perly adapted, I find it difficult to determine. That it may be executed with safety, there is no doubt; and that it has been sometimes practised with success, seems to be very well vouched.* When the disease depends upon a general hydropic diathesis, it cannot alone prove a cure, but may give a temporary relief; and when other remedies seem to be employed with advantage, the drawing off the water may very much favor a complete cure. I have not, however, been so fortunate as to see it practised with any success; and even where it was most promising, that is, in cases of partial affection, my expectations have been disappointed from it.

SECTION III.

Of Ascites, or Dropsy of the Lower Belly.

1710.] THE name of Ascites is given to every collection of waters causing a general swelling and distention of the lower belly; and such collections are more frequent than those which happen in the thorax.

1711.] The collections in the lower belly, like those of the thorax, are found in different situations. Most commonly they are in the sac of the peritoneum, or general cavity of the abdomen: but they often begin by sacs formed upon, and connected with one or other of the viscera ; and perhaps the most frequent instances of this kind occur in the ovaria of females. Sometimes the water of ascites is found entirely without the peritoneum, and between this and the abdominal muscles.

1712.] These collections connected with particular viscera, and those formed without the peritoneum, form that disease which authors have termed the encysted dropsy, or hydrops saccatus. Their precise seat, and even their exist

*In the memoirs of the Academy of Sciences at Paris, for 1703, M. Du Verney relates the case of a woman who had both an Ascites and Hydrothorax. He first emptied the abdomen by tapping, and a few days afterwards he pierced the thorax with a trochar, near to the spine, between the second and third false ribs, by which opening he drew off a considerable quantity of water: the operation gave immediate relief to the patient, and she was able to return to her ordinary employments in about a month's time.-Bianchi also relates a successful operation of tapping the thorax; but he seems to be timid in his practice, and confesses that he has seldom ventured on the operation. The practice of evacuating water contained in the thorax by an incision is very old. We find it recommended by Hippocrates, with particular directions for performing the operation, in his second book on diseases. See the Geneva edition of Foesius Hippocrates, pag. 483.-That the practice was frequently attended with success, in those early ages, is sufficiently evident by the context; for Hippocrates, after describing the operation, and the subsequent management of the patient, says, "If pus appear on the plaster covering the wound on the fifth day after the operation, the patient generally recovers; if not, he is seized "with a cough and thirst, and dies."

ence, is very often difficult to be ascertained. They are ge nerally formed by collections of hydatides.

1713.] In the most ordinary case, that of abdominal dropsy, the swelling at first is in some measure over the whole. belly, but generally appears most considerable in the epigastrium. As the disease, however, advances, the swelling becomes more uniform over the whole. The distention, and sense of weight, though considerable, vary a little according as the posture of the body is changed; the weight being felt the most upon the side on which the patient lies, while at the same time on the opposite side the distention becomes somewhat less. In almost all the instances of ascites, the fluctuation of the water within, may be perceived by the practitioner's feeling, and sometimes by his hearing. This perception of fluctuation does not certainly distinguish the different states of dropsy; but serves very well to distinguish dropsy from tympanites, from cases of physconia, and from the state of pregnancy in women.

1714.] An ascites frequently occurs when no other species of dropsy does at the same time appear; but sometimes the ascites is a part only of universal dropsy. In this case, it usually comes on in consequence of an anasarca, gradually increasing; but its being joined with anasarca, does not always denote any general diathesis, as for the most part an ascites sooner or later occasions ædematous swellings of the lower extremities. When the collection of water in the abdomen, from whatever cause, becomes considerable, it is always attended with a difficulty of breathing; but this symptom occurs often when, at the same time, there is no water in the thorax. The ascites is sometimes unaccompanied with any fever; but frequently there is more or less of fever present with it. The disease is never considerable, without being attended with thirst and a scarcity of urine.

1715.] In the diagnosis of ascites, the greatest difficulty that occurs, is in discerning when the water is in the cavity of the abdomen, or when it is in the different states of encysted dropsy above-mentioned. There is, perhaps, no cer tain means of ascertaining this in all cases; but in many we may attempt to form some judgment with regard to it.

When the antecedent circumstances give suspicion of a general bydropic diathesis; when at the same time some degree of dropsy appears in other parts of the body; and when, from its first appearance, the swelling has been equally over the whole belly, we may generally presume that the

water is in the cavity of the abdomen. But when an ascites has not been preceded by any remarkably cachectic state of the system, and when at its beginning the tumor and tension had appeared in one part of the belly more than another, there is reason to suspect an encysted dropsy. Even when the tension and tumor of the belly have become general and uniform over the whole; yet if the system of the body in general appear to be little affected; if the pa 'tient's strength be little impaired; if the appetite continue pretty entire, and the natural sleep be little interrupted; if the menses in females continue to flow as usual; if there be yet no anasarca; or, though it may have already taken place, if it be still confined to the lower extremities, and there be no leucophlegmatic paleness or sallow color in the countenance; if there be no fever, nor so much thirst, or scarcity of urine, as occur in a more general affection; then, according as more of these different circumstances take place, there will be the stronger ground for supposing the ascites to be of the encysted kind.

The chief exception to be made from this as a general rule, will, in my opinion, be when the ascites may with much probability, be presumed to have come on in consequence of a scirrhous liver; which, I apprehend, may occasion a collection of water in the cavity of the abdomen, while the general system of the body may not be otherwise much affected.

1

1716.] With respect to the cure of ascites when of the encysted kind, it does not, so far as I know, admit of any. When the collection of water is in the abdominal cavity alone, without any other species of dropsy present at the same time, I apprehend the ascites will always be of difficult cure; for it may be presumed to depend upon a scirrhosity of the liver, or other considerable affection of the abdominal viscera, which I conceive to be of very difficult cure, and therefore the ascites depending upon them. At the same time, such cases may often admit of a temporary relief by the paracentesis.

1717.] When the ascites is a part of universal dropsy, it may, as far as other cases of that kind can, admit of cure; and it will be obvious, that such a cure must be obtained by the same means as above proposed for the cure of general anasarca.*

It frequently happens, that the ascites is attended with

* See the notes on article 1684.

a diarrhoea; and, in that case, does not admit of the use of purgatives so freely as cases of anasarca commonly do. It is therefore often to be treated by diuretics almost alone. The diuretics that may be employed, are chiefly those above-mentioned; but in ascites, a peculiar one has been found out. It is a long continued gentle friction of the skin over the whole of the abdomen, by the fingers dipped in oil. This has sometimes been useful in exciting an increased flow of urine; but in most of the trials of it which I have known made, it has failed in producing that effect.

1718.] The ascites admits of a particular means for immediately drawing off the collected waters: and that is the well-known operation of the paracentesis of the abdomen. In what circumstances of ascites this operation can most properly be proposed, it is difficult to determine; but, so far as I can judge, it must be regulated by very much the same considerations as those above-mentioned with regard to the paracentesis of the thorax.

The manner of performing the paracentesis of the abdomen, and the precautions to be taken with respect to it, are now so commonly known, and delivered in so many books, that it is altogether unnecessary for me to offer any directions upon that subject here; especially after the full and judicious information and directions given by Mr. BELL, in the second volume of his System of Surgery.

CHAPTER IV.

OF GENERAL SWELLINGS, ARISING FROM AN INCREASED BULK OF THE WHOLE SUBSTANCE OF PARTICULAR PARTS.

1719.]

UPON

TPON the subjects of this chapter, several nosological difficulties occur, and particu larly with respect to admitting the Physconia into the order of General Swellings. At present, however, it is not necessary for me to discuss this point, as I am here to omit entirely the consideration of Physconia; both because it can seldom admit of any successful practice, and because I cannot deliver any thing useful either with regard to the pathology or practice in such a disease.

1720.] The only other genus of disease comprehended under the title of the present chapter, is the Rachitis; and

this being both a proper example of the class of Cachery, and of the order of Intumescentiae or General Swellings, I shall offer some observations with regard to it.

OF RACHITIS, OR RICKETS.

1721.] THIS disease has been supposed to have appeared only in modern times, and not above two hundred years ago. This opinion, notwithstanding it has been maintained by persons of the most respectable authority,* appears to me, from many considerations, improbable; but it is a point of too little consequence to detain my readers here. The only application of it which deserves any notice is, that it has led to a notion of the disease having arisen from the lues venerea, which had certainly made its first appearance in Europe not very long before the date commonly assigned for the appearance of rachitis : but I shall hereafter show, that the supposed connection between the Siphylis and Rachitis is without foundation.+

1722.] In delivering the history of the Rickets, I must, in the first place, observe that with respect to the antecedents of the disease, every thing to be found in authors upon this subject, appears to me to rest upon a very uncertain foundation. In particular, with respect to the state of the parents whose offspring become affected with this disease, I have met with many instances of it, in children from seemingly healthy parents, and have met likewise with many instances of children who never became affected with it, although born of parents who, according to the common accounts, should have produced a rickety offspring: so that even making allowance for the uncertainty of fathers, I do not find the general opinion of authors upon this subject to be properly supported.

1723.] The disease, however, may be justly considered as proceeding from parents; for it often appears in a great number of the same family and my observation leads me to judge, that it originates more frequently from mothers than from fathers. So far as I can refer the disease of the children to the state of the parents, it has appeared to me most commonly to arise from some weakness, and pretty frequently from a scrophulous habit in the mother. To con

*Boerhaave was of this opinion. See Van Swieten's Commentary on Aphorism 1482. + See article 1728.