes ; and efpe-

* Sir Hans Sloane, Idem, vol. 9. 5;. + Galen de locis

affedlis, lib. 3.C. 5. et lib. 6. 5. J Hildanus, Cent. 6. Obf. 12- rranckfort. 1682, fol.

dally

Of the HEAD. ij

cially if (from the florid and turgid complexion of the perfon, his fhort Neck, whofe Mufclts are likewife environed with fat, his full feeding, drinking re- peatedly, violent paffion of joy or furprize by whofe actions on the nervous parts too much Blood may be thrown on the Brain, want of exercife to carry off the load, or break down the Grumes into which the Blood of the infarcted vefTels may be apt to run) there is reaibn to think this Venter is loaded with blood : For all fuiinefs of this Organ is to be held much more dangerous than a fuiinefs of any other, as the very compreflion of the medullary tracts, which eafily yield from the foftnefs of texture, fufpends all communication between the Organ and the reft of the fyftem, which is immediately necef- fary to the life of the perfon; exciufive of the pof- fible and defperate confequence of extravafation. And even if the caufe Ghould be extravafated Lymph, the emptying the vefTels by copious bleeding may relieve the Brain for the prefeiit, and poflibly con- tribute fomewhat to its reforpti.on, provided the ef- fufion of it be recent. Dr. Gibbons f of Oxford cured one held deplorable, by taking away fixty ounces at once, which by the moll exact eftima- tions may be five ninths of the Blood contained in the vefTels when they are moderately full. And Cole himfelf cured a Vertigo remaining from an at- tack of an apoplexy in a Lady of feventy-feven years old, by taking thirty ounces at once, and in a week after as much. Befide this immediate and plentiful depletion, it is alfo requifite to add a very ftimulating

f Cde en Apoplexies, Oxon. 1689. p. 173.

Clyfter

26 Of the HEAD.

Clyfter of fuddcn operation, fuch as warm water with a fourth or a third part of Tincture of Jalap or of the antimonial Wine ; and at the fame time two fcruples or half a drachm of the compound powder of Scammony out of fome fimple or fpiricuous water, and given by fpconsful, in order to clear the whole inteftinal Canal •, for by thefe means the Blood of the Mefenterick Arteries having an eafier flux through the Membranes of the Inteftines and Mefentery, than when they were comprefTed by the Repletion, the Ve- locity in the deicending Aorta above thefe veffels will be thereby accelerated by the removal of the refiftance of the columns of Blood in thefe Arteries. Befides the preffure on the Trunk of the defcending Aorta by the Inteftines being removed, the Blood will run down the Spine and Iliacs with the greater free- dom, and in conlequence of all this the derivation from the Carotids and Vertebrals will be very conli- derable : Thus you will obferve how clear and light the Head will often become in fevers from the ex- hibition of Clyfters, of which phenomenon this this feems no irrational account.

Befides the foregoing proceedings, it will alfo be expedient to lay Blilters on the Neck, Shoulders and Legs •, a fevere though a juft proceeding ; for the falts of the flies getting into the Blood, by their mix- ture with it will draw the attracting Globules afunder, the Globules being more flrongly attracted by the Salts than by each other •, and by their ftimulus on the fenfible and irritable Fibres will raife the Vibra- tions of the Membranes, and in confequence acce- lerate the Fluids they contain, which acceleration

will

Of the HEAD. iy

will be propagated throughout all the nervous Mem- branes by confent. And fhould the apoplexy be of the ferous kind, the derivation of Lymph from the origins of the Nerves muft needs be of fignal ufe.

There is alfo another way of ftimulus, by Cau- tery, which may be tried if neceffity require ; for if the Skin be touched near the Neck, or any other part therewith, as being a nervous and fenfible Mem- brane, it will foon tranfmit its feeling to the Brain, if there is any life at all remaining, and roufe it to a fuccefiion of the obftructing Matter.

Laftly, if by thefe feverities we are fo lucky to get over the fit, then nature may be affifted with fpirituous cordials : Such are Pennyroyal or Cinna- mon fimple waters, with a fourth or thereabouts of compound fpirits of Lavender, a twentieth of fpirits of Harts horn or the volatile Aromatic fpirit, given at fmali intervals and repeatedly by fpoonsful.

Among the antecedent caufes we have afligned above, are full feeding, an inactive life, want of due difcharges, and fudden paflions of the mind : But the Air itfelf has been obferved productive of this diforder in the epidemical apoplexy in England about the year 1688, and that by its fenfible quality cold. The reafon of which feems to be, that the Skin is fo conflicted as not to fuffer the due proportion of vapour to exhale, and if fome other Gland does not officiate for it, a plenitude muft be the natural con* fequence, provided the quantity of food is given during the time of this coldnefs from day to day ; befide, the Fibres of the whole fyftem of Mufcles are fo tightened up, that their blocd is driven into

the

28 Of the HEAD,

the Interior parts and Membranes, infomuch that they are inundated therewith ; and if this conftitu- tion of the Air continue for a time, the Heart and internal Membranes may, from their oppreftion, be rendered wholly unable to return it into the parts above the Bones. As to the conftitution and make of parts liable (caeteris paribus) to this diforder, that of a fhort Neck has been obferved, yet I do not re- member any reafon afiigned why it mould be pro- ductive of it. The reafon may be, that the appulfe of the Blood is quicker on the Brain (ceteris pari- bus) than where the Neck is longer ; for inftance, let F exprefs the force of the Heart, L the length of the Carotides and Vertebrals, D their diameter : Now it is demonflrable, from the doctrine of Hydrau-

v-F

licks, that the velocity in Pipes is — —- therefore

when F and D are given the velocity will be as j t-

Now if the Appulfe is quicker at every fyflole of the Heart, the fweliing in confequence of the Mem- brane and Cortex will be more iudden, and efpe- cially if the Egrefs of the Blood is any way retarded by the comprefiion of the Fat upon the Veins de- fending from the Head.

Hitherto we have confidered the antecedent and immediate caufes of this diforder, let us now trace the consequential effects : When the fit is difcuffed, the veffcls of the Membranes and Cortex are often left fomewhat dilated and defective of their juft Ela- sticity ; moreover by the fweliing antecedent, the re- lative pofitions of the medullary tracts are probably

changed

Of the HEAD. 29

changed among themfelves ; and it is by this dila- tation and change of relative pofition, that the vef- fels are fo liable to returns of obftruction, and the actions of the thinking thing which is within us are often impeded, as depending on the due fituation of the medullary tracts : And thofe impediments are manifeft by the vifible decay of apprehenfion, me- mory, reafon, and lively voluntary motion, of which lad there is often left in fome part a total defect. And if the fit were of the ferous kind, the Membranes, and the Brain itfelf, are left fo moift, that they are as liable to returns and other imperfections, as if from the expanfion of the vefTels in the other kind ; the Vibrations being thereby lefs vivid.

In this cafe, the cure will partly depend on diet and partly on medicines. The ufe of any medi- cine intended to reftore elafticity to dilated Fibres, or dry the humid Membranes, is vain. But it is evi- dent, that by whatever means the vefTels of the parts can be conftantly emptied or preftrved from intumefcence, that by perfeverancein the care there- of, the veiTels of the Cortex may recover their tightnefs, and the medullary tracts their relative po- rtions among themfelves : But the vefTels can be kept from fwelling again only by detracting from the diet or encreafing the difeharges •, cf which the former is by much the more eligible, as carrying with it an uniformity and certitude the others are incapable of. If a man's diet in a natural day be five pounds, or fixty ounces troy, and he detract a fifth, and the fum of the Secretions be to the food ftill in a given proportion, and the Secretions alfo

to

3<j Of the BEAD.

to each are invariable, then will every part lofe in proportion to its fize ; and if thefe methods are continued, the loaded part will at length recover itfelf : And if the drink is leffened in a greater pro- portion than the folid food, the fwelling or dilata- tion will not only fubfide, but the Membranes or the Cortex, being drier by thefe means, will be the more difpofed to reimbibe any fluid which may there extravafate. But as there are fome who are ufed to intemperance, to whom this perfeverance would be worfe than death, then the encreafing the difcharges is the only way ; which is done either by bleeding, as Cole did, or repeated purging with fome warm tincture, as Tinclura Sacra with a fourth of tincture of Senna, or any other of like power : For Diureticks, which have that power without adding to the quantity of Serum, can be fcarcely relied on, as they lofe their Simulating powers moftly before they arrive at the Kidnies.

In all the foregoing cafes, we have feen that pa- ralytick affections, having their caufes within the Skull, are attended withdrowfinefs or other change in the powers of the underftanding •, that is, the mind, having loft its power of propagating its in- fluence to the exterior ends of the Nerves, fo alfo has it of receiving impreiTions at the ends of. the Nerves, with the vivacity it ought to do, or reafoning duly about what it has fcarcely and flowly received. Whence we may fafely fay that paralytick affections, with perfect underftanding, have their caufes rather exiltent in the Medulla Ob- 5 longata

Of the HEAD. 31

iongata and Spine, and poffibly in the Cerebellum. Now thefe caufes are fuch as produce a Faralyfis or the whole man, but differ in this, that the perma- nent fwellin°;s in the Membranes or Cortex of thefe parts, or extravafation of Blood or Lymph, is lefs diffufive than in the firft; and the idea is juft the fame, fubftituting only vertebral Sinufes * and arte- rial Rings within the Spine, for Carotids and ver- tebral Arteries and Plexufes, and venal Sinufes in the Head ; and though treated juft in the fame way, yet they are often difficult of cure, partly for the impofTibiiity of abforbing extravafations of Blood, and the difficulty of imbibing the Serum, or dii- cuffing the materials congefted in the Membranes where the Nerves of the parts arife.

It was by lefifening his diet, and changing the proportion of his drink to his folid food, that the late Dr. Robinfon -\ cured himfelf of a paralytick diforder in the year 1744. His weight, being then 164 pounds, by leffening his food in the pro- portion of eighty-fix to fifty-eight, his drink a third, and folid a fixth, and perfevering in ir, he loft of his weight in 17 months twenty pounds : Now the proportion of lofs in the Head and Spine carried with it the weight with which the Nerves and their origins were loaded and oppreffed -9 which, by the reafons above, very probably arofe from Congeftion. not extravafated, and which had not broke the medullary texture of the Spinal Marrow or its ori-

* Willis Cerebi Anatome, fub finem, Oxon. 1664. 410. f Food and Dicharges, p, 35, 61.

32 Cf the HEAD.

gin, the Medulla Oblongata, between the Brain and it.

Hitherto I have not confidered either the quality of the Blood, or the Fibres of the Mufcles, among the caufes of paralytick diforders ; it is true, that when the Fibres are foaked in Serofuies, being thereby relaxed and weakened, they lofe their elaf- ticity, but the effect of that lofs will be rather an impotent or weak tremulous motion, as in St.Vitus's Dance*, than what is properly called a Paralyfis: For take a limb truly paralytick in your Hand, weigh it, and the fenfe of the weight is fuch as of the whole quantity of (he limb -, but weigh a limb rather weak than paralytick, and you will find a perception of a caufe counteracting the gravity, it falling towards you only with the excels of gravity above that caufe.

As to the poverty of the Blood, by which it may be conceived unable to fupply the Brain with fpi- rituous fluid, if that Poverty be univerfal through the whole Mafs, as it mutt, then will all parts of the Brain be equally deftitute of fpirituous fluid, and the whole fyftem of Nerves and Fibres of the Muf- cles in confequence \ and thus will the whole man fall down Apoplectick. If the Blood be equally fizy throughout, the fame may arife from a total obstruction of the Membranes and Cortex, pro- vided the Membranes and Cortex are in an uniform aptitude to be obftructed *, but if the Blood be un- equally fizy, then may fome of the Lentors (top,

* Galen de tremore,

infarct

Of the HEAD. 33

infarct and fwell a part of the Membranes or Cortex* the confequence of which may be a Paralyfis of iome part as before obferved : Herein I confider the qua- lity of the Blood only fo far as it caufes obftruclions or extravafacion by erofion ; and the Fibres only fo far as their impotence may arife from want of due nutrition, which follows the obftruclions of their Nerves.

In the fecond, fixth, and ninth Obfervations the purulent Matter, diftilling from the Diploe, fhcwed an extravafation, and poilibility of Apoftems form- ing in the Bones : For that the Bones are vafcular we may infer from this ; and further from their be- ing tinged, by dieting Creatures with madder root * in their food, the black jaundice f, and yet further from the injections of Rufcius, and the prepara- tions of Dr. Hunter and Mr. Cleghorn, which be- ing tranfparent you may fee the lines of the VefTels through the Lamellae of the Bones.

In the ninth Obfervation we have feen that the Caufes of an Epilepfy are one or more Abfceffes in the Dura Mater, and that not by any Spaf.n in the Membranes, which we have (hewn impoflible ; but rather by its Ichor dripping on the Pia Mater, or its vapour expiring toward, and by its irritation dip turbing, the Brain, through that Membrane.

Of other Caufes of Epilepfies difcovered by dif- fection are Lymph extravafate about the Cerebel- lum (pofticam Capitis partem), induration- of the Ce- rebrum, and connection with the Dura Mater, and

* Tranf. Phil. vol. 9. p. 102. t Mead Prsccpt. Med. cap. 9.

C extra-

34 Of the HEAD.

extravafation of Lymph, within the Pia Mater, Cerebrum, and in the Ventricles •> which growing acrid by ftagnation or effervefcing as Pifo * con- ceives, produces thofe undulations in the Nerves, the Caufes of the Fits : So alfo are Caufes acting on the Nervous Membranes at a Diftance from the ori- gins of the Nerves, whofe effect is propagated in power to the Brain and reflected to the Mufcles, or internal Nervous Parts ; fuch are worms in the In- tefbines, Urine pent up in the Ureter f, or kept in the fyftem by want of power in the Kidnies to fecern J, and by its irritation acting like the txtra- vafated Lymph obferved by Pifo.

And it univerfally appears, that however the motion of the Heart may fometime continue inde- pendant of the Brain, yet the fyftem willfoon grow cold, inert, and fpiritlefs, for want of whatever it is that it derives from this fun of the Microcofm.

* Pifo de Morb. a Serofa Colluvie, p. 140, Edit Paris, 1663.

f Tran. Phil. v. 7. 486.

J Ridley Obferv. 30. Lond. 1703.

J Hoadly on Refpiration, p. 99 Lond.. 1740.

SECT.

t 35 ]

SECT. II.

Of the Neck and Chest.

OBSERVATION I

putney from a Swelling of the Larynx %

THE old Man* tells us, that in a Quincy or fenfe of fuffocan^n, it is an ill fign when no intumelcence appears either in the mouth or exter- nally ; and Galen f affirm0, that when there is afbong elevation o* the Spine and Cheft in the a& of infpiration , a* d the heat of the Cheft is moderate, it fignifies a ftridure of the Inftruments of refpiration ; and that it is fomeriines caufed by a refolution of the Mufcles of refpiration, which laft kind 1 have feen myfelf lately in an Hemipltcftick

* Progn. & Coacas Praenot. t De Loc. affedt. 1. 4. c. 3. 5.

C 2 Perfon;

36 Of the NECK and CHEST.

Perfon; but the diffeftions of later times have found, befides the intumefcence of the Uvula, Tonfils, and Mufcles of the Neck from Blood or Lymph, either in their Veffels, or extravafated into their interftices, that a Quincy is caufed by fwelling of the Epiglottis, Membranes of the Rimula, and Larynx. Reafon has alfo traced its caufe exiftent near the origin of the Nerves of the Larynx, which by irritation of the Nerves has thrown its Mufcles into fpafms ; or by irritation of the Trachea in the mode of natural perception * has produced a fimilar effed.

A man about thirty came to Stee- vens's in December 1755, with a very laborious breathing, ufing a ftrong extenfion of the Spine and elevation of the Cheft at every infpiration ; but his expirations were eafy, being paffive, and as it were a remiflion of infpiration only. His voice was fharp and low,

* Glifibn dc Natura Subftantiae, c. 15. & de Ventriculo, &c. c. 7.

but

Of the NECK and CHEST. 37

but audible and clear, no fwelling ap- peared either in the mouth or exter- nally; his pulfenot irregular, excepting that you might feel an intermiflion fometimes. He was free from pain, in- ternal heat, or fever, and walked about the hofpital the firft, fecond, third, and fourth of December, and played at cards iri the evening : On the fifth in the morning he was fuddenly fuffocated.

In removing the Mufcles of the La- rynx they did not appear in the leaft intumified ; nor was there any Lymph extra vafated in the interfaces of the fibres, nor any falling within the Mouth evident to fenfe ; but on tak- ing out the Larynx the Epiglottis ap- peared fwelled, foft, and (Edematous, fo alfo were the Artenoid Cartilages, and Membranes forming the Rimula. On fpliting open the Cricoid Cartilage, the Membrane lining the Larynx appeared very much fwelled and cedematous, but not red ; the Membrane of the Air Pipe was quite red, as if filled with a very fine injection, and fo down C 3 through

38 Of the NECK and CHEST.

through the Lungs as far as we could trace ; the right Lobes of the Lungs ad- hered to the Pleura, Mediaftinum, and Diaphragm univerfally.

Now as there was no internal heat or fever we conld not fay the Lungs and their Membranes were inflamed, though they adhered to the Membranes of the Chcft as parts in a ftate of inflammation are wont to CO •, but that the Membrane of the Air Pipe and its branches were inflamed, was evident to £nfc ; io the Trachea may be inflamed, independent O- the reft of ihe Lungs ; but the foft fwellings of the Larynx were the immediate caufe of his death, the afflux of Lymph clofing the Rimula, inspiration was cohibittu thereby.

Thus repeated Defluxions on thefe parts may, by the Fibres of the Membranes lofing their elafti- city, induce a permanent Oedema, and effect fuf- focation. The weakened Fibres yield to every fu ex- ceeding defluxion, being unable to exprefs the addi- tional congeftion ; and as the interior membrane of the Interline in an habitual dyfentery, fo will the Membrane of the Trachea fometin es from repeated inflammation and fluxion, ioofen from the pipe in the a6l of coughing, and caufe inftantaneous death. It was the principal part affeded in the fever epide- mical in Cornwall in the year 1749, which proved fatal almoft to every one, and efpecially thole of younger ages. Sometimes too the Mucus of the Trachea, when the fluxion is great, not very acrid

and

Of the NE CK and CHE ST. 39

and repeated, will be Co infpifiated on the Mem- brane, that it has been coughed up refembling the Membrane, or a Vefifel of the Lungs, as in the Cafes related by Tulpius *, Lofiius f, Samber J, and Nichols, and thereby the perfon happily relieved.

Hence we may infer the ufe and even necefiity of Biifters on the fides of the Neck, and the whole Larynx, after general evacuations by Bleeding, Purg- ing, Sweating, and Biifters on the Back, in Quincies where the Larynx and its Membrane are the parts affe&ed, fuch as were directed by the late Mead ||.

The antecedent caufes of fwellings in the Larynx are either the confinement of the vapour exhaling from the Neck, as in fudden accefs of cold air •, or going againft a wind uniformly blowing on the Neck, without fufficient covering •, or too great a proportion of folid to fluid in Diet, by which the Blood, not fufHciently diluted, runs into Lentors, and flops in parts apt to be obftructed ; the vcflfels being charged with unaiTimilated fluid, yielding materials for fluxion, principally caufed by want of juft pro- portion of the Sum of the difcharges to food in a given time.

jdjlhma from an Induration of the Lungs.

Hippocrates § fays, that if the Lungs grow dry and do not expectorate, they

* Lib. 2. c. 13. f Lib. 2. Obf. 13. J Tran. Phil. vol. 7. 564. |] Precept. Med. §. 94. 1754. § De Morb.

C 4 harden,

40 Of the NECK and CHEST.

harden, and terminate in death : And Galen * difcerns a bhortnefs of Breath from a fuppuration or fluxions in the Treachea by the wheeling, and from an induration by its increafe without wheeling. How far an induration of the Lungs may extend, together with its fymptoms and effects, the following obfervation will demonftrate,

OBSERVATION II,

In winter 1753, a man about fifty, tail and corpulent, coachman to one of the phylicians of the hofpital, came to St. George's in London. He had a Shortnefs of Breath for many years, un- altered in all politions of the Trunk, and without Hydropical Swellings in his Legs. After taking repeatedly the mod approved medicines, as well be- fore he came to the houfe as after his acceflion, he tired of them all, and died toward the end of November.

* Dt Loc. affed. 1. <t. c. 7.

In

Of the NECK and CHEST. 41

In the rio;ht fide of the Cheft there was fome extra vafed water of a dilute red Colour ; and a hole in that lobe as large as an orange ; in the left fide there was no water, but the Lungs were hardened into a rude inorganical mafs, without Membranes or Vefiels, or Fluids : In the pulmonary Artery- there was a polypous concretion of the thicknefs of a goofe quill, in colour white and red intermixed, and branch- ed ; and the Pericardium filled and diftended with water.

Now as one half of the Lungs were fo obftructed that no Fluids could move there, and a fixth (fup- pofe) of the other half broke up and confumed, there remained but two fixths or one third of the Lungs for the Blood to move through ; fo that a man may live fome time with lefs than one half of the Lungs continuing unobftructed.

A fhortnefs of breath perfifting for years, and nearly the fame in all pofitions of the Trunk with refpect to the Horizon, and without Hydropical Swellings of the Legs, may fometimes indicate an induration of the Lungs •, and agreeable to Ga- len's defcription it was unattended with wheefing (Jtertore).

Indurations

42 Of the NECK and CHE S T.

Indura ions of the Lungs may arife either by fluxions infpiflfanng in the Bronchia?, which by de- grees obftruct the finer branches of the pipe, and the reft in fucceffion, or by Lentors flopping in the Bronchial Arte.ies that fwcll the Tunics of the Pul- monary Veflcls, fiiit near their extremities, an in fuccefnon near the heart; or laftlv by Lentors flop- ping near the extremities of the Pulmonary Artery, though I believe but feldom, by reafon of the rapid motion ut the Bkiod through the Lun^s*. But in all theie incipient obil ructions an aptitude in the Fibres of the Tunics is required either iu^eivenient or native-, fuch are a want of elafticuy, or too rigid a flate, either of which are attended with vibrations toj feeble for exprefling the materials of incipient infarctions.

That obftruclions of the Lungs fometimes com- mence in the Air Pipe we may argue from their being coughed up in the form of the Trachea-, and that they b<-gin in the Pulmonary Artery, fometimes we have feen in this obfervation*

Auhmas are alfq 9aufed by induration and thick- ning of the Pleura; Pus between the Intacoflals and Pleura, in the Mediaflir.um, and Cavities •, frones in the Lungs ; pre dure of the Di iphragrn by fwelled Liver and Spleen, or enlarged by unequal nutrition, induration of, and enlargement of the Glands in or upon the Trachea ; and thefe caufes are permanent and without imermiffion, and are difco- vered by diffeclion ; and reafon has alfo difcovered their caufes near the origin and termination of the

* Hales' s Haem, Exp. 10 63.

Nerves,

Of the NECK and CHEST. 43

Nerves, of the Lungs and Mufcles of refpiration, exciting fudden undulations in their ethereal me- dium ; in the Blood itfelf, which either by Lentors infarcling, or turgefcence from rarefaction, or quan- tity by reafon of full feeding and fmall difcharges, and in the thicknefs of the veflels by over nutrition of their Fibres, corresponding to fuch affections in the Liver and Spleen.

Since Afthmas then may terminate in fuch changes of the Lungs as in the obfervation, may we not infer the great ufe of fuch means when this diforder is forming as are known to keep the Blood's motion brifk through the Lungs, and the whole fyftem ; fuch are conftant riding, if the bufinefs of the perfon will admit; for thus fluxions are inhibited to fubfide on, and line the Membrane of the Air Pipes, and the fuperfluity of the humidity in the whole fyftem driven off through the Skin and Kidnies ; and the congeftions fubfiding in the Bronchiag by a more ftrcng and diffufive exhaling of the vapour in the Lungs, are thinned, diflblved, and, by the ftrength and quicknefs of refpiration carried off -9 and by the fame means fizy Blood or Lentors are cohibited from uniting with the Fibres, from the languor of their motion : But mould it happen either from the avocation of the man, or fome indifpofuion of an- other part, that the cure by riding cannot be com- plied with, Emetics now and then, with a mode- rate operation, will exceedingly contribute ; for in the operation of Emetics the Mufcles of the Belly are drawn by confent with the Stomach into (bong fpafms -, and by the repeated fuccuflions the con-*

tents

44 Of the NECK and CHEST.

tents of the Belly are forced on the Diaphragm, which motion communicated to the Lungs, they are enabled therewith to exprefs their incipient con- gestions : But if the agitation of vomiting be from peculiar dirpofition infupportable, as it fometimes is, then Emetics may be fo contrived as to keep up a gentle working in the Stomach, lefs than fufficient for a total ejection of its contents, which will have nearly an equal effect. And if both thefe ways are attended with averfion, the motion of the Cheft may be raifed by Twinging irons with leads append- ed, which by the alternate elevation and depreflion of the Cheft will communicate a motion to the Lungs additional to their own \ fo alfo will playing on the German flute or other wind inftrument, which increafes the number and ftrength of expira- tions in a given time. But all thefe mechanical ef- fections ought to commence with the fymptoms, before tubercles of any fize, ulcers, or fuppurating tumours have time to form, and efpecially vomit- ing •, for if from the time of continuance and the other fymptoms there is caufc to fufpect fuch a change o! conformation as in the obfervation, then reafon tells us, that vomits are fo far from giving relief, that they may effect: an imprellion on the Lungs much to the detriment of the perfon -, and the fame may be argued when there is reafon to fufpect water or any purulent colluvies between the Ribs and Pleura, at large in the Cavity, or in the Mediaftinum, or other immutable caufes we men- tioned above.

"Water

Of the NECK and CHEST. 4S

Water in the Pericardium was concomitant with this Obftruction in the Lungs. Probably for this reafon, that the motion in the Pulmonary Arteries being more languid than it ought for a long fuccefc fion of time, and in confequence of the right Ventri- cle and Auricle, the Blood coming from the coro- nary Vein, being fomewhat retarded, did by per- fiftence and eafy delay dilate the Tunics of the Veins on the Membrane, and let the Lymph infiltrate.

OBSERVATION III.

Dropjy in one Cavity of the Cheji.

Wilfon was thirty years old in the year 1755, and from a cold in the winter complained of flying pains through the Mufcles and Membranes of the Cheft, which ended at length in a fixed pain of the left Side. From this time he languished and wafted with a flow fever. In February 1757 he began to breathe with difficulty, found an unufual weight when he lay on the right Side ; and when he lay on the left he was alfo difturbed by a fliort troublefome cough; but was far mod cafy when he turned himfelf

prone.

46 Of the NECK and CHEST.

prone. The left fide of the Cheft was fomewhat enlarged : The urine fmall in Quantity, with a white Recrement. There was no intermiffion of the Pulfe, nor preternatural beating of the Heart, but what you might expedl in a flow febrile commotion. We took him by the fhoulders and ihook him, and heard the undulation of fomething fluid in the Cheft. After due evacuations, which fomewhat relieved him, an aper- ture was made between the third and fourth Rib, computing from below; and about three pints of a ferous collu- vies drawn off: But this was fucceeded by fo violent a fit of coughing and fenfe of fuffocation, that Mr. Blundell the furgeon was obliged to ftop the aperture to prevent a total Suffocation. The flow fever continuing, we gave him half a drachm oi the bark three times a day till the fourth of March, when the fever intermitted. On the feventh the v/ound, which had hitherto a cadaverous appearance, began to digeft. On the

ninth

Of the NECK and CHE S T. 47

ninth the fever returned, and fo con- tinued till the 26th, when he died.

A poffible confequence then of a neglected pleu- rify is a dropfy of the Cheft. With refpect to the mode by which it was effected we may gather from the antecedent caufe, (for we were not permitted to infpect the contents of the Cheft) of catching cold, the immediate one of painful ob ft ructions in the Membranes of the Cheft, the flow fever, and the white fubfidence in the urine, that an ulcer exiftenc in the Pleura did by dripping its Ichor, fill the Cavity. Thus alfo from the fituation of the ulcer on the interior furface of the Ribs, the exterior furface of the Pleura, or between the Membranes of the Mediaftinum, may a dropfy between the Intercoftals and Pleura, or in the Mediaftinum, be effected : But fhould it be doubted that an Ulcer can yield fuch a multitude of Ichor, let it drop into the Cavity once in half an I lour ; then in twelve hours will it drop twenty-four times •, in three natural days, two drachms ; in a week, half an ounce -, in a month, two ounces; and in twenty-four months, forty-eight ounces, which is equal to three pints.

It appears moreover, the fymptoms of the exift- ence of water in one fide of the Cheft are an uncafinefs and fenfe of \ veight in lying on the oppofite, and the undulation 1 audible by fhaking the Cheft, But this laft fympt om, though decifive of extravafation, is by no means of necelTity connected with it -, for

when

48 Of the NECK and CHEST.

when the cavity is full and the fluid thick, there will be no fluctuation, as the old man has obferved *.

We may alfo note, that the bark will take off" an indifpofuion of the Blood, which proceeds from diftempered Membranes ; but as the caufe fubfifts, the taint and fever confequently will return ; and that it will bring about a digeftion in an ill-conditioned wound, whofe fibres have a cadaverous appearance.

OBSERVATION IV.

Dropjy in both Cavities.

In March 1753, came to Steevens's, a woman about 20, corpulent and flo- rid: fhe had a very difficult and labo- rious breathing, a great oppreflion and deje&ednefs ; to thefe fymptorns fuc- ceeded anafarcous fwellings in her legs : her pulfewas depreffedand intermitted, purgers of water relieved her at times, yet the Serum tranfuded from the Membranes of the Cavity, inotwith- ftanding thefe derivations. At length fhe became univerfally anafarcous, and

• Coacse pranot

the

Of the NE CK and CHE ST. 49

die fhortnefs of breath increafing, fhe could not lie down : her Pulfe oftener intermitted, and funk fo low that it was fcarce perceptible. Laftly, fhe coughed up Blood, and died the 25 th of the fame month.

The Cheft was enlarged on both fides. In removing the Sternum the water jetted up a foot in height, as foon as ever the Intercoftals and Pleura were pierced. The removal of the Sternum exhibited both fides of the Cheft filled with water. The lower Belly was alfo full ; and the Cellular Membrane of the Mufcles every where. Nor could we difcern any change of ill conforma- tion anywhere, either in the Cheft or lower Belly. The Auricles and Ven- tricles, or great veffels of the Lungs, we were not fuffered to infpedt.

A Shortnefs of breath then, nearly the fame in the beginning for any given time, and in all filiations of the trunk, excepting fupine, and that towards the end, attended with an intermiffion of the Pulfe, an enlargement of the whole Cheft, and fucceeded with ferous fwellings of the Legs, are fymptoms of the exiftence of water extravafate in both Cavities of the

D Cheft:

. Y |j

iai3 Atf Of the NECK and CHEST.

)L OF M^^^Cheft : the fhortnefs of breath indicates a flricture on the Bronchiae, the deprefTed and intermittent Pulfe a prefiure on the vefifels of the Lungs, and the hydropical fwellings of the Legs obftrudtions to the freeafcent of the Blood from the Iliac Veins receiving and returning the Blood from the inferior extremi- ties, and the enlargement of the Cheft the fulnefs of the cavkies.

It appears moreover that water will fometimes perfift to accumulate by fucceflive effufion •, that it will at length {o prefs the Lungs as to force the Blood into the Bronchiae and fuffocate.

Until the exiltence of Lymphaticks in the human fubject fhall be more generally agreed on, and the prefiure, erofion, or rupture they may fuftain from Tumors in the Membranes of the Lungs, or qua- lity, quantity, or motion of the Lymph flowing therein, the following hypothecs will ferve, till re- peated di flection fhall either fettle or reject it *. Let any caufe prefs the common Vein into which the Veins of the Cheft unload themfelves, then is it evident the tunics of thofe Veins will be rarer at their origins in the Membranes than they were before, and will be difpofed thereby to let their Lymph in- filtrate ; and the place of extravafation may be any of the fpaces mentioned in the lafl obfervation. Pro- bably the Pleura may fometimes fwell and thicken fo as to effect this prefiure when the Membrane is the part affected in the pleurify, where the pain is near

* Vid. Morgagnia adverf. anatom. in Differ, de ven. fine pari. p. 86. Leidae. 1723.

5 the

Of the NECK and CHE ST. 51

the Vertebrs of the Back, and on the right Side ; or even on the left, if fuch a Vein exift on this fide, which has been fometimes obferved : and extrava- fation may arife from a fwelling of the Membrane of the Lungs, where the Azygos crofTes and defcends to the Cava. The like mode of effection may like- wife proceed from intumefcenfe of lentors or cold congeftions in the fame Membranes ; or the fwel- ling of the pleura might in places, at a diftance from that where the Azygos pafTes, prefs the Intercoftal Veins to a fimilar effect ; or partial coalefcence may happen'in the Azygos, by a fwelling of its Tunics, like as it does in the Nafal duct in the difeafe of Lachrymal Fiftula. Sharp on Operations, C. 30.

Again, mould the Blood be obstructed frequently in pafTing from the pulmonary Veins into the left Auricle, as where the Auricle or its Ventricle are partly infarcted with a polypous concretion* ; or when the valves of the Auricle or the Ventricle are ofTified, petrified, or otherwife indurated f, the Lungs and their Membrane will as often fwell, and by fwelling diffufe the Lymph through their Membranes, even to exfudance, and fo may the Cavities fill from thefe Caufes -, and yet more, if the fyftem is overcharged with Lymph by obstructions in the Skin, Kidnies J, or Membrane of the Trachea : And truly reafon would incline one to think a dropfy of the Cheft ought rather to be effected from thefe caufes, than a dropfy of any other part ; for when the fyftem is

* Mead Prxcep. raed. 129, 175 1, Lond. f Cooper

Tranf. Phil. v. 5. 220. % Idem in eodem loca.

D 2 tumid

j2 Of the NECK mid CHEST.

tumid with Lymph, the Lungs ought to find a more fenfible impreffion of it than any part, as the whole of what exifts in the Veffels mud repeatedly crowd through the Vifcus, which is not a contingence elfe- where ; and this will fooner happen in Gibbolities or Incurvations of the Spine and Sternum, by reafon of the flower motion of the Blood down the aorta, affu- ming the flexure of the Spine. Now fhould the Lymph, fo confined in the fyftem, and flowing through the Lungs, pafs off by the Trachea, the fit ends with a copious catarrh and expectoration ; but if it extravafate into the Interftices of the VefTels, the Afthma proceeding therefrom becomes habitual ; and if the blood in the repeated Syflole of the Vif- cus be, as from a wet fpunge, expreflfed from the Membrane, the infiltration induces a dropfy of the Cheft ; and a dropfy of the Cheft thus formed, may come fuddenly on, and more fo if the Membrane of the Lungs is weaker conftituted than the other Membranes of the fyftem.

That an univerfal dropfy fhould follow from a dropfy of the Cheft, and be dependant thereon, is not very difficult to fhew -, for fince at every infpi- ration fpace is allowed for an additional exfudance, in time the quantity of water will be fo increafed as to raife the Ribs, and the preflure will be very great, not only on the Lungs, but trunks of the Cavas and common venous receptacle of the Blood of the Back, and Membranes of the Cheft : A preflure at fir ft, though lefs than any given one, on the def- cendingCava, will, by uninterrupted fucceflion, fwell the" Veins of the Neck and Face, and extravafate the

Lymph

Of the NECK and CHEST. 53

Lymph in thefe parts, and in the fuperior extremi- ties and Mufcles of the Back ; nay, in the internal Membranes of the Head and Spine themfelves: And preffbrc on the common Vein of Azygos will have the fame effect in the Mufcles of the Back, Membranes, and parts where its branches arife ' On the Cava aicending, will nil the Liver, and in confequence the Spleen, Mefentery, Interlines, and cavity of the Belly •, and by retarding the Blood coming from the Iliac Veins, the inferior extremi- ties, as we fee in Gravidation ; the truth of all which you will readily deduce from the anatomy of Veins. Dropfies of the Cheft are relieved from time to time by draining the v/ater through the Interlines, whatever caufe they may depend on •, but when the relief from purging becomes infenfible, or next to none, the Paracentefis is requifite to prevent fuffoca- tion. This total cure will turn on the Membranes of the Cheft and Lungs, being free from any immu- table diftemper -, 2s alio from any incurable obftruc- tion of the Skin, Kidnies, or Membrane of the Bron- chise, by whofe crganical power and effection the fyftem is dried ; and becaufe it is rarely the condi- tion of the parts in this diforder, they are juftly held by Phyficians among the mod unhappy of thofe to which we are liable. It is probable then, that when they admit of cure, they have arole from mere ful- nefs of Serum, from Perfpiration, Urine, or Vapour of the Bronchias being accidentally confined, whofe Organs re-afiuming their function, and draining the Syftem of its fuperfluity of water, that which in- filtrated through the Membranes of the Cheft or D 3 Lungs

54 Of the NECK and CHEST.

Lungs has been re-abforbed •, for that it is pofljble the Membranes of this Venter may imbibe water there extravafated, we may infer from the experi- ments of Mufgrave >, for having injected three pints and a quarter of warm water into the Cheft of a dog at different times, in the fpace of a month, found it all imbibed by the recovery of the creature from the fymptoms of diftrefs he fhewed at the time of in- jection *.

Mary Pane, about eighteen, in November 1762, at Mercer's, had from repeated colds a dropfy of the Cheft. When (he came to the hofpital me was totally tumid, her Eyes watry, the Cheft elevated, a great oppreflion and fhortnefs of Breath, the Pulfe almoft imperceptible, and anafarcous fwellings of her Legs ; of all which allociation of fymptoms fhe was cured by repeated purging :- At lead reafon, led by thefe fymptoms, their antecedent caufcs and mode of cure, did conclude thefe fymptoms arofe from that caufe.

When the puncture is made to let out the water after what is in the cavity is drained, yet mould the orifice ftill remain, left the clofing of it might, by the Cheft again filling, neceffitate a new aperture, as it did in the inftance related by Willis f.

*Tranf. Phil. vol. 3. yS. f Pharm. Rat. 230. Oxon.

1675.

OBSER-

Of the NECK and CHEST. $j

OBSERVATION V.

Hcemoptoe.

In October 1756, a Man about 30 years old, tall and lean, who had been ufed to all forts of excefles in the an- tecedent caufes of difeafes, came to Stcevens's with an Hsemoptoe: He coughed up Blood in large clots repeat- edly in the day, without pain, and continued fo to do for three weeks, and died the 2 2d of the fame month. He had likewife a conftant difpofition to ftool, but with ineffectual efforts.

In the Lungs of both iides of his Cheft were large Grumes chiefly to- ward the back, an univerfal Echymofis viflble throughout the Membrane, and above a pound extravafate in the cavi- ties ; the fmall Inteftines too were ex- ceedingly enlarged and inflated, and the diameter of the Colon double of its due lize, which enlargements were D 4 manifeft

5 6 Of the NE CK and CHEST.

manifeft before the opening the body as a Tympanites.

It is obfervable too that no part of the Blood extravafated here had the appearance of corruption.

An Hsemoptoe therefore may not only fignify that the VefTels of the Bronchiae let go their Blood, but that the fame difpofition may prevail through- out the whole Lungs, and even the Membrane itfelf.

One caufe of the extending and retarding the mo- tions of the Interlines is, their being inflated with vapour. * The Blood, according to authors, extra- vafates into the Eronchiae by rupture, as in a vio- lent fit of coughing, or from external incidents ; by tranfudation ; or laftly, by aperture or enlargement of the orifices opening into the Bronchia, and this either by their natural terminations or adventitious by erofion : But from the appearance of the Lungs in this fubjecl:, wherein was a total confufion of Fibres and Cruor, the Haemoptoe was rather confe- quential of a diflblution of the Fibres, which let the Blood extravafate as well into the Interftices of the vefTels as into the Cheft and Bronchiae. And its be- ing unattended with pain fignified its coming from the fubftance of the Lungs by reafon of the obtufe fcnfe of the Vifcus, its Nerves not reaching the parts near the furface or Membrane, as Galen obferves f ,

* Femelius lib. 6. C. 10. f Gaten de loc. affeft. lib. 4. Cap. 4.

or

Of the NE C K and CHE S T. 57

or probably iervient rather to the organical motion of the Vifcus, and vital union of the Lymph with the Fibres than fenfibility of the part.

Bleedings from the Lungs caufed by rupture, pro- vided the ruptured veflels are not very large, are cured by repeated bleeding, to leflen the quantity in the whole fyftem, by which the ruptured veflels will be lefs extended ; and by leffening the diet in a given time, and changing its quality to a cooling one ; for by leflening the diet the Lungs will be kept from intumefcence, and by changing the qua- lity of a cooling one, the rarity and turgefcence of the Blood will be lefs than in an oppofite diet *, and thus will the veiTels collapfe by their emptinefs, and regain continuity by apportion.

Bleedings caufed by erofion, as when the fliarp Ichor of an ulcer deftroys their tunics, are partly treated by fuffumigations, whereby the digeftive va- pour of the rofins, gums, and balfams, coming into contact with the Ichor, abate its fharpnefs -f, provided they are not too detergent ; and by medicines con- tinued for a long time, which are held to give fuch a difpofition to the Blood and Lymph that the ulcer may loofe its fupply of ill quality, and receive di^ geftion from what fuceeed.% fuch are fperma ceti in any form, Locatellus's Balfam, and the like ; and dieting partly or altogether on new churned butter- milk, milk juft broke with churning, and aflfes milk, An Hasmoptoe from this caufe is diftinguilhed from

f Bennett Theat. Tabid, excer. 30. Mead, Frecept. Med. C. 1. Sect. 10.

the

58 Of the NECK and CHEST.

the preceding by the errors antecedent of intem- perance and colds, by the nature of the expectorated Blood which is mixed with purulent phlegm, and from the ftench of the vapour returning from the lungs.

An Haemoptoe by mere tranfudation or aperture of the orifices terminating in the Bronchiae, if caufed by rarity or turgefcence of the Blood and violent pro- grefiion from drinking, exercife, or irritating matter hurrying the fyftem of irritable Membranes, is flop- ped for the prefent by bleeding, reft, dilution of the irritating matter, and thofe medicines which in- fpifTate the Blood, conftringe the Fibres, and fufpend their Vibrations ; fuch are fimple waters, foured with fpirit of vitriol, fanguis draconis, alum, the peruvian bark, and opiates.

But if the bleedings are the fimple effect: of weak Fibres, as in thofe who are conftituted with weak Lungs, then are they treated more eligibly in the die- tetic way. Fibres which are weak from native construction, medicines may aftringe, ftrengthen they cannot : befide the perpetual repetition of in- effectual medicines, takes away the appetite, hurts digeftion, and induces ill habits and diforders different from thofe they are intended to amend •, therefore ought we rather to depend on temperance in quantity of food, abftinence from liquors overheating the Blood, too violent exercife, fudden paffions of the mind, and have careful regard to the times of deep, fince Fibres grow out of the Blood chiefly in found deep : As bleedings of this kind are more incident to youth, they prefer ve themfelves from dangerous Haemor- rhages

Of the NECK and CHEST. 59

rhages till they advance into years, when the hard- nefs of the Fibres cohibits thefe effluxes ; as the Hae- morrhages are not only dangerous by their quan- tity, but quiefcence ; for if the extravafated blood reft below, it endangers apoftems, ulcers, flow fe- vers, and confumptions*.

It was in this ftate of weak Fibres (I conceive) that vomits, fo luckily directed by the late Dr. Robinfon, were attended with fuccefs ; for vomits, though they flop the Motion of the heart, almoft totally in the a<fb of vomiting, yet after operation the motion rifes higher than before, not only in the Lungs but even in the whole fyftem ; and by the total fuppreffion of the motion in the act of vomiting it is, that the infiltra- tion or effufion is checked for the prefent, and by the increment of motion after operation it comes, that the Blood moving ftronger through the great vefTels of the lungs, its courfe and tendency is de- rived from the vefTels of or near the aperture, which is eafily deducible from the doctrine of Hydraulicks, and even by antopfy in the pellucid Membranes of creatures ; and I have myfelf often directed vomits in Bleedings caufed by the erofion of Ichor, and ob- ferved them fometimes of fervice, but never any Haemorrhage encreafed thereby. Yet in fudden and great effufion from rupture or erofion of the Tunics of great vefTels, or where there is reafon to fufpect a total echymofis or extravafation from the Mem- brane of the Lungs, one would incline to defer ic till all other means were tried, and even altogether.

* Hip. Aph. Sect 7. Aph. 15. f Galen de prsecogn. ex pulfibus,

Ne

60 Of the NECK and CHEST.

Ne videaris occidijfe quern fervare non potes *. But if any one mould fay, how fhall we conjecture this to be the condition of the Lungs ? you will eafily eftimate by the perfiftance of the Hasmoptoe, and grumous quality and quantity of the expectorated Blood, compared with a conftitution ruined by- colds, eternal drunkennefs, and venery : For it is evident that repeated colds filling the fyftem with acrid Lymph will (hake the Lungs by the coughs they occafion, and perpetual drinking will rarify the Blood, and as often expand their Fibres whofe nu- tritious powers are weakened by exceffes in venery, and waking, all which were the errors of the refer- able fellow whofe Lungs we defcribed.

And now we are fpeaking of the mode of action, and one ufe of vomiting, it may not be totally fo- reign to the prefent purpofe, to confider fuccinctly their ufe in general. Vomits then can be of little fervice (at lead reafon would incline us to think fo) in primary affections of the Head, fuch as produce the fymptoms of drowfinefs, paralytick affections, and epilepfies •, but if any of thofe diforders fhould arife from the Stomach by confent, as where the Stomach is fretted with fharp bile, or other hu- mor, phlegm, or crude undigefled food, their ufe here is evident ; fo likewife in recent infarctions of the Lungs, either from fizy Blood or fluxions thick- ened in the Trachea, they far exceed the common pedorals in their effects : fo alfo in recent obstruc- tions of the Blood or Bile VefTels in the Liver, Spleen, or Mefentery ; and univerfally they raife

* Celfws in Prsefat,

the

Of the NECK and CHEST. 61

the Blood's motion in the whole fyftem, even in the Mufcles themfelves, and may be of fignal ufe in languid motion from weak Fibres and fizy Blood in all parts, and in removing fluxions (the gout for in- stance) falling on the Membranes of the Cheft and lower Belly •, due circumfpeclion had to the fullnefs of the fyftem, and to the difpofitions of the parts, that they are free from adherances, immoveable obftruclions, apoftems, ulcers, and preternatural conformation, and the Cavities from extravafation. Laftly with refpect to Bleeding in haemorrhages of the Lungs, the following obfervation may carry with it a caution touching the extent of this mode of proceeding.

OBSE R VAT I ON VI.

Dropjy anafar com from Lofs of Blood.

In March t 7 5 2 , a woman of forty- eight was taken in at Steevens's for an anafarcous Dropfy. About four years before this time fhe coughed up Blood from the Lungs to the quantity of three or four pints in three days, and to flop it, nearly as much was taken from the arm in the fame time : Thence- forward her legs began to fwell, and the water afcending fhe was inundated

there-

6i Of the NECK and CHEST.

therewith 3 and died the later end of the fame month.

As a great Iofs of Blood then may be attended with a dropfy, and efpecially in the female, and in the decline of life after moderate Bleeding in the arm or elfewhere, it were rather eligible to try what medicines which cool and infpiffate the Blood, and aftringe the Fibres, and check their vibrations can effect, than perGft in Bleeding, which, even if it flop the prefent extravafation of Blood, may give origin to an equally fatal infiltration of Lymph.

OBSERVATION VII.

Empyema and Apojlem of the Lungs.

In September 1753, a boy about fourteen was brought to St. George's in London. About three weeks be- fore he got a cold, and a violent cough, by changing his cloaths, and putting on a light unaired fuit. When he came to the hofpital his cough was rather lefs in degree ; he breathed fo that you might hear the air in its tranfit pafs through fome tenacious matter, both in infpiration and expiration ; he had a pain and forenefs in the right fide of

his

Of the NECK and CHEST. 63

his CI left, and was fomewhat incur- vated that way ; his countenance fweaty, pale, and tumid ; ' his pulfe quick, which quicknefs was increafed in the evenings ; and in coughing he brought up of thick tenacious matter about half a pint in the day ; and died in three weeks from his coming to the hofpital.

Fart of the right fide of the Lungs was confumed by an abfeefs, the mat- ter of which was expended in the Ca- vity.

As the Lungs then may impoftumate from a cold and ftrong cough neglected at firft, it fhould feem as if the act of coughing did extravafate the Blood in the Interfaces of the Veffels, and the Blood by corruption effected the impoftume, or that the act of nutrition or apportion of Lymph to the Fibres being difturbed brought on a congeftion, which ended by putrefaction of the congefted matter ; and that the impoftume fo formed did communicate its corruption, as well to the parts neareft, as to the Blood itfelf, which being tainted therewith raifed the flow fever, more obfervable in the evening than at other times of the day ; and the fymptoms of matter in the Lungs and Cavity are a laboured refpiration with a wheefing, a coughing up of matter, and inclining of the Trunk toward

the

64 Of the NE CK and CHE ST.

the part affecled •, a pale, tumid, fwelled counte- rs; ce, preceded by a cold and ftrong cough, and fucceeded by a flow fever, the cough being caufed by the vapour flopped in the Skin, and exhaling in the Trachea, or by the acrid Lymph fecreted in the Glands of that irritable Membrane.

Since colds therefore by loading the Vefifcls with fcalding ferum and vapour, may caule fuch agita- tions of the Lungs, we may deduce the utility in the beginning of colds and ftrong coughs, of lelTen- ing the quantity of Blood by Bleeding, which will alfo cool it, and of purging with cooling purges ; fuch are infufions of rhubarb, fenna, and manna, in order to drain oft the acrid ferum, and of fuch dia- phoretics as have this power without heating, which the teflaceous powders given out of cold wa- ter fometimes have •, abftinence from vinous and fpirituous liquors, and diet conferving the ill dif- pofition and heat of the Fluids •, and we may further note, how cautious thofe who are conflituted with Lungs weak and liable to fluxion ought to be in changing their apparel.

Suppurations in the Cheft then are curable or not according to the circumftance. If the Cavity of the Cheft is full of Pus, which is known by the en- largement of the Cheft and flow fever, attending j and the Lungs, Pleura, Mediaftinum, Intercoftals, and Diaphragm are free from abfcefTes, ulcers, and other morbid affections -9 and the Blood is not too faturate with pus by its long exiftence in the Ca- vity, the letting out the matter by incifion will prefently fucceed •, but if the Lungs or their Mem- brane

Of the NECK and CHEST. 65

brane have abfceded, which is known by the puru- lent expectoration and wheeling, and other fymp- toms in the obfervation •, it is required they adhere to the Pleura, and that it be fignified by the prick- ing pains in the act of coughing near the united parts, and the external intumefcenceand forenefs, fo that the materials of the collection be drawn off by the aperture •, for that abfceffes of the Lungs may be thus totally cured, we may infer from the au- thority of Cooper * ; but if the apoftem is fituate in the Lungs, and they do not adhere, or between the Lungs and Diaphragm or Mediafiinum, and the Lungs adhere round the Apoftem fo as to en- cyft it, the cure will depend on fome effort of the parts to caft it through the Larynx, or on the Vef- fels abforbing and transferring it through the Kid- nies, or other fecreting organ, the poflibility of which we have from the authority of Galen f ; and I have feen it myfelf in a fuppuration of the Mufcles.

When by the aperture the tumor is apparently drained, yet dill, as in a dropfy of the Cheft, is it proper to p refer ve an opening ; for if the Lungs do not adhere, but the pus be at large in the Ca- vity, yet the Pleura, Diaphragm, Media ft inum, or Membrane of the Lungs, may by an ulcer there exifting, drip fo as to occafion a new aperture.

Whether there are medicines which afiift nature in ejecting an apoftem of the Lungs, either through the Larynx or Emunctories, has been fometimes doubted ; but that medicines barely inoffenfive are of ufe, is not only agreeable to experience, but rea-

* Tranf. Phil. vol. 5. 221. f De Loc. affed. 1. 6. 4.

E fon,

66 Of the NECK and CHEST.

Ton, which likewife holds in other difeafes, were it no more than to calm the mind ; for when the mind is at eafe, and not follicitous about the event, the motions exerted will be more uniform and propor- tionable to the intent of nature, and fo more likely to effect it.

But fometimes two fluxions, not fo acrid as the vapour in the preceding, will either of themfelves erode, or by exciting a conftant though not very troublefome cough, fo difturb the nutrition of the Fibres as to induce a congeftion, or by rupture, ex- travafation •, which ending by ulcer draws on an uni- verfal colliquefcence through the Vifcus, viable by the quantity of the expectorated matter ; and which may be either of a black or variegated colour ; and the materials of the ulcer being from time to time re-ablbrbed by the Vcffels, raifes the Blood into fe- brile effervefcences, correfponding in proportion to inoculation ; and interior Membranes of the Heart and other irritable Membranes into preternatural vibrations, by which fanguification nutrition and fecretion being diftributed, the VefTels are loaded with heterogenous Fluid, which is repeatedly hurried off through the Skin and Interlines in form of colli- quefcent fweats and loofenefs, fucceeded by an uni- verfal marafmus and diffolution of the fyftem.

OBSERVATION VIII.

Mary Tigh, about twenty-five years old, from a cold contracted a cough,

which,

Of the NECK and CHE S T. 67

which, though not very violent, did by periiftance in the Ipace of four months draw with it a Marafmus, attended with a colliquefcence through the Lungs of variously coloured ftufF, fucceeded with repeated colliquefcent fweats and loofe- nefs, which brought her to her end at Mercer's, the 25 th of Odlober laft.

The right Lobes of the Lungs were variegated with black and white tu- bercles, the latter of which bore an exad: Similitude to condenfed fat ; the left Lobes had feveral finuous ulcers larger than a middle lized peacod, and full of fuch vifcid, variegated colluvies which £he conftantly ejedled by cough- ing.

E 2 SECT,

[ 68 ]

SECT. III.

Of the Liver.

OBSERVATION L

Suppuration in the Liver.

A Woman about fifty in 1756 came to Stevens's ; five months before fhe had a Jaundice, and a full- nefs appeared in the region of the Sto- mach. The Jaundice difappearing, left the fwelling, which diffufed itfelf into both Hypochondria, and was attended with an internal heat and forenefs; fometimes too an acute pain was propa- gated from the right Hypochondrium to the fhoulder of the fame fide. She came in January, and toward the end of the month began to cough and fpit up a vifcid thick matter, of a very bit- ter tafte and intolerable ftench, about a

pint

Of the LIFER. 6g

pint in the day, and even fkins of Hy- datids. In the middle of February the {pitting, which ftiil continued, was at- tended with a loofenefs of the fame fort of matter, a wafting, and a fluttering intermittent pulfe, and all this perfift- ed till April, when fhe left the hofpital perfectly recovered, the tumor difap- pearing as (he coughed up the matter.

The materials of a tumour in the Liver then, by the union of the Liver with the Diaphragm, and Diaphragm with the Lungs, afiifted with motions inftituted by nature, may pafs the Lungs, and be emptied through the Larynx : For that it exifted in the Liver I infer from the jaundice appearing before the commencement of the fwelling, which (hewed that fome caufe either prefied the Ducts near the Sinus of the Porta, or difturbed them in their mo- tions, from the bitternefs of the fluff coughed up, the pain propagated to the Shoulder *, and the appearance of hydatids, which are more obfervable in the Liver than Lungs, Tunics of the Colon, or Stomach. Now when the Liver is inflamed in its upper furface, or ulcerated, it will adhere to the Diaphragm, and inflame and ulcerate it ; and the like continuity of adherence may be between the Diaphragm and Lungs •, and thus by continued fup- puration, the matter, and even Skins of Hydatids,

* Hippocrat. lib. de Intern. Affect.

E 3 may

7o Of the LIVER.

may find their exit by the Bronchise -, fo that we need not difcredit Galen's* affirmation, that Pus or Blood in the Cavity of the Cheft may be abforbed by the Membranes of this fpongeous Vifcus, and be ejected by the Larynx.

Befides our knowing how far the parts will fome- times exert themfelvcs in their own defence, and free themfelves from noxious materials, we may draw this ufeful inference, that in a fimilar cafe we may rather afiift nature with foft pectorals to eject the filth, becaufe we are aflured of the pofiibility of motions inftituted for this purpofe bcin^ able to effecl: it, than proceed to immediate operation -, for that which has once happened may return again.

OBSERVATION II.

Apojlem of the Liver.

In September 1752 a man about twenty-five was brought to Stevens's ; fix weeks before, he arofe from a con- tinual fever which held him a fort- night, and terminated without crifis by fweats or other fenfible fecretion ; from that time he had a pain and fore- nefs in the right Hypochondrium, could not bear the leaft preffure on the part,

* De Meth. medendi, Jib, 5.

and

Of the LIVER. 71

and was fomewhat incurvated that way : Thefe iymptoms were likewife at- tended with a loofenefs of white ftools, yet the urine was not preternatural in colour or otherwife ; his countenance pale, languid, and yellow. In fome days he was taken with a continual vo- miting, and died the 25 th of the fame month.

On removing the Integuments and Mufcles of the Belly, we found the right fide of the Liver and Gail Blad- der confumed by an abfcefs, the fluid of which was expanded in the Cavity.

A fever therefore, when the materials of it are not fecerned in a faiutary crilis, as by the Skin, Kid- nies, Salivary or other Glands, may poflibly ter- minate-by a depofition of the matter on fome part, as the Liver, cauie it to inflame and fuppurate, and effect the apoftem termed Per Decubitum, and the fymptoms of it are a forenefs in the Hypochon- drium, attended with a loofenefs, and an inclining of the Trunk toward the part affected. By this in- clination of the Trunk the part affected refts on the parts underneath, a more eafy fituation than depend- ing from the Diaphragm in an erect pofition of the Trunk, which keeps the tender ulcerated Fibres in

E 4 a

yz Of the LIVER.

a ftate of painful tenfion, the loofenefs being caufed partly by the irritation of the matter lying on the Inteftines, and partly by its pafTing through the Biliary Duels into their Cavity ; the white ftools partly to a want of fecretion of the Bile, and partly to the pus flowing into the Inteftine and tinging its contents.

Impoftumes in the Liver then are curable or not, according to the circumftances, like thofe of the Lungs great Inteftines, or other interior parts. If the apoftem is in the center of the Liver, its cure will depend on fome effort of the parts to take it up into the habit, and transfer it to the Kidnies, or other outlet, or on ics breaking into the Intef- tines and pafTing off that way : But if it exift in the Tunic of the convex part, it may, by adherence with the Diaphragm, fuppurate the Septum, and falling into the Cavity of the Cheft, be drawn off by an aperture, or be taken up by the Lun-^% and ejected through the Larynx, the poffibiiijy of which may be gathered from the preceding ; but If the apoftem exift in the fimbriae of the Liver, it is re- quired it unite with the Membrane of the Cavity, and from the fuppuration of the Membrane fignify itfelf by railing the Integuments, fo that with pro- per applications it may thin the Integuments, and be drawn off by incifion ; but if it exift in the con- cave fide of the Liver it may fall among the In- teftines, and end as above.

Jaundice

Of the LIVER. 73

Jaundice and other EffeEis of Stones in the Gall Bladder.

If the bile be difpofed to form ftones in the Liver, Duds, or Gall Bladder, then it is evident it muft be difpofed to Lentors prior to its hardening into flone.

Let the Bile run into Lentors from any eaufe, fuchas a fedentary life, and in con- sequence a want of due vibration of the Liver and its appendages ; then if it run intoLentois within the pores or in the Hepatick Dud, and a ftone formed in theie parts, or Cyft, or its dud:, by fome vibration of the parts, or other motion, by riding, falling, vomiting, or paffions of the Mind, be thrown out of the Liver or Cyft, or duds of either, into the common dud, then will a jaundice Commence, attended with white ftools : and if the obftrudion perfift, the Blood will become fo faturate with bile, even to blacknefs, that neither will the Heart uniformly move, nor will the fecre-

tions

74 Of the LIVER.

tions be in proportion to the food, nor to one another, nor will the Lymph vitally unite with the Fibres; but the whole fyftem, as from an internal fup- purationor other foul irritating matter, having no Gland to fecern it, will go to confufion, and terminate in death. And the fame may be argued if any immoveable tumor of a neighbouring part fhould prefs the common Dud, or a fweiling of its own Tunics or the Tunic of the Inteftines through which it pafles, or a preffure on the Orifice within the Inteftine, which cannot be removed.

But if a Lentor or Stone in one or more Duds within the Liver or He- patick Dud perfift there, then will the bile return to the Cava, and tinge the Serum, and produce the fymptoms of pale yellow fkin, and urine of a deeper yellow; and if the Lentor or Stone does not wholly conftipate the Hepatick Dud", the bile palling the unobftruded Duds in the Liver, and between the Stone or Lentor and the Tunics of the

Dud,

Of the LIFER. 75

Dud, will conferve the ftools of a yellow colour; or fhould there be a to- tal obftrudion of the Hepatick Dud, the ftools will be coloured by the cyf- tick bile as long as the bile kfts therein, if it receives all its bile by the cyftick dud ; and even during the whole time of the jaundice if it receive its bile from the Liver diredlv, through its Tunics*.

But fhould there be feveral ftones in the Duds of the Liver or Cyft, which pafs off into the Inteftine, in fometime after their failing into the common Dud, then will the jaundice, if the Dud be totally conftipated for the time, be attended with white ftools; but as the ftone falls into the inteftine it will intermit, and be attended at the time with a looienefs of yellow ftools, and return again when another defcends; but it the ftones be notfo large as wholly to conftipate the Dud, then in the time of the jaundice, as when it intermits, will

Drake's Anthropologia V, 1. 102,

the

76 Of the L IF ER.

the ftools be yellow. Again, if the Duds in the Liver be agitated with a Spafm, or the Hepatick or common Dud, as from any affedion of the Mind, or by confent with fome nervous Membrane, as the Skin or Inteftine, or with the irritation of the bile itfelf, too fharp for the Duels, the bile will return to the Blood and affed the jaundice ; but as thefe caufes are not of duration, the bile, when the Duds are in diaftole, will fall into the Intes- tines, and colour their contents, and the jaundice will be of a fhort duration, like the caufes which produced it.

But as to that fort of jaundice which is fometimes obferved to arife from ftones in the Gall Bladder, the follow- ing obfervation may contribute fome- thing towards a more exad knowledge of the nature of this diftemper and ef- fects than I have found it.

OB-

Of the LIVER. 77

OBSERVATION III.

Symptoms and EffeEls of the Stone in the Gall Bladder.

Mrs. Bolton was forty years old, had led a very fedentary life, and was trou- bled with repeated fits of the jaundice, which wore away and returned at un- certain periods ; and was ever liable, as well about the times of the jaundice as at other times, to pains in the lower Belly. On the 2 3d of April 1756, fhe was feized with a violent pain near the pit of the Stomach, and retraction of the part toward the Spine, and a ffcrong vomiting; the pain was propagated acutely from the pit of the Stomach in the direction of the Gall Bladder to the Back, but without any quicknefs of the pulfe or other febrile appearance ; the fit was eafed, and afterward entirely re- moved by the Thebaic Tindture. On the firft of January the following year, the pain and other fymptoms returned in the fame place, with an intumefcence feemingly in the Mufculi Re&i, near

the

78 Of the LIVER.

the Navel, and without fever as before* About the fourth of the fame month it wore off by degrees, and the ufe of the fame tin&ure ; but there immediately fucceeded a quick pulfe or flow fever, attended with purulent urine, and deep fweats ; and on the feventh of June fol- lowing, a ftrong loofenefs fupervening, fhe died.

The body by her particular defire being the next day opened by Mr. Ruxton and Lifter, we found in the center of the Liver, which was other- wife very well conftituted, an apoftem of the iize of a pullet's egg, of very well digefted pus ; the Colon under- neath the Liver was denigrated for a hand's breadth, and the Fibres of it$ external Tunic rent afunder. In the Gall Bladder there was two ftones, one of the fize of a nutmeg, and the other lefs ; we faw nothing preternatural in the Dudls or elfewhere in this Venter ; the Lungs were livid, with tubercles here and there, which being cut with the apex of the knife, emitted innu- merable

Of the LIVER. 79

merable drops of well digefted pus, which had infiltrated into the Inter- faces of the Veffels, from the Blood being therewith faturated by the reflux of the pus from the Liver,

Now as the flow fever was confquent only of the laft fit, and as fuch fevers arife from internal fup- purations tainting the Blood, we may conclude the formation of the apoftem recent, which was even ma- nifest from its appearance only •, but the violent pain immediately preceded, and was tranfverfe through the Colon and Liver •, and pain being the uneafinefs which attends the idea of continuity folving, we may fafely affirm that the formation of the apoftem was owing to a rupture of the Fibres of the Liver, and an extravafation in confequence, and the more efpecially as the Fibres of the Colon were evidently rent. It was owing therefore to fpafms of the Li- ver that its Fibres were folved, and let the Blood ex- travafate ; and to the like fpafms that the Tunics of the Colon were rent and gangrened. But if any man mould fay, how can a gangrene arife from a fpafm ? Let it be confidered that a fpafm will not only extravafate the Blood into the Inteflines of the VefTels of any parf , but the Fibres by being ftretch- ed iofe their elaftacity, and fuffer the extravafate Blood to reft there, and the circulation in the part being totally fufpended, the part muft evidently die. *

Again, as we obferve that a (tone in the Kidney being diflodged from its ufual place of eafy refi-

dence,

8o Of the LIVER.

dence, and either fo turned in the Kidney or its Pelvis, or having fallen into the Ureter with the flux of urine in the Diaftole of the Ureter, will draw not only the Kidney, but Ureter, Bladder, Sto- mach, and Inteftines into very painful fpafms ; fo one or more (tones in the Gall Bladder may, by mu:a:ion of place, either in the Bladder or its Neck, or Cyftick Duel, from fome extraordinary motion or vibration of the Gall Bladder or its Duels, draw the Liver and its Duels, Colon, and Stomach, into fuch fpafms as may not only return the Hepa- tick Bile into the Cava for the prefenr, but by that extreme tendon iblve the union of the Fibres of one part, and rend and gangrene the Membrane in an- other.

We may further obferve, that a fwelling in a Mufcle may arife from a fpafm by extravafating the blood into the Interfaces of its Veflels, or by forcing and conserving more Blood therein than it has when uninfluenced by difturbing cauies.

And yet further that pains in a part without a fe- "ver may be held fometimes to arife from fpafms of the Fibres, rather than quantity, quality, or motion of the contents of the part.

As to the treatment of the perfon where there is reafon to fufpecl: (tones (for there are often many (tones in the Gall Bladder and Duits, as there arc in the Kidnies, without Ggnifying themfelves either by jaundice or pain) reafon tells us that it ought to be nearly the fame where we have reafon to think there are (tones in the Kidnies. A dififolvent for a cy- itick (tone, if we had one, would be much lefs likely to fucceed here than in the Kidnies, by reafon

5 °f

Of the LIVER. Si

of the difproportion of Blood and urine flowing through the Kidnies, and the Blood and Bile palTing through the Cyft ; for as to diflbive a ftone in the Kidney, Ureter, or Bladder, the Blood and Urine muft be fo changed that they fhall be a menftruum for the ftone, lb the Blood and Bile of the Cyft muft be fo changed as to be a menftruum for the cyftick ftone. However, until this matter be fettled by trial and experience, it may be of ufe to keep the Colon pretty free of contents, left the prefiure fhould caufe any effort of the Gall Bladder which fhould bring on a fit : Abftinence from exceflive feeding, fpintuousl.quors, and violent exercife, may contribute to the lame effect.

And laftiy we may note, that a free communica- tion with the external air is neither neceftary to the putrefaction or irritable quality of the extravafated Blood.

But fhould this reafoning be erroneous, we may at lead affirm that inrlammacion and its confequences, apoftem and gangrene, may be caufed by (tones in the Gall Bladder •, yet if it was an inflammation, then fuch can be aife&ed without a quicknefs in the pulfe.

OBSERVATION IV.

Vomiti?ig from a7i Incluratwi of the Pancreas.

A man about forty, of a middle fize, was taken into Stevens's in March 1756.

F He

S2 Of she LIVER.

He complained of a ficknefs at Sto- mach, a vomiting after meals, and in confequence a coftivenefs ; in fome time aiter his coming to the houfe a tumour appeared in Epigaftrio, the tu- mour was hard, and when prefled with the hand exhibited the fenfe of a full pulfation, correfpending to the pulfe in the Wrift. The tumour increasing brought on an inceffant vomiting when he took any food, and fo a general ma- rafmus, and death on the eighth of June following.

In the Cavity of the Cheft every thing was right. In the lower Belly the IntefHnes were black, and chiefly the fmall ones ; underneath the Sto- mach and Colon a tumour appeared, the fmall Inteftines being removed,: it reached from the Duodenum to the left fide of the Stomach, Spleen, and Kidney, to all which it firmly adhered, particularly to the poflerior part of the Stomach, which was likewife indu- rated, and rent in the feparation of it from the tumified part : Now the Sto- mach

Of the LIVER. 83

iliach and Colon being carefully re- moved from about the tumour, it ap- peared an indurated Pancreas diffufed from the Liver through the whole Epi- gaftrum to the Spleen ; and the Gail Bladder was extended to three times its natural fize*

A permanent ficknefs at Stomach therefore, a Vomiting after meals, a hard fwdling arifing in the Epigaftrum, attended with a pulfe correfpond.ng to the Pulfe in the Wrift, may fometimes fignify an intumified and indurated pancreas.

It appears too that parts difeafed communicate their ill difpofitions to each other, and efpeciajly to thofe nearly in contact with them, and fo the Dura Mater being inflamed and ulcerated, will adhere to and ulcerate the Pia Mater, the Membrane of the Lungs will infect the Pleura, of the Liver and Spleen the Diaphragm, and fo on ; and indeed I have obferved even an apoflem of the Lungs arifefrom a large fuppuration in the Loins ; the naufeaand vo- mitings were caufed by the diflemper of the Sto- mach derived from the pancreas \ the pulfation felt at the pit of the Stomach was very probably propa- gated through the denfe and indurated body from the Aorta, on which this vifcus immediately refts ; and this lafl fymptom is ftronger for the exiftence or induration of fomething between the Trunk of the Aorta and Integuments than any other; for if the parts above the Aorta are foft and pliable, the

F 2 Pulfe

84 Of the LIVER.

PuKe is loft in ihe Membranes, nor can it be per- ceived unlefs in very emaciated bodies, wherein I have felt the Pulfe of the Aorta as clear as in the Wrift, and the fame too has been obfrrved by Ga- len *. And it is rather indicant of an induration of the Pancreas than any other part, for this reafon, that being a Gland f conftituted of a convolution of Arteries and Veins, it is more liable thereby to obstructions and fwellin-s than the Membranes about it whofe Veffcls are more rectilineal.

The enlargement of the Gall Bladder was owing to the prefifure of the tumour on the common Duel: of the Liver and Bladder, or the Duodenum, from whence we may make fome eflimate of the intenfity of the power with which the Bile is exprefTed from the Liver, either immediately through the Tunics of the Cyft, or by the mediation of the hepatick and cyftic Duds into the Bladder, or that in the Diaftole of the Cyft, it receives Bile, which not be- ing able to emit, it enlarges, as the Bladder of urine does, or the Ureters, or any Artery or Vein will, when unable to exprefs their contents.

We may note by the way too that a prefTure on the common Duct abie to expand the Cyft: was unable here to force back the Bile through the Liver into the branches of the Cava ; moreover if the Cyft is filled directly from the Liver, the Ducts either mud have Valves, as the Thoracic Duct has at its exit in the Subclavian, or pafs oblique through the Tunics of the Cyft, as the Ureters do in their route through

* In Introdufl. in Pulfura, & de dignofcend. Pulf. f Idem de Meth. medendi, 1. 13.

2 the

Of the LIVER. 85

the Membranes of the Bladder of Urine, or el ft: there mud have been a great accumulation of Bile in the branches of the Pores, or a black jaundice if the Cyft communicate with the branches of the Porta in the Liver directly, inafmuch as the Bile of the Cyft is blacker than the Bile of the Pores.

As to the treatment of the Perfon where there is reafon to fufpeft an induration and enlargement of this Vifcus, mould the Stomach be unable to bear medicines intended to clear the Inteftine, the ex- hibition of laxative Clyfters, fuch as a weak infufian of fenna, with lenitive electuary, and oil, will, by removing the contents of the Colon, take off the: preflure from the tumour, whereby the motion of the Blood through the Aorta and Cava will be more uniform, and the anxiety confequent of the inequa- lity of motion through thcfe Vefiels thereby remit- ted, if not totally removed for the prefent ; which probably will give opportunity to exhibit broths or other nourifhment by fpoonfuls to keep up the powers of the fyftem, until by the increment of the tumour, the motion of the Aorta, and in confe- quence the heart, fhall end in coniufion, and the fyftem itfelf in putrefaction and death.

I faid above that I had obferved an apoftem of the Lungs confequent of another in the Loins ; the following obfervation. will illuftrate the truth of the affirmation.

?3 QBSER-

36 Of tie LIVER.

OBSERVATION V.

Abfcefs in the Lungs from another in the Loins. ■

Miftrefs Graham in her thirtieth year, and in the feventh month of her preg- nancy, fell down flairs, and hit herfelf in the fall on the left Loin, a little above the Ilium, againft the edge of one of the flairs; her flays preferved the inte- guments from contufion, but the whole force of the blow being tranfmitted to the Spine, the contufed flefh being neg- lected, did there impoftumate. From the time fhe lay in about the end of December 1758, her left thigh became ufelefs and fwelled, and an exceeding great pain was propagated from the Ilium, in the direction of the Pfoas Mufcle, through the Groin, and along the Iliac vefiels and nerves, which was attended with a flow fever. On the eighteenth of February 1759,^ large fof t intumefcence appeared in the Loin

above

Of the LIVER. 87

above the Ilium : On the twenty-fixth a Diarrhoea fupervening, the tumor de- creafed, another appearing in the Groin. The fourth of March the Po- tential Cautery was applied to the Loin : On the fifth the Efchar being pierced, about three pints of a purulent collu- vies were drawn off; the fever fubiifted. On the fourteenth the flux from the Loins flopping, the Groin, which had fubfided fince the fifth, again fwelled: On the fixteenth, from a violent paf- fion of anger, the tumor in the Groin difappeared. The feventeenth a total fuppreffion of Urine, attended with an Intumefcence of the Hypogafirium. The eighteenth a copious flux of Urine coming on, it again fubfided, the fever fubfifting writh great pain and fwelling and immobility of the Thigh, a trou- blefome cough, loofenefs, and wading. On the fixth of April fhe died.

On opening the Body the next day, we found the urinary Bladder mode- rately diftended with Urine; from the Spine along the Pfoas Mufcle and Iliac F 4 Veffels

88 Of the LIVER.

Veflels into the Groin and Thigh, the whole fpace was inundated with Pus. In the left fide of the Lungs too was a very large abfcefs covered by the Pleura, to which the Lungs ftriclly ad- hered.

Now fince Mrs. Graham before the Fall was not unhealthy, we may reaibnably fay, the formation of this pulmonary abfctfs commenced fince the fuppu- ration at the Loins, and derived its origin from it; but as the Blood, faturate with the pus flowing through the irritable Membrane of the air pipe, occafioned the cough, throw the irritable Membranes of the Intef- tines the Diarrhoea, and through the ventricles of the Heart the fever or quicknefs of the pulfe, fo did it death which terminates the whole; forafmuchas when the Blood is faturatewith heterogeneous materials, and there be no gland to fecern it, neither will it affimi- late the food, nor vitally unite with the Fibres, nor animate the Syftem.

And it appears moreover that an apoftem and irritable pus may be formed deep in the Mufcles, and from an external caufe, without free communi- cation with the external air.

SECT.

[ «9 1

SECT, IV.

Of the Dropsy.

OBSERVATION L

j&naf area from an Uterine Httmorrhage.

A Woman about fifty came to Ste- vens's in. May 1752. Six months before, Hie had the catamenia for the laft time, and the flooding continuing fome months; firfther legs fwelled, and in fuccefiion the whole fyftem of the Mufcles, and fhe died the latter end of the fame month. In O&ober the fame year another of thirty-eight, in Ste- vens's, had an Uterine Haemorrhage con- tinuing for a year ; firft her legs fwel- led, then an afcites fucceeded.

Women

9o Of the DROP S Y.

Women are therefore liable to fall into dropfies from an uterine haemorrhage, and that near the time of the termination of the Catamenia chiefly.

In great loffes of Blood, whether from the Lungs, as in obfervation 6, Sect. 2, or from the uterus, as in thefe, by the emptinefs of the veffeis, and confe- quent lofs of motion in the Fibres, fanguification is fo far enfeebled, that the fluid in the veflfels is moftly an ill concocted Serum, whofe particles are but loofely connected, which by the rarity of the veffeis from a defect of blood in their Tunics, and want of vivid motion in the fecretory organs to drain off the abun- dance, and want of motion in the Heart to throw it round by the veins •, it refts in the veins firft and then tranfudes, either into the interfaces of the Muf- cles or Cavities $ for when the veffeis are filled with healthy Blood, enriched with Spirits, the motion of the Heart, Veffeis, and Secretions will be much more vivid, and the Tunics of the Veffeis denfer ; for the Heart and Fibres owe not only their nou- rifhment but their motion to the Blood.

Again, from weaknefs of Sanguification the poor effect of Lymph appofited to the Fibres is neither af- fimilate nor vitally united, nor yet thrown off from the Fibres, fo that by new acceffion of Lymph, and diffufion of it over the Fibres, it at length drips thence into the interflices of the Mufcles, and effects that fort of dropfy termed Anafarca, which it may alfo do in the Membranes within and effect a dropfy of the Cavities ; and thus we may conceive how a dropfy arifes from Haemorrhages and weaknefs of Sanguification, and nutrition in confequence.

OB-

Of the DROP ST. 9i

OBSERVATION II.

Auafarca from ObJlruElio?i i?i the Skin.

In fpring 1753, a young woman about twenty came to St. George's, in London: fhe had taken cold by tra- velling in a coach from York to Lon- don about three weeks before, and had not only the Catamenia flopped, but became univerfally anafarcous. Eva- cuations artificial relieved her fome- times ; but fhe was taken v/ith a ftrong loofenefs about two months after, which continuing three days, fhe was there- by cured.

The Skin therefore, by being obftru&ed from cold, may turn away the courfe of fecretion from the fur- face of the Body ; and if the confined Lymph be not drawn off by the Kidnies, or other lecretory or- gan, it may tranfude into the cellular Membrane of the Mufcles, and fill their Interfaces univerfally.

A flrong Diarrhoea coming on, a Leucophlegmatia cures it*. That is, the vefTels of the parts will

* Hip. _Aph; et lib. cs diebus judicatoris et Coacae prse- r.Oiiones.

feme-

$% Of the D RQ P S r.

fometimes abforb extra vafated Lymph, and tranf- fer it to another part, and there excern it.

We may likewife obferve too, that the fulnefs of the vefTels and the change induced in their mo- tions, may by its action on the Uterus flop the Cata- menia.

OBSERVAT IO N III,

Af cites from obfiruEliom in the Skin*,

In Auguft 1752, a cooper came to Stevens's, who from colds by working in the open air, had not only an ana- farcous dropfy, but even an afcites.

And I obferved the fame in a brick- layer at the fame time.

An afcites therefore as well as an anafarcous dropfy, may arife from the antecedent caufes of colds, or flop to perfpiration from the Skin. That is, the confined Serum may exfude as well from the Mem- brane of the Cavity as the Cellular Membrane of the Mufcles ; for as we obferve fuch copious exhala- tions from the Skin in violent exercife, or ftrong and inceilant labour, which by condenfing puts on the form of fweat ; fo may we eafily conceive, that if the exhalation is confined in the Skin, and the rare- faction and vapours arifing from the Blood ftill con- tinue, that the vapour afcending from the Blood

may

Of the DROPS T. 93

may find a vent from the internal Membranes, and by there condenfing produce a dropfy of the Cavity, or by f welling the ferous veflels of this Venter to a Diairefis.

OBSERVATION IV.

Afcttes from ObJlruElions in the Kidnies.

A boy about thirteen, in St. George's in London 1753, had fupprefiions of urine, and being fearched with the catheter, no ftone was perceived. He had been cut for the ftone, and one extracted from the Bladder two years before ; but thefymptoms of fuppreffion and pains in the Loins, chiefly the left, toward which he was fomewhat incur- vated, perfifting, attended too with an urinous vapour, exhaling from and moiftening the Skin, he fell at length into a dropfy of the Belly.

From the continuance of the fymptoms after ope- ration, and the urinous humidity ever exhaling from the Skin, it is more than probable that one if not both Kidnies were infarcted with fand, gravel, or ftone. And as this dropfy came long after opera- tion, from which he was very well recovered, we

may

54 Of the D RO P ST.

may fay that an Afcites may arife fometimes from obftru&ion to the fecretion of urine.

And that the quantity flopped in the Veflels from feparation, by the Kidnies being infarcted, will in time caufe an accumulation fufficient for the pur- pofe, even though a great part of what ought to be drawn off by urine exhale in the fkin -, we may ga- ther from the rules of Sanftorius, Keil, and Robin- ion, if the quantity of drink is given for a time 5 and the like may be argued of a fupprefiion of fe- cretion by the Skin.

OBSERVATION V.

Afcites from ObJiruSiions in the Liver.

In March 1752 a girl about fixteert was taken in at Stevens's, who had a tumour below the Cartilage of the Ster- num, nearly midway between the Hy^ pochonders, rather inclining to the right, attended with a dropfy afcites ; it pointed after fome time, and was livid at the apex, and feemed like an abfeefs from an inflammation. Emol- lient and warm cataplafms being ap- plied, it broke in a few days, and above three pints of hydatids came from the orifice at times, and fome alfo by the

Reclum

Of the DROP ST. 95

Redhim. In a few weeks after fhe was difcharged well of her ulcer and dropfy, but with fome degree of jaundice, ap- pearing only in the Tunica albuginea of the eyes.

Now as it is a known property of the Liver to be liable to fuch obftructions as generate hydatids, it is very probable her dropfy took origin from this tumour exiftent in the Liver ; for if the Vein termed Porta is prefled by any caufe, the Mefentery, In- teftines, and Spleen being thereby fwelled, their Vefifels will be rarer at their terminations in the Membranes than they were before, and will thereby be the more difpoied to let their Lymph tranfude in the manner of Diapedefis ; or if there are ferous VefTels in thefe Membranes, not admitting red glo- bules of Blood, more Lymph may be turned into thefe Veffels than their tender Tunics can bear, fo to that it may tranfude as by Diapedefis, or by the way of Dicerefis let their Lymph fall into the Cavity ; and the fame may arife by a pre flu re on the branches of the Cava in the Liver, by which the Membranes of the Vifcus may be given to fweil. But the Hy- datids with their contents, by the adherence of the Liver to the Peritonei] m* and fuppuration of the Membrane and parts above it, finding an exit from within the Liver, fuffered the Blood to go on more freely throughout the unobftrudled part of the Vif- cus, and fo the fwrlling of the Spleen, Interlines, and Mefentery fubfiding, the extravafation (lopped,

and

$6 Of the DROPS T.

and that which had formerly leaked was again ab- forbed, leaving however fome degree of preflure on the Biliary Duels, which returning the Bile to the Cava tinged the Serum, and caufed that flight ap- pearance of jaundice which remained ; and I the ra- ther take this to be the mode of efteclion* for the rupture of the Hydatids would probably afford too fmall a quantity ot water to make an afcites vifible.

And it appears too that though a Liver enlarged by unequal nutrition, which is only the affection of its Fibres, or fwelled by too much Blood or cold congeftions in the Porta, will not of neceflity pro- duce a jaundice, yet a tumor may be of fuch a fort and fituation in this Vifcus as to effecT: it fometimes.

But fometimes too obftru&ions in the Liver, of another kind than thofe which raife Hydatids, or rather a peculiar fort of tumors, by their preflure on the branches of the Porta, differing in fpecies from the former, may caufe a dropfy of the Belly, I had an oportunity of feeing, while I was reviewing thefe obfervations.

OBSERVATION VL

A boy of fourteen came to Mer> cer's * in Auguft, with an immenfe af- cites, for which he had been repeatedly

* Regifter of caufes. at Mercer's for 1762.

tapped ;

Of the DROP ST. 97

tapped ; but the water ftill tranfuding, he died on the I oth of September 1762. In the Lower Belly we found the Liver wholly conftituted of little firm globules, quite folid to fenfe, corre- fponding to the defcription of Marcel- lus, Malpighius*, or like the vitella- rium in a laying hen f, except that thefe globules were among themfelves more near in a proportion of equality than thofe of the vitellarium are. This Liver however weighed but one pound fifteen ounces Troy, and the Spleen one pound ten ounces.

Now though Malpighius defcribes his Liver as a conglomerate Gland, yet the injecYions of Rufchius and other anatomifts have put it out of difpute, that Malpighius's Livers were morbid, or their ftruc- ture preternatural ; and as the Spleen in no wife dif- fered from a (late of nature but weight, at lead as to fenfe, we may fafely conclude that the preflure of thefe little bodies on the branches of the Veins in the Liver, were the immediate caufe effective of the leakage. And indeed the largenefs of Spleen would incline one to think, that from the flower motion of the Blood in that Vifcus, by reafon of its obstruction

* De Hepate, c. 3. f Hen-ey de gen. an. e^ccr. 3.

G in

5)8 Of the DROPSr.

in the Liver, the Spleen, by unequal nourifhmeht, had outgrown its ordinary ilze and juft proportion to the Liver.

And univerfally I believe from the various and great impediments the Blood meets in Its tranfk through the Membranes of the Lower Belly, k eomes that dropfies are more frequently obferved in this venter than in the two fuperior.

But as to the above fubject, there was nothing of morbid difpofition or ill conformation to be feen in any other part of the lower or middle Venter, and we may affirm the fame of the upper Venter, from his preferving a flate and powers of undemanding and lively voluntary motion, even to the hour- of his death.

But obstructions like wife in the Liver will, for the reafons afilgned, extravafate Lymph, and even Blood, into the Cavity of the Interlines; and thefe extravafations are attended with fcarce any uneafi- ntfs, but that of an obfcure pain and weight in the right Hypochondrium, and even fometimes none at all •, but a very great and repeated dejection of mind and faintnefs. And indeed thefe fluxes, compared with antecedent caufes, are no mean argument of fuch obftiuctions exiting in the Liver. I once myfelf obferved one who, from an anxious folitary life, took to drinking diftilled fpirits by way of re- frefhment or diflipation of care, and was turned of fifty, and often jaundiced -, that thefe fluxes return- ing at uncertain periods relieved her greatly from that load and oppremon fhe complained of before Uie ejection of the Blood, Now feeing that diftilled

fpirits

Of the DROP ST. 99

fpirits are known to inipiflate the Blood, and ib conflict the Fibres for the prefent, that they are weaker fometime after a dram *, and that infpif- fated blood will rather be given to flop in the Li- ver than any other part, forafmuch as this bowel, though its Vein be denfer and ftronger j than even the Cava and Aorta, yet as wanting eiafticity to give its Blood the Arterial Jet, the progrefs of the Blood will be flower, and obftructions more likely to be formed herein, and efpecially as the Blood returning from the Inteftines J after depofiting its phlegm there, as alfo after its Serum is drained off in a good meafure by the Kidnies, is more infpif- fated than that which pafTes in other parts, even in a ftate of texture agreeable to nature, and totally uninfluenced by the admixture of coagulating me- dicines ; and if the Blood be accumulated in the Membranes of the Lower Belly, by reafon of an obstruction in the Liver, we need not be furprifed at the great dejection of mind and faintnefs which attends, the Heart being thereby deficient of its due quantity of Blood, which Blood gradually accumu- lated, being thus extravafated, the Veflfels of the Me- fentery are again at freedom to renew their vibra- tions, and forward the Blood they receive from the branches of the Celiacs through the part of the Liver remaining unobftructed.

It having been an opinion of fome, that the Bile in a jaundice returning to the Blood does by its fa- ponaceous quality thin it, and caufe it thereby to

* Hale&'s Hasmofticks, Exp 15. f Clifton Wintring*

ham, Exp. 47. Lond. 1740. j Gliflbn an.it. Hep. c. 41.

G 2 be

IB?

Of the DROP ST.

be more liable to exfude from the Membranes, which though one would not totally deny, yet fee- ing that this quality of the human Bile has not been fettled by fufficient experience, I had rather fay- that, that ftate of the Liver which returns the Bile does, by obstruction and loading the Mem- branes, give occafion for the more ready exfudance of the finer part of the Lymph. For if the Pores in the Liver are tumid with Bile they will prefs the branches of the Porta, and by conftant perfeverance, will infenfibly fill the Membranes of the Belly to an exfudance of their Lymph. Laftly, if artificial (oaps have fimilar powers wich the natural, thofe who take foap pills even to an ounce in the day, for concre- tions in the urinary parts, lhould be liable to the dropfy, which is oppofite to experience.

OBSERVATION VIL

Afcites from an objlruEied Spleen.

In October 1752, a woman about thirty-five was brought to Stevens with an immenfe afcites. Seven years before this £he received a bruife in the left Hypochondrium. In fome time from the accident the dropfy became fenfi- ble and afterwards encreafed. She was tapped in the hofpital, and five gallons

of

Of the DROP ST. io.i

of water drawn off by thetrochar, when an immenfe fpleen prefented itfelf, fil- ling the whole Hypochondrium. A little before her coming to the hofpital, by a fright, fhe was taken with a vo- miting of Blood, but not very great in quantity, nor of long continuance, I obferved likewife here that ftatc of mental confidence noted by Areteus and Mead.

If obftru&ions and fwellings of the fpleen arife from others in the Liver, it is no very difficult mat- ter to conceive the manner in which a dropfy of the Belly may be thus effected ; for if the motion is im- peded in the Splenick Vein, as it is when the Liver is obftructed, the fpleen and its Membrane will in- fenfibly fill, and fo the Lymph may exfude : Or by filling the Lymphaticks with more Lymph than, their tender Tunics are able to fupport without ex. fudance or rupture. But in obftructions of the fpleen, independent of the Liver* fuch as may arife from a diftemper of the fpleen itfelf, it is not fo eafy to make it out clearly. An ulcer exiftent in the Tunic may partly, by erofion of the Tunic, not fo great as to let the red Globules pafs, and partly by the irritation of its Ichor inciting an arHux of Serum that way, drip fo for a long feries of time, as to fill the cavity of the Belly, which can be rea-

G j dily

io2 Of the "DROP ST.

dily known by computing the number of drops an ulcer may be conceived to let fall in a given time.

But in this cafe, where the fwelling of the fpleen was exceeding great, it is probable the Blood extra- vafated therein by the bruife, did fo by its prefiure on the Veins change the progreffion of the Blood in the Arteries of the Vifcus, that the Blood con- flantly difTufed through its Membrane fwelled it, or the Membranes of the Stomach, to an exfudance of their Lymph, at every fyftole of the Vifcus ; fo that we may fay de fafto^ that a dropfy of the Belly was concomitant with a fwelled and obftructed Spleen, and by reafon that it had its origin from it. I feem alfo to gather that vomiting of Blood may be caufed by the fame indifpofition -, for in the paffion of fudden fear, the Blood being hurried to the Spleen and not finding an exit there with eafe and freedom, it returned to the Stomach and there -extravafated. And we may alfo note, that the Arteries not only fuffer their Lymph to exfude into the Stomach when its Membranes are loaded, but even red blood through their orifices opening to the Cavity when expanded. I fay the Arteries -, for had the vomiting of Blood been concomitant with obftruelions of the Liver, the Hemorrhage would have come from the Veins of the Stomach, ending in the Splenick Vein . as it happened to Mrs. Hudfon, a relation of mine, who died of a jaundice and dropfy, ending at length with an incefTant vomiting of Blood.

In the general reflection of the firft feclion we ihewed, from the authority of Webfer, the poffibility

of

Of the DROP ST. 103

of water extravafating in the Head and Spine, to- gether with its antecedent caufes, fymptoms, and effects ; and we feemed to think this water fweated from the weak Membrane lining the Ventricles, or from the Membranes about the Brain, or exhaled therefrom, and then condenfed into the form of water, by reafon that fuch obftructions of or prefTure on the Veins defcending from the Head, would fwell up the Membranes or vafcular part of the Brain too fuddenly, and be vifible by its effects on the me- dullary tracts, before the Lymph could collect in any fenfible quantity, unlefs the prefTure or ob- ftruction were lefs than any afTignable one, and per- filled for a long time ; fo that the whole contents of the Skull, by the diffuficn of the Lymph, fhould at length become fo humid as to diftill part of that humidity from the moift Membranes.

And we may alfo infer, that a rupture of one or more Lymphaticks (if there be fuch) would fuddenly drown the Brain, as it pofTibly did in the cafe of Chriftopher Weiler, recited by Bruner.

And further, that an ulcer exiftent in thefe Mem- branes would mew itfelf by convulfive motions in the fyftem of the Mufcles by its irritation, before it would fill the interftices of the Membranes or Ven- tricles ; and that thefe reafons may be transferred to the Membranes and cinericious parts of the Spinal Marrow. And as the prefTure on the Veins of the Omentum and Gut ftrangled in an Hernia fills the fack with water, fo in the third fe£tion tranfudation from prefTure in fome Veins of the Cheft has been (hewn from reafon to be a pofTible caufe of a dropfy G 4 here ;

104 Of the DROP ST.

here ; and we may fay from reafon too, that obftruc- tions in the Veins of the Intercoftals returning to the Azygos and Auricle, may fill the Tunics of the fame Veins near their origins in the Membranes, and have the fame effect ; though thefe Veins are por- tions of cones, whofe angles at the vertex are exceed- ingly acute, yet may, like the Pulmonary Veins, be fufceptible of obftruction ; and all this [in the mode of extravafation by Diaptdefis.

Moreover wefhewed, from obfervation and reafon, that an ill cured pleurify leaving diftempered Mem- branes produced it alfo, either by dripping their Ichor, or prefting of their tumor on fome Vein of the Cheft : And this by the mode of Diaerefis and Diapedefis.

And we alfo infer from the authority of Cooper, that a dropfy of the Cheft may be concomitant with, and by reafon did arife from, obftructions in the Kidneys •, for he tells us * that on opening the Body of an elderly gentleman who died of an afthma from water in the Cheft, that the right Kidney was but a third of its natural fize, and that too with large Hydatids on its furface ; the left Kidney alfo JelTened, but not fo much as the right, and its ureter almoft impervious from its petrification : And the mitral Valves of the left Ventricle petrified in feveral places alfo, fo that we may fay the fyftem, loaded with Serofities, fufTered part thereof to exfude from the internal Membranes 5 and rather from thofe of the Cheft, by reafon the petrification of the Valves

• TranfPhil. V. 5. p. 240.

ef

Of the DROP ST. ioy

of the Ventricle hindering the uniform egrefs of the Blood from the Lungs, its Membrane was there- by more tumid with Lymph than it otherwife would be: And the fame may be argued of a polypous Concretion in the pulmonary Vein. And we alfo mewed that a dropfy of the Pericardium was con- comitant with, and probably arofe from, a permanent obstruction of the Lungs.

And we likewife conclude by reafon, that if there are Lymphaticks in the human Cheft, that by their continuity folved from quantity, quality, or unequal motion of their Lymph, or by Diapedefis from their extended Tunics, the fame may arife.

In the fixth obfervation of the lecond fection, we likewife proved, by mere obfervations, that a dropfy of the Mufcles, termed Anafarca, did arife from a great depletion of the Blood from the Lungs and Arm. And in the preceding obfervations we faw that not only an anafarcous dropfy but even an Af- cites, followed profufe Hemorrhages from the Uterus, together with the mode by which it was effected ; and that both forts are caufed by obstructions in the Skin i and that an afcites is caufed by obftrudtions in the Kidnies and Liver *, the former by filling the whole fyftem, and the latter by filling the Mem- branes of the Lower Belly with Lymph ; and that an afcites was concomitant with, and very probably arofe from, obstructions and diftempers of the fpleen, and fuch are fome of the material caufes of drop- fies. Moreover, if there are Lymphaticks in this

* Galen: de locis affedtis, lib. 5, C, 7.

Venter

io6 Of the D ROPSr.

Venter of the human Subject, we may fay, as in a dropfy of the Cheft, that by obftruction to its uni- form motion, or continuity folved from the quantity or quality of their Lymph, a dropfy of this cavity may be effected.

Among the antecedent caufes of water congefting in the Cavities then, we have afligned want of due fecretions by an inert life, or difproportion of fluid to folid food, and quantity of both too great for the powers, by which the whole Syftem is turgid with Lymph, which flowing through weak Membranes, does by expanding difpofe them to leak : But I argue further, that it is pofiible the paflions of the Mind may antecede and be effective of a dropfy of either Cheft and Belly, if the Heart and Veffels be agitated with Spafms, as we often fee in the paflions of fhame, fear, joy, furprize, and fudden grief. If thefe paf- lions perfevere, or return ever and anon, then will the left Ventricle by its tremulous motion return the Blood as often into the Lungs, which in their Syftole may exprefs the Lymph into the cavities, and by repetitions of it caufe even a notable congeflion ; and if the right Ventricle be often agitated by the fame difturbing caufes, the Blood will return through the Liver, and expand its Membrane, as alfo all the Mem- branes of the Lower Belly : But I only mention this as a pofiible effect: of thefe difturbing caufes, leaving it to be either proved or rejected as it (hall be found conformable to experience or not : Nor is it pofiible that thefe extravafations mould arife from any re-* peated difturbances of the Ventricles only, but the fame confequential effects may be caufed by like

agita-

Of the DROP ST. 107

agitations of the Diaphragm, at lead I fee no con- trad ict ion in it.

If water is fufFereri to reft extravafate, it will have thefe effects, that either growing acrid or putrid, it will fcald and corrupt the parts about it, or bycon- geftion incommode the functions of the parts which are near it. In the Legs it will produce ulcers tending to gangrene; fo will it corrupt the Mem. branes of the Lower Belly. In the Ventricles of the Brain it will expand them even to dilate the Brain to the thicknefs of a Membrane, if the Bones give way as they do in Hydrocephalus Fcetus's and Infants*, if not, it comprefTes the medullary tracts, and ends either in an apoplexy or paralyfis, as theA preffure is univerfal, or greater on fome than other tracts. If the extra vafation is above the cortical part, it will prefs it down to a third of the fpace it before pofiefTed. In the cavity of the Cheft it will, by fucceflive congeftion, whether by infiltration or effufion, raife the ribs firft, and when the ribs are at the utmoft expanfe, prefs the Lungs and Heart, even to fuffocation and fwooning. If between the In- tercoftals and Pleura, that Membrane will befeparated from the Ribs, and prefs the Lungs to the fame ef- fect:, which appears from defection ; forafmuch as when the Sternum has been raifed and removed there at firft appeared as if there were no fuch parts as Heart or Lungs in the Cheft. In the Medi- aftinum it uill have the fame impreffion on the great veffels ariftng out of and ending in the Heart.

♦ Mauriceu de Mu!. Morb. lib. 3, c, 28.. Paris 16S2.

In

108 Of the DROP ST.

In the cavity of the Pericardium it will interrupt the expanfion of the Auricles and Ventricles. In the cavity of the Lower Belly it will force the Dia- phragm up into the Cheft, and by lelTening the fpace of its cavities, bring on a fhortnefs of Breath ; and prefting the Liver and Kidnies, hinder their na- tural fecretions, and by prefling the Stomach and alimentary Canal, the due progrefTion of the food therein: And if it arife and congeft within the Ovaria, it will extend the Ovary, until prefling the Illiac Nerves and VeiTels, the Hips and Thighs are tortured with acute pains and fwellings -, and the Urine by its preflure on the Ureters, if both Ova- ria are affected, or even one only, will be co- hibited.

Elinor Proudfort, about twenty, in September 1762 came to Mercer's : fhe had an acute pain in her Hip, which propagated itfelf down the Thigh and Leg, even to the Ancle : we bled, purged, bliftered, and applied the plafter in common ufe,. of Burgundy pitch and turpentine, with an eighth of euphorbium, to little purpofe : In the beginning of October a large circumfcribed fwelling appeared in the Illiac region, which infenfibly diffufed itfelf toward the Spine, and the foregoing Symptoms in- creafed, even to a Iofs of the Limb, with a fup- preflion of the inteftinal and urinal Excretions. In November me left the Hofpital for fear of being di fleeted.

Now as there is no part in the Iliac Region fo liable to a large circumfcribed increafing Tumor as the Ovarium is, we may fay that an enlargement of

lhat

Of the DROPS T. 109

that part, whether by increment of Fibres, as in the cafe of unequal nutrition, or by water extrava- fated into the interftices of its VefTels, effected the oedema of the extremity, and the acute pain and fever concomitant with it.

Tumors of this kind I have obferved to attend abortions, difficult labours, and long retention of the Catamenia, though none of them were incident to Proud fort.

Between the Mufcles and Peritoneum it will have the fame effect as between the Intercoftals and Pleura. If any man mould fay, how is it poffible that water can extravafate, collect, and act with fuch exceed- ing prefTure ? Let it be confidered that all foft or- ganical parts are ever in a date of Syftole and reci- procal Diaftole. If the fine Membrane of the Ven- tricles or Glands of the Plexus are given to leak in every Diaftole of the Brain, there will be a fpace left to be fupplied by a new diftillation, and the Brain will lofe fo much of its due dimenfion, and in procefs of time the lofs of fpace, though lefs at firft than any given one, will become fenfible, and the fame may be argued of any other part into which the Membranes may be given to exfude. More- over if the leakage mould come from the Dura or Pia Mater, the fubfidence of the Brain will allow fpace for fucceffive drops.

That a dropfy of the Head and Spine, or rather the (late of the parts in the Head and Spine, where- in the Brain and Marrow, and their Membranes, are foaked in ferofities without much congeftion in the Cavities, and which are fignified. by the fytnptoms

of

iio Of the D ROP ST.

of vertigo, drowfinefs, head-achs, and paralyfes* may be fometimes cured by purging frequently re- peated, to invite the Serum to the Inteftines, and by leffening the diet, and chiefly the drink, and perfe- vering therein for many months, We (hewed from the authority of Robinfon and Mead, and other eva- cuations near the part affected, in the general obfer- vation of the firft feclion.

That a dropfy of the Cheft, if it arife from mere exfudance, and the Membranes of the Cheft are free from permanent fwellings, ulcers, or ferous ab- fcefTes, or other ill difpofitions of the Lungs, may be cured by the powers of the Membranes, I argued by comparing them with the artificial dropfy pro- duced by Mufgrave •, and that it is relieved from any caufe by draining the whole fyftem of its Serum by purging repeatedly \ and the immediate danger put off for a time, by the paracemefis.

That a dropfy in the Belly too may be cured by the Membranes refuming the extravafated Lymph, we may infer from the reafons of the celebrated Kaw *, inferring the neceffity of reforbing from the conftancy with which the Membranes exhale 5 and it would very probably be proved, if fuch experi- ments as thofe of Mufgrave were made in this Ven- ter, by deductions ftronger than reafon only f. But when a dropfy of the Belly admits of cure by purg- ing, diureticks, and the paracentesis, we may con- clude that the extravafation arofe rather by reafon the whole fyftem was turgid with Lymph, by con-

* Leids 173S. t Sharp on Operations, c. i3*Lond. 1758.

finemenc

Of the DROPST. in

finement of fome fecretion of the Skin or Kidnics, fo that the ferous Veflels leaked in the mode of dia~ pedefis ; but the organs refuming their functions, the water is either abforbed or drained by falling or the other mode of artificial evacuations by irritations as above •, or that it arofe from the inertnefs of the Liver, by which the Membranes of the Lower Belly were loaded with Blood, and for want of due progrefiion depofited its Lymph, which probably was the cafe where the vomits recommended by Sy- denham had fuch extraordinarv effects ; but if a dropfy of the Belly arife from a fixed obftruction of the Liver or Spleen, or incurable infarction of the Kidnies, or ulcers or tumefactions in the Mefentery, then we mud draw off the water by irritation, and the paracentefis repeated as neceffity requires ; and the ufe of warm, generous, and fpirituous cordials, which enliven and fupport the Heart, while the fy- ftem fhall continue to move.

Laftly, that a dropfy anafarcous may be cured by the part reforbing the Lymph, we proved pre- cifely in the fecond obfervation of this fection, where being transferred to the Inteftines it was there extra- vafated ; but an anafarcous dropfy arifing from mere fullnefs and confequent leakage, is to be treated by irritation of the Inteftines, and then of the Kid- nies, a remarkable inftance of which Sir Richard Blackmore relates, wherein all the water was driven off through the Kidnies by chalybeat waters, in an otherwife infuperable anafarca -, and if it arife from profufe hemorrhages, the cure by irritation is to be deferred, till the VefTels are filled with Blood, of fuch

quality,

in Of the DROP ST.

quality, that the Heart, enabled thereby, may throw it round through the fyftem of the Veins, in order to (lop the infiltration, which is done by generous diet to fupport the powers and keep up the fecre- tions, and then by diuretics, not too much adding to the quantity of Lymph ; and laftly, by innumer- able punftures of the hydropical parts, which cor- refpond in proportion to the paracentefis of the Ca- vities : But care is be taken here that the feclions of the extremities be not too large, efpecially if the anafarca extend throughout the whole fyftem of the Mufcles (for in a partial anafarca the danger cannot be very conficerable) by reafon I have fcen more than once, which has been likewife obferved by Ga- len * and Mead t, where the incifions being three or four inches long, the Serum running out too fuddenly, they have been taken with rigors and fhudderings, with an immenfe fenfation ofcoldnefs, and in two or three days have died fo ; very pro- bably for this, that the preflure being taken off the Arteries of the Mufcles, left the interior Arteries and left Ventricle deficient of Blood, and the preflure being taken off the Veins of the Mufcles, relaxed by foaking in the Lymph, neither they nor the foftened Fibres of the Mufcles had elafticity enough to ex- prefs the load of Blood they were too fuddenly filled with *, or the Serum extravafed, at once drawn off, the remainder in the VefTels leaked out after it, and left the Cruor within too infpiflate for motion, or the whole fyftem fo empty, that its organical parts were deftitute of fluid to conferve their motions.

* De Arte med. ad Glaucoaem, lib, i. t Precept, med.

Should

Of the DROP ST, uj

Should a dropfy anafarcous arife from prefiure on the Trunks of the Cavae, as in a dropfy of the Cheft, or iwelled Ovaria, either by water therein or enlarged in the mode of Sarcofis, then will it be re- lieved from time to time by draining the Serum through the Inteftines, forcing part thereof through the Kidnies, and Punctures, until the fyftem by the increment of the prefiing caufe (hall terminate in death.

But fometimes there are tumors of the Belly hav- ing their origin in the Mefentery, and contain a fluid therein, which raife the Integuments and MufcJes of the Belly, and are attended with fymp- toms not diflimilar to a dropfy of the Belly ; fo that it might be taken for a tumor effected by extrava- fated water at large in the Cavity. The undulation of the water in an afcites proper, is readily per- ceived by placing the palm of one Hand on the fide of the Belly and tapping with the other, but the fluctus of Water encyfted is not fo evident.

OBSERVATION VII.

Elizabeth Flyn, about fourteen, had a tumor gradually increafing in the middle of the Lower Belly for three months, till it came to the fize of an ordinary afcites. The undulation of water was very obfeure, and it was harder than a tumour from water in H the

ii4 Cf the, DROPSr.

the Cavity : Purging relieved her from time to time, but £he died on the fourth of O&ober laft 1762.

When the Integuments and Mufcles of the Belly were removed, there ap- peared a tumour arAong the Inteftines adhering to the Mefentqry, and being divided there flowed out a gallon or more of a dilutered fluid ; the Ovarium of the right flde too was larger than a pullet's egg.

Now feeing the Belly may enlarge from fuch different caufes, we ought to be the more circum- fpect in tapping, left we leave the perfons worfe than we found them, and difcredit an operation of fervice to mankind when juftly inftituted.

SECT

"S

SECT. V.

Of the Intestines.

DYSENTERIES, like other dif- eafes, are either epidemical or acute ; the Symptoms of which are a loofenefs attended with gripes, mucus, blood in the ftools, and a quick pulfe ; and their immediate caufe, fluxion on the Inteftines ; but they are fometimes diuturnal, and their immediate caufes are either habitual fluxion or apo- ftem.

OBSERVATION L

Dyfentery from an Apojlem in the ReEiurn.

A failor about fifty came to Ste- vens's in October 1756, who for two years had a dyfentery, contracted at firft in America 5 fometimes by the aflift- H 2 ance

it 6 Of the IN TE S TINE S,

ance of medicines it (lopped for a mcnth or two, and then returned ; the looienefs was not vifcous, bloody, or watry, nor attended with much pain, but ftercoral. At length an ulcer ap- peared near the Sphincter of the Rec- tum, and being fearched it was found to be a compleat fiftula : The operation for a fiftula being duly performed, and the part healed, the flux returned no more.

In that fort. of chronical dyfentery then, where the loofenefs is ftercoral, and without acute pain, fever, and gripes, we may conceive the caufe to be rather the Pus or Ichor of an apoftem, fretting the Inteftine near the place of its exiftence, and propa- gating its effects through the whole Canal, than an acrid ferum or humor flowing on, or fecerned in, the Tunics of the Inteftines ; and thefe fymp- toms may diftinguifh fometimes whether the caufe be from fluxion or apoftem •, the reafon of which difference is, the Inteftines are at the fame time fti- mulated, and their contents diluted with the ma- terials of the fluxion.

Should a dyfentery be caufed by an apoftem higher in the Tunics of the Rectum, or in the Co- lon, as it may according to Bartholine * and Hux- ham 7, and the apoftem be recent, the cure will

* Cent. 6. Obi". ?. f Tranf Fhil. v. 7. 518.

depend

Of the INTE STINE S. it;

depend on the materials of it being taken into the habit, and transferred to the Emunctories, or on its breaking into the Inteftines, that the whole Pus may be difcharged in ftool ; but if the Ichor diftil into the Cavity of the Inteftine, either conftantly or from time to time, it will be requifite to fheath the In- teftine from its irritation and corrofive effects by foft unguents and balfams, fuch as that of Locatellus, or others of like power, and to clear the Interline repeatedly with lenitive electuary or rhubarb, until the motions exerted by nature fhall exprefs all the materials of the apoflem.

The mediate caufes of the iliac paffion are either fcalding humour flowing in the Membranes of the Inteftines, or fecerned by their Glands into their Cavity, or an acrid vapour exhaling therein, whofe exit has by colds or other antecedent caufes been confined in the (kin; and thefe caufes have been difcovered by reafon: obftructions by induration of their contents -, hernias at the Navel *, Diaphragm f , and Groin ; and involutions J have been traced by diflection : But as iliac paflions are acute, and the Inflammations raifed in the Inteftines moftly termi- nate by gangrene in a little time when they do not refolve, fo are they fometimes intermittent, and of length, and fatal in the end.

* Amand. Tranf. Phil. vol. 9. 159. •(• St. Andre, vol.

y 267. % Riverius Cent. 306. 26.

H 3 OBSER.

nS Of the INTESTINES.

OBSERVATION II.

Iliac Paff.on from Adherence of the hiteflines.

In April 1753 came a man from Edinburgh to St. George's hofpital, who had for three quarters of a year infufferable pains in the Lower Belly, and fometimes a vomiting, with a total fuppreffion of ftools and urine. The violence of thefe pains were often al- layed by the affiflance of ftrong purges, the compound powder of fcammony, with a grain or two of opium, and a clyfter in an hour or fo, to folicit it downward. Sometimes too the tor- ment intermitted of itfelf for a few days, but on the 21ft pf May he was feized with a fit of violent pain, in which the day following he died.

On removing the Sternum fome hard tubercles appeared in the Lungs dif- perfedly, but not fo many or fo great as. to incommode their functions. In the J,p\ver Belly the whole volume of the

Inteftines

Of the INTE S TINE S. 119

Inteftines adhered univerfally, exhibit- ing the appearance of the Brain when the Pia Mater is removed ; and their furfaces, together with thefurface of the Liver, Spleen, and Stomach, were white, as if fodden in fcalding water ; on the iniide of the Stomach were many fpots of extravafated Blood, about the iize of a filver two-pence ; and in the Cavity of the Belly was a brown liquor dif- fufed over the furface of the Inteftines ; there was no other changes evident to fenfe in the organical conftitution of any part, nor could it be found whence the water extravafated.

From the Colour of the Inteftines then, and other parts in this Venter •, from the inflammatory ftate of the Stomach, and adherence of the Inteftines, whofe difpofuion it is, in common with other Membranes in the fyftem, to coalefce from antecedent inflam- mations •, and from the water found extravafate in the Cavity, we may fafely infer, that an acrid hu- mour fweated from, or a fcalding vapour expired from the Membrane of the Cavity, by whofe action on the Inteftines the accidents related were pro- duced ; for if acrid humours are often generated in the Blood of fo corrofive a quality, as we obferve in the humour termed fcrophulous, and others fpecifically H 4 different,

1 20 Of the INTE S TINE S.

different, corroding even the bones themfelves, no wonder then that an humour fimilar in power fhould raife fuch extreme perception of pain in thefe exqui- fitely fenfible Membranes, inflame and effect their unition before they had time to corrode as they do in parts deftitute of feeling or vifible irritation. So then we may infer by reafcn, that an iliac paflion may arife from fluxions at firft •, and by diffedion, that the effect of the fluxions may be inflammation of the Membranes, their union among themfelves, and confequent obftruclions from defect in their motions, returns of infufferable pain thereby, and death in the end.

And by the way we may note, that a fuppreflion of urine may be caufed by the Ureters confenting in fpafms with the Interlines, as the Inteftines are known to do from irritations in the Ureters.

OBSERVATION III.

Iliac Paffton by Involution.

In Auguft 1752, came to Stevens's a failor from Yarmouth, a little Man, about twenty-five years old : He had intolerable pains in the Lower Belly, which began fix weeks before, and con- tinuing for fome hours, then intermit- ted. At thefe intervals of pain he re-

3 turned

Of the 1NTE S T INE 5. 121

turned to feed as at other times, but when the Inteftine began to fill, the food flopped in its pafTage below the Navel, and then the torment com- menced, and perfifted till, by the afiift- ance of very ftimulating ciyfters, fome ftools were promoted, and thus he was eafier ; but thofe means were at length ineffectual, fo the intermiffions being lefs, the pain became almoft continual, and in a violent exacerbation one morn- ing he died, being two months after his arrival at the hofpital.

The Caecum with its appendicle, and three or four inches of the Ilium, were forced up into the Colon and ad- hered thereto ; and the Colon, rent from its adherence to the Mefentery, lay down in the Pelvis.

Now a little before the commence- ment of thefe Pains this miferable man had taken very ftrong cathartic pills repeatedly for a virulent gonorrhoea, which wrought him almoft inceffantly.

So then an Iliac Paflion may arife from the invo- lution of one part of the Inteftine into another, from

its

122 Of the INTESTINES.

its inflammation and adherence, which obftruc"l the contents of the Inteftine endeavouring to defcend, and from the violent and painful Lucius between, the Inteftine and Obftacle i and this fort of Iliac paffion is indicated by the (loppage of the food at a certain place, of which this unhappy man was per- fectly fenfible.

It appears too, that pain will arife in the Intef- tines, as well by obftruction of its cavity, as from fluxions on or obftructions in the Veffels of the Membranes, or fpafms by affections of their Nerves.

Nor is it diffonant to reafon to conclude, thefe ef- fects took origin from the violent motions of the Interlines raifed by the pills •, for by the ftrong ac. tions of the Diaphragm and Mufcles of the Belly exerted in inteftinal excretions, combined with the morions of the Interlines from the fame caufe, that fuch an effect may arife is not very difficult to con- ceive to one who confiders the flrength of thefe mo- tions, and compares them with the experiments of the celebrated Haller *, who by irritation has made introfufceptions in the Inteftines of creatures at plea- sure, which introfufceptions however, by a feries of experiments of the fame author, will not produce the Iliac Paffions without the inflammation and ad- herence of their Membranes.

And thus exclufive of the confequences of im- moral hernias, fwellings of the Tefticles, and too

* Opuf. parth-jJog Ob. 27, Lufannse 1755. Tran. Phil*

v. 5, 269.

fud-

Of the INTESTINES. 123

fudden ftoppage of the flux from the Urethra, which are known frequently to follow the repetition of ftrong cathartic pills of aloe, fcammony, and colo quintida, in treating a virulent gonorrhoea we reafon- ably reduced a poflible confcquence, worfe than the precedent.

OBSERVATION IV.

Sup pre [ft on of the Contents of the Intef tines ^ from weaknefs of their Fibres.

Sherman tells us, that Thomas Phi- lips, of Eaftthorp in EfTex, was very well in every refpedt till he was a year and a quarter old, and after a loofenefs had fuch an obftrudion of the Intef- tine, that he did not ftool for a fort- night or three weeks together, and from thence it proceeded gradually to an in- terval of feventeen or eighteen weeks, and continued fo till about the age of fifteen, when he re-affumed his natural powers for four or five years ; but then the obftru&ions returned, and conti-? nued increasing till he died, even to above twenty weeks interval ; and when he did go tq ftool he evacuated

many

2 2+ Of the INTESTINES.

many times a day, and fevcral days to- gether, till he had emptied himfelf, the contents being always thin and foft: he lived to be near twenty-three years old, and walked about almoft to the hour of his death; but his mother would not permit him to be opened : And Cooper in his annotations on this cafe attributes it to a weaknefs in the Periftaltick motion of the Inteftine. The following obfervation will fhew how the part was affected in a fimilar inftance,

A boy about twelve years old wTas brought the twenty-ninth of January 1756 to Stevens's hofpital. Six years before he began to grow coftive, not difcharging by ftool for feveral days, his Belly enlarging by degrees : This habit fo far increafed, that he ftooled but once in three weeks, and then nearly emptied the whole Inteftine at an effort, but it was full fix weeks fince he difcharged when he came to the Hofpital ; his Belly was exceeding pro- minent, and to light it appeared like g,

tympany,

Of the INTESTINES. iif

tympany, attended with a fhortnefs of Breath, and total lofs of appetite, great thirft, and a partial fuppreflion of urine. In three weeks from his arri- val at the hofpital, without emptying the Inteftine, he died.

On opening the Body the next day, we found the whole cavity of the Belly almoft filled with the Colon ; its mean diameter was about four inches, and filled uniformly throughout with foft contents, except at the fphindter of the Pwedum, where the contents were fome- what indurated. The fmall Inteftines were crowded into the leaft fpace they could poffibly be contained in, inclu- ding nothing but vapour ; the Liver, Spleen, and Stomach, were with the Diaphragm forced up into the Cheft, compreffing the Heart and Lungs ; the Kidnies were found, and the right Ure- ter of a due fize ; but the Ureter on the left Side, dilated to five times its natural diameter, was, with the pelvis of the Kidney proportionally dilated, filled with urine.

As

12 6 Of the INfES flNE S.

As in an habitual Ifchuria then, proceeding from' the Bladder, this receptacle may lofe that power of reftitution to exprefs the urine, and even fuffer di- latation thereby, fo may the Colon likewife lofe that power, which co operating with the Mufcles of the Belly and Diaphragm, force out the refiduum of the aliment, after the finer is abforbed by the Lacteals ; and by this fo great may be the collection as to prefs the circumambient parts and incommode their functions, fo far as they depend on the free motion and due fize of thefe parts, and even force them into the Cavity of the Cheft, lefTenits Cavity, check infpi ration and the motion of the Heart, and even flop it at length. And this enlargement of the Belly may be diftinguifhed from that arifing from extravafated water by its want of fluctuation, compared with the gradual fuppreflion of the Fasces.

We may likewife note too, that the predion of the Colon in given circumftances is greater on the left than the ris;ht Ureter ; for the Colon being ex- tended beyond the bounds of nature is no objection, forafmuch as the diftenfion was proportionable throughout the Inteftine, and yet the right Ureter was not extended by its prefiure ; fo that the in- farction tended to make the difference of prefiure vifible. We may likewife note too how ufeful are warm gentle eccoprotics, where there is reafon from the coftivenefs of children to fufpect weak Bowels ; to which may be added, fweating the Belly to conferve its contents from enlarging: And further, that the tumid appearance of the Bellies of infants may be fometimes caufcd by fulnefs of the

In-

Of the INTESTINES. 127

Inteftine, as at other times, by the enlargement of the Liver, Spleen, and Meientery.

And we may likewife gather in fome meafure the reafon why clyfters are generally of fignal ufe in fuppreflions of urine, and of the plentiful efflux of urine fucceeding ; for all infarctions of the Inteftine being removed by clyfters, the Ureters are more at freedom to vibrate, and confequently the better exprefs the urine coming down from the Kidnies : And the tumefaction of the Kidnies from the Blood and Urine confined therein being thus removed, the pain in the Back, the confequence of their tume- faction, ceafes.

Coftive habits are fometimes faid to be the effect of ftrong Bowels, forafmuch as the bibulous orifices of the Lacteals draw off the humid contents, and^ leave the reft fo exficcated that the Inteftine is fcarce able to exprefs it ; but ftrong Bowels fignify themfelves by the drynefs and hardnefs of their con- tents ; whereas weak Bowels in coftive habits fignify themfelves by the foftnels and quantity of their con- tents and intumefcence of the Belly ; and thus ftrong Bowels are fo termed from the intenfity of the ab- forbing powers of the Lacteals; and weak Bowels from the weaknefs of the powers of the Lacteals, and want of periftakick motion in their Fibres.

We may laftiy note too, that as reafon denomi- nates parts weak from their fofcnefs and impotence in moving, as in the Mufcles, and from their being liable to fluxions, as the Brain and Lungs, and from their being given to Congeftions, as the Liver in

fome

ia8 Of the INTESTINES.

fome difcafes of the Vifcus, fo we collect from this obfervation that Parts are conftituted weak in the* human fyftem fometimes not from reafon but dif- fedion.

OBSERVATION V,

Flat Worms.

In fpring 1752, a woman about forty in Stevens's complained of a con- ftant inquietude, and chiefly in the night, a want of fleep, a fulnefs of the Belly, a coftivenefs, and a want of ap- petite.

She pailed per fedem an immenfe length of white flat worms, half an inch long, and linked together.

At the fame time another about fifty had a fulnefs of the Belly, and a rum- bling of the Inteftines, who paffed a vaft quantity of like worms by flege.

Another about thirty, who had a fulnefs of the Belly, and an enormous appetite, vomited up an innumerable multitude of the lame worms.

In fummer the fame year# in Ste- vens's, a boy who had convulsive tre- mors

Of the INTESTINE S. 1 29

mors and great faintnefs at times, ftooled an endlefs length of the fame.

In the fame year a young man of twenty, who had voided per fe^iem thefe worms for ten years, had a con- ftant gnawing pain in the left Hy- pochondrium.

By thefe examples then an inquietude, a fenie of fulnefs, a coftivenefs, a want of appetite, rumblings of the Inteflines, convulfive twitches, tremors, and pain in the Hypochondrium, may be fymptoms of flat worms in the Inteftines, and an enormous ap- petite and vomiting may indicate their exiftence in the Stomach.

* From the motions and irritations of the Intef- tines arife the inquietude and rumblings •, which ir- ritations being propagated to the origin of the Nerves, From the fenfible and irritable Fibres of the Inteftines, and reflected thence to the Fibres of the Mufcles, may produce the convulfive twitches and tremors ; the fenfe of fullnefs and want of appetite from their number, and the pain in the Hypochon- drium to their gnawing and fixing themfelves to the Inteftine, for the head of this worm when viewed in a microfcope exhibits two circles of fangs, as we fee in the cut given us by + Tyfon, who defcribed this worm with very great exaclnefs ; and the enor-

* Galen de Caufis Symptomatica, C. 3. f Tranf. Phi!. v. 3- 131.

mous

i3o Of the INTESTINES.

mous appetite may be owing to their abforbing the Chyle by the multitude of mouths in the fi-es of their djviuons defcribed by the fame author, and the vomiting td the fame fort of irritations which oc- cafion the rumbling and other motions by confent with the inteflinal.

And thefe obfcrvations teach us that thefe worms are incident to either fex, or to any age.

Whether this worm is one only, or a chain of diftinft worms adhering to each other as fwarms of bees do, or whether it be the fame in fpecie with that whofe head and tail are defcribed by Daniel Le Clerc *, whoever Genres to be further informed of, jxuy confuk the different opinions and controver- fies compiled by this learned author, who being more follicitous about the mode of formation and ftruclure than figns of their exiftence, I have en- deavoured to fupply the deficiency out of the fore- going obfervations ; which collection offymptoms however cannot be held as decifive of their exifl> ence in the Intcftines, without the antecedent or co*> comitant apoearance of fome.

OBSERVATION VI.

Round Worms.

In June 1752 a boy of fifteen in Stevens's had a conftant flux of faliva

• DcLtt&briCp Ger.evae 1715, 4to. Cap. 3, C. 9.

from

Of the INTESTINES. 13 1

from his Mouth, a rumbling of the Belly, a devouring appetite, a loolenefs and fenfe of motion tending from the bottom of the Belly towards the Dia- phragm.

In the fame month he pafled by fiege three worms, round, red, and four inches in length, and of the thicknefs of a goofe quill.

OBSERVATION VII.

In December 1752 a boy of feven years old died of a worm fever. I found in the fmall Inteftines fifty-fix round worms, whofe mean length was fix inches, of the diameter of a goofe quill in their middle, defcending fmaller to- ward their terminations and white in colour ; they filled the fmall Inteftines completely, and were immerfed in mu- cus ; Nothing was in the Stomach or great Inteftines but mucus and vapour. He died the Day before, and wras not emaciate.

The fymptoms of round worms therefore may

fometimes be a flux of the falivary glands, a rum~

I -2 bling

i32 Of the INTESTINES.

bling of the Belly, a devouring appetite, a loofenefs and fenfe of motion tending from the bottem of the Belly toward the Diaphragm ; and it appears that round worms, by multiplying, enlarging, devour- ing the aliment, and feeding the Blood with the im- purities of their faeces, may raife a fever and termi- nate in death.

Round worms, from their greater activity and ftrength, may raife ftronger vibrations in the Intef- tines than flat ones, which being propagated to the faliva/y glands, may draw them by confent into pre- ternatural fecretions, and fo difturb the Inteftines as to produce a loofenefs, and that motion of the air -which always exifts in the Inteftines, to keep them from collapfing, fenfible by the rumblings-, the de- vouring appetite being caufed partly by their ab- forbing the Chyle, and partly to that uneafinefs the perfon feels when the Inteftines are empty, exciting 2 defire of food to fariate, and prevent their fucking and preying on the Membranes of the Inteftine, and the tending of fomething from the bottom of the Belly to their endeavouring to get at the aliment above them.

The ftruclure of the Mouth, Stomach, Inteftine, and ether interior organs of this worm, we have from Tyfon, with a caution not to give the pow- der of the worms as fpecifick, left more be rege- nerated from it.

SECT.

[ 133 ]

SECT- VI

Of theKiDNiES andBLADDER,

OBSERVATION I.

Total Supprejfion of Urine from weak** nefs in the Bladder.

A Young woman, whofe name was Bolton, having fuppreffions of Urine after lying-in, came to St, George's in London in the year 1753* The Catamenia v/ere according to na- ture, and fo were the inteftinal excre- tions both in quantity and time; the moft approved medicines for thefe in-? dications could not bring away the urine, and others were exhibited with- out effect. A blifter between the fhoul- ders once caufed it to flow ; but when the power of the Flies was abated it I 3 flopped

i34 Of the KIDNIES

flopped as before, fo that for half a year it was drawn off with the catheter twice a-day, and fo fhe continued till I left the hofpital in 1754.

Now as the catamenia were according to nature in time and quantity, and the birth not attended with diftreffing circumftances ; the fupprefllon could hardly be attributed to the Uterus, which by prefT- ing, as being charged with catamenia *, or other- wife fwelled, might (lop the egrefs of the urine ; and the fame may be argued of any preflure it might .fuftain from the Rectum ; nor was it owing to a (lone or caruncle in the Bladder or Urethra, for the catheter and even the Finger had an eafy in- grefs, without perception of impediment in the in- troduction : Befide, (he never had been troubled with nephritick fymptoms which are ufed to ante- cede the (lone in the Bladder ; and from the conti- nuance of the fupprellion it could not be deduced from an hyfterick or fpafmodic affection of the Bladder, Ureter, or Kidnies, forafmuch as fuch dis- orders are not of duration ; and from the eafy ingrefs of the catheter and Finger, it could fcarce be effect- ed by a tumor of itfelf ; it was therefore cau fed by a weaknefs of the Membranes, or lofs of elafticity, which Membranes in a (late of health co-operate with the Mufcles of the Belly to exprefs the urine dimitted from the Kidnies. Now as this weaknefs commenced in the time of gravidation, it muft hav*

* Ca'cn cle Loci* affe&is, lib. 6. 5.

been

and BLADDER. 135-

been caufed by the prefTure of the ulcers, which by retaining the urine, drained the Membranes till they were unable to contract.

We may alfo note by the way, that fome medi- cines are elective in their actions. Were the actions of cantharides by mere ftimulus indifferent to all the Membranes, why fhould it be exerted on the uri- nary parts the rather than on the Membranes of the Inteftinal Canal, which are much more fufceptible of imprelTions from irritating caufes than the Mem- branes of the Kidnies, Ureters, and Bladder are ?

OBSERVATION II.

Total Suppreffion from Weaknefs in the Bladder.

A man about fifty, the 24th of July 1756, was feized with a total fupref- fion of urine, which was drawn off the fame day, as alfo the following day, with the afliftance of the cathe- ter, but he made water after with- out afliftance till the 26th of Novem- ber, when the fuppreflion returning, he was brought to Stevens's in a high fever, with very great pain ; the whole Hypogafter was tenfe and elevated, and he had a ftrong inclination to vomit. The urine let forth with the catheter, I 4 the

i3rf Of the KIDNIES

the elevation fubfided, and the tenfion and fever remitted : T he urine drawn off was of a dark colour and muddy, about three pints in quantity. For a month after the urine was let out in like manner twice a day, morning and evening ; the left Tefticle fwelled and abfceded, painful fenfation was pro- pagated in the direction of the Sperma- tick Chord to the Back ; and a fungus fhot out of the abfcedinp- Tefticle. In fome time after a whitiili mucus came off in the urine like the mucus of the nofe, when the fluxion of the nofe is duly concocted, but fubfiding in the urine, and unattended with pain in the region of the Bladder.

The fymptoms therefore of the Bladder being full of the urine, in a fupprefEon at the Bladder, are an intumefcence of the Hypogaftrick Region, attended v/ith a fever, and inclination to vomit, and pain through the Belly.

The fame fort of fuppreffion in the preceding v; as unattended with the pain or fever, the Membranes of the other fex being more chftenfible and moift, afhd consequently propagating in their time of ten-' iion lefs painful fenfations, and fcarce effecting in- flammation

end BLADDER. 137

flammation like the tenfe and rigid Membranes of the male.

Was the inflammation of the Tefticle and fubfe- quent abfeefs owing to the frequent introduction of the catheter ? For an inflammation of the Urethra will fometimes arife from this caufe, and the fpafms of the Fibres of the Vas Deferens refulting poffibly therefrom, being propagated to the Tefticle, might draw its Veins or the whole Tefticle into fpafms and inflame it ? Or was it owing to the ftricture of the Tendons of the Mufcles of the Belly fqueezing the Chord ? For you will obferve pains and ftricture of the fpermatic Chords and Tefticles in affections of the Nervous Membranes of the Lower Belly, to which thofe Mufcles are given to confent ; and it has been likewife obferved by Areteus * in affections of the Colon and other Inteftines.

Moreover while I was confidering the fungus of the Tefticle, it occurred to me that it bore fome analogy to the fungus (hooting from the Brain in fome wounds of the Head 5 and that poffibly it might be fome fore of argument of the Brain being of the glandular kind,

OBSERVATION III!

Total Retention from a Stone in the Bulb of the Urethra.

A man about fifty, who had been mowing down hay in fummer 1752,

* De Caufis & Signis diuturnorura morb. c. 8.

was

i38 Of the KIDNIES

was feized with a total fupprcfllon of urine, and prefently bled, and plenti- fully purged, but without effedt. That evening he was brought to Stevens's in miferable torment, where he raved im- mediately, and fevered, and fo died.

On opening the Lower Belly next day we found the Bladder rent at its fundus, and the Pelvis filled with the urine, caufed by a black ftone, of the fize of a filbert, in the bulb of the Ure- thra, which flopped it compleatly.

From this calamitous incident then we may fee the dangerous effects of a total fuppreflion of urine on the male, from a (lone in the Urethra, if the re- moval of the flone be deferred : Had he been car- ried directly to the Houfe, and the incifion infti- tuted in the Perinasum, which is eafily and readily done, he would have been undoubtedly faved.

We may like wife in fome degree eftimate the ftrength with which the urine is exprefled from the Kidnies and Ureters, or the intenfity of the efforts of the Bladder to free itfelf from the urine, or the flrength of both thefe caufes acting in fuccefllon ; for how active the Kidnies are in forcing the urine, we may collect from their effects on the Ureters when they have been repeatedly plugged with ftanes near their terminations in the Membranes of the

Bladder,

and BLADDER. 139

Bladder, or when the Ureters are prefled by any caufe •, for they will be often fo enlarged by fuch caufes obftructing or prelTing the Ureters as to emulate even the Inteftines themfelves*; the co- lumn of urine dimitted from the Kidnies, and Hill exprefied, by increment, expanding their Mem- branes.

And that equally fatal effects may follow from too long retention of urine, which by gradual incre- ment dilates, and at length inflames in this fex, we are afiured by Fabricius Hildanus *f, who tells us, the famous Tycho Brahe, the Danifh aftronomer, by flaying too long at an entertainment in Prague, had his Bladder overcharged with Urine, and thereby- inflamed, by which he fevered and died. And Dominicus Panarola J fays, that he found in three fubjects who died of this difeafe the Bladder exceed- ingly diftended by the multitude of Urine, which in fome amounted even to twenty pints, which fhews thofe Bladders had loll their powers of refti- tution •, for the healthful Bladder reftores itfelfin the egrefs of the Urine to the leaf! fpace it can pof- fibly contract ; and he alfo obferves this diforder is unheeded at firfl, but in procefs of time h diftem- pers the Bladder, and confumes them. Nor in- deed is the reafon difficult to feek ; for the Bladder having loft its elaflicity, like an inanimate Bladder juft taken from a fubject, collapfes into itfelf, and thus continues till the fucceeding Urine enlarged it to its firft dimenfions, when from the lofs of its

* Panaro'a, Pent. 4. Cbf. 31. Hanovise 1643. t ^e

tuend. Valetud. Franc. 1682. J Pwn.. i.Cbf. 27.

7 fpring

t

140 Of the KIDNIES

fpring the Urine Magnates, till let out with the in- ftrument ; and at length the Bladder, by being re- peatedly {trained, and its Tunics fqueezed between the incondenfible Urine within, and the power of its connection at the bottom of the Pelvis at every the created diftenHon, for want of due circulation in its Tunics (in which too very probably the Blood ex- travafates) it gangrenes or ulcers, correfponding in proportion to the Interlines in an hernia-, for inflam- mations of the Inteftines are given to terminate by gangrene rather than apoftem, when they do- not re- iblve, or it fuddenly gangrenes, as it probably might in the cafe of the iiluftrious Brahe.

And as the Bladder fills and dilates either from inattention of the mind, as in deep meditation or fieep, or from necefTity, as in affemblies, entertain- ments, or riding, even to a lofs of refiitution, fo like wife has it been obferved to (ill and enlarge by reafon of want of due communication with the me- dullary tradts in the Spine * or Head ; fo that the irritation of the Urine, or the {braining of the Fibres, do not fignify themfelves by the propagation of painful fenfation. Now this (rate of the Bladder cannot be diftinguifhed by any other means than the carries which antecede paralyfes, nor even by all of thefe, unlefs they are vifible, as in great (hocks or wounds in the fpinal Marrow, or compreffion thereof by luxations of the Vertebrae: For if a paralyfis of the Bladder is caufed by extravafations of water or Blood, or congeftions in the Membranes about

* Teverovicius de affieil. Renum & Vejjcae, c. 2. 40.

Leidx 1636.

the

and BLADDER. 141

the medullary tracts where its Nerves have their ori- gins, it will be difficult if not impofiible to affign the precife caufe, unlefs fome exterior Mufcles are affected with coldnefs, numbnefs, and impotence, as they are in paralyfes from thefe caufes ; and there diftinctions are of fignal ufe for the mode of cure in a refolution of the Bladder by compreflion near the origins of its Nerves, fuch as bleeding, purging, and fparing diet would be totally ufelefs where the Membranes are ftrained by the prefllire of the Ute- rus, and the quantity of Urine being kept in there- by, or in the other caufes of inattention, orneceffity of fituation as above -, for thefe affections of the Bladder are treated by cold bathing, blifters, orcan- tharides inwardly given, and great temperance in drinking, efpecially at night •, for if the quantity be fuch as being fecerned copioufly, paffes down to the Bladder, it will contribute to conferve the inlarge- tnent of the Bladder, and if the quantity be great will really do fo * from the inattention of the mind during fleep to the motions of the parts, and the irritations of their contents.

Laftiy, we may note too, that violent exercife will move a (lone out of the Bladder into the Ure- thra, and caufe a total fupprefiion of Urine, as it will out of the Liver or Hepatic Duct, or out of the Gall Bladder and Cyftick Duct into the common Duct, and caufe a total fupprefiion of Bile.

In the preceding we have feen a total retention arife from weaknefs of the Bladder, and from the authority of Beverovicius that the fame may arife

• Galen de Locis afTeclis, lib. 6. 4.

from

142 Of the KIDN1ES

from a Paralyfis of the Membranes ; and we have feen too the Urine fupprefTed by a (lone in the bulb of the Urethra. But Femelius tells us *, the Kid- nies, as other vafcular parts, are liable to inflamma- tion, though but rarely from their firmer texture, and defcribes their fymptoms and confequential ef- fects. Having myfeif had an opportunity of feeing fuch inflammation, it may not be improper here to recite it, together with its antecedent caufe and fymp- toms, fuch as I have obferved them.

OBSERVATION IV.

Total Retention from a,7t Inflammation in the Kidnies.

A man about thirty, in March 1755, by drinking muddy porter to an excefs, had his Urine totally fupprefTed, with great pain in his Loins, Hypochonders, and Belly, attended with a high fever. The fuppreffion continued five days, and was at length removed by the re- peated exhibition of clyfters, bleeding, and purging, with infufions of fenna, manna, and falts ; but the pains in the Hypochonders remaining were at laft

* DePart. Morb. & Sjmp. cap. 12.

removed

and BLADDER. 143

removed by the ufe of an electuary made of rhubarb, foap, and fyrup of althea.

Note, there was no intumefcence of the Belly in this cafe, nor pain in the region of the Pelvis.