Chapter XV: Section XXV: 15 (1)

6. The puncta lacrymalia, with the lacrymal sack and nasal duct, compose a complete gland, and much resemble the intestinal canal: the puncta lacrymalia are absorbent mouths, that take up the tears from the eye, when they have done their office there, and convey them into the nostrils; but when the nasal duct is obstructed, and the lacrymal sack distended with its fluid, on pressure with the finger the mouths of this gland (puncta lacrymalia) will readily disgorge the fluid, they had previously absorbed, back into the eye.

7. As the capillary vessels receive blood from the arteries, and separating the mucus, or perspirable matter from it, convey the remainder back by the veins; these capillary vessels are a set of glands, in every respect similar to the secretory vessels of the liver, or other large congeries of glands. The beginnings of these capillary vessels have frequent anastomoses into each other, in which circumstance they are resembled by the lacteals; and like the mouths or beginnings of other glands, they are a set of absorbent vessels, which drink up the blood which is brought to them by the arteries, as the chyle is drank up by the lacteals: for the circulation of the blood through the capillaries is proved to be independent of arterial impulse; since in the blush of shame, and in partial inflammations, their action is increased, without any increase of the motion of the heart.

8. Yet not only the mouths, or beginnings of these anastomosing capillaries are frequently seen by microscopes, to regurgitate some particles of blood, during the struggles of the animal; but retrograde motion of the blood, in the veins of those animals, from the very heart of the extremity of the limbs, is observable, by intervals, during the distresses of the dying creature. Haller, Elem. Physiol. t. i. p. 216. Now, as the veins have perhaps all of them a valve somewhere between their extremities and the heart, here is ocular demonstration of the fluids in this diseased condition of the animal, repassing through venous valves: and it is hence highly probable, from the strictest analogy, that if the course of the fluids, in the lymphatic vessels, could be subjected to microscopic observation, they would also, in the diseased state of the animal, be seen to repass the valves, and the mouths of those vessels, which had previously absorbed them, or promoted their progression.

III. _Communication from the Alimentary Canal to the Bladder, by means of the Absorbent Vessels._

Many medical philosophers, both ancient and modern, have suspected that there was a nearer communication between the stomach and the urinary bladder, than that of the circulation: they were led into this opinion from the great expedition with which cold water, when drank to excess, passes off by the bladder; and from the similarity of the urine, when produced in this hasty manner, with the material that was drank.

The former of these circumstances happens perpetually to those who drink abundance of cold water, when they are much heated by exercise, and to many at the beginning of intoxication.

Of the latter, many instances are recorded by Etmuller, t. xi. p. 716. where simple water, wine, and wine with sugar, and emulsions, were returned by urine unchanged.

There are other experiments, that seem to demonstrate the existence of another passage to the bladder, besides that through the kidneys. Thus Dr. Kratzenstein put ligatures on the ureters of a dog, and then emptied the bladder by a catheter; yet in a little time the dog drank greedily, and made a quantity of water, (Disputat. Morbor. Halleri. t. iv. p. 63.) A similar experiment is related in the Philosophical Transactions, with the same event, (No. 65, 67, for the year 1670.)

Add to this, that in some morbid cases the urine has continued to pass, after the suppuration or total destruction of the kidneys; of which many instances are referred to in the Elem. Physiol. t. vii. p. 379. of Dr. Haller.

From all which it must be concluded, that some fluids have passed from the stomach or abdomen, without having gone through the sanguiferous circulation: and as the bladder is supplied with many lymphatics, as described by Dr. Watson, in the Philos. Trans. v. 59. p. 392. and as no other vessels open into it besides these and the ureters, it seems evident, that the unnatural urine, produced as above described, when the ureters were tied, or the kidneys obliterated, was carried into the bladder by the retrograde motions of the urinary branch of the lymphatic system.

The more certainly to ascertain the existence of another communication between the stomach and bladder, besides that of the circulation, the following experiment was made, to which I must beg your patient attention:--A friend of mine (June 14, 1772) on drinking repeatedly of cold small punch, till he began to be intoxicated, made a quantity of colourless urine. He then drank about two drams of nitre dissolved in some of the punch, and eat about twenty stalks of boiled asparagus: on continuing to drink more of the punch, the next urine that he made was quite clear, and without smell; but in a little time another quantity was made, which was not quite so colourless, and had a strong smell of the asparagus: he then lost about four ounces of blood from the arm.

The smell of asparagus was not at all perceptible in the blood, neither when fresh taken, nor the next morning, as myself and two others accurately attended to; yet this smell was strongly perceived in the urine, which was made just before the blood was taken from his arm.

Some bibulous paper, moistened in the serum of this blood, and suffered to dry, shewed no signs of nitre by its manner of burning. But some of the same paper, moistened in the urine, and dried, on being ignited, evidently shewed the presence of nitre. This blood and the urine stood some days exposed to the sun in the open air, till they were evaporated to about a fourth of their original quantity, and began to stink: the paper, which was then moistened with the concentrated urine, shewed the presence of much nitre by its manner of burning; whilst that moistened with the blood shewed no such appearance at all.

Hence it appears, that certain fluids at the beginning of intoxication, find another passage to the bladder besides the long course of the arterial circulation; and as the intestinal absorbents are joined with the urinary lymphatics by frequent anastomoses, as Hewson has demonstrated; and as there is no other road, we may justly conclude, that these fluids pass into the bladder by the urinary branch of the lymphatics, which has its motions inverted during the diseased state of the animal.

A gentleman, who had been some weeks affected with jaundice, and whose urine was in consequence of a very deep yellow, took some cold small punch, in which was dissolved about a dram of nitre; he then took repeated draughts of the punch, and kept himself in a cool room, till on the approach of slight intoxication he made a large quantity of water; this water had a slight yellow tinge, as might be expected from a small admixture of bile secreted from the kidneys; but if the whole of it had passed through the sanguiferous vessels, which were now replete with bile (his whole skin being as yellow as gold) would not this urine also, as well as that he had made for weeks before, have been of a deep yellow? Paper dipped in this water, and dryed, and ignited, shewed evident marks of the presence of nitre, when the flame was blown out.

IV. _The Phænomena of the Diabetes explained, and of some Diarrhoeas._

The phenomena of many diseases are only explicable from the retrograde motions of some of the branches of the lymphatic system; as the great and immediate flow of pale urine in the beginning of drunkenness; in hysteric paroxysms; from being exposed to cold air; or to the influence of fear or anxiety.

Before we endeavour to illustrate this doctrine, by describing the phænomena of these diseases, we must premise one circumstance; that all the branches of the lymphatic system have a certain sympathy with each other, insomuch that when one branch is stimulated into unusual kinds or quantities of motion, some other branch has its motions either increased, or decreased, or inverted at the same time. This kind of sympathy can only be proved by the concurrent testimony of numerous facts, which will be related in the course of the work. I shall only add here, that it is probable, that this sympathy does not depend on any communication of nervous filaments, but on habit; owing to the various branches of this system having frequently been stimulated into action at the same time.

There are a thousand instances of involuntary motions associated in this manner; as in the act of vomiting, while the motions of the stomach and oesophagus are inverted, the pulsations of the arterial system by a certain sympathy become weaker; and when the bowels or kidneys are stimulated by poison, a stone, or inflammation, into more violent action; the stomach and oesophagus by sympathy invert their motions.

1. When any one drinks a moderate quantity of vinous spirit, the whole system acts with more energy by consent with the stomach and intestines, as is seen from the glow on the skin, and the increase of strength and activity; but when a greater quantity of this inebriating material is drank, at the same time that the lacteals are excited into greater action to absorb it; it frequently happens, that the urinary branch of absorbents, which is connected with the lacteals by many anastomoses, inverts its motions, and a great quantity of pale unanimalized urine is discharged. By this wise contrivance too much of an unnecessary fluid is prevented from entering the circulation--This may be called the drunken diabetes, to distinguish it from the other temporary diabetes, which occur in hysteric diseases, and from continued fear or anxiety.

2. If this idle ingurgitation of too much vinous spirit be daily practised, the urinary branch of absorbents at length gains an habit of inverting its motions, whenever the lacteals are much stimulated; and the whole or a great part of the chyle is thus daily carried to the bladder without entering the circulation, and the body becomes emaciated. This is one kind of chronic diabetes, and may be distinguished from the others by the taste and appearance of the urine; which is sweet, and the colour of whey, and may be termed the chyliferous diabetes.

3. Many children have a similar deposition of chyle in their urine, from the irritation of worms in their intestines, which stimulating the mouths of the lacteals into unnatural action, the urinary branch of the absorbents becomes inverted, and carries part of the chyle to the bladder: part of the chyle also has been carried to the iliac and lumbar glands, of which instances are recorded by Haller, t. vii. 225. and which can be explained on no other theory: but the dissections of the lymphatic system of the human body, which have yet been published, are not sufficiently extensive for our purpose; yet if we may reason from comparative anatomy, this translation of chyle to the bladder is much illustrated by the account given of this system of vessels in a turtle, by Mr. Hewson, who observed, "That the lacteals near the root of the mesentery anastomose, so as to form a net-work, from which several large branches go into some considerable lymphatics lying near the spine; and which can be traced almost to the anus, and particularly to the kidneys." Philos. Trans. v. 59. p. 199--Enquiries, p. 74.

4. At the same time that the urinary branch of absorbents, in the beginning of diabetes, is excited into inverted action, the cellular branch is excited by the sympathy above mentioned, into more energetic action; and the fat, that was before deposited, is reabsorbed and thrown into the blood vessels; where it floats, and was mistaken for chyle, till the late experiments of the ingenious Mr. Hewson demonstrated it to be fat.

This appearance of what was mistaken for chyle in the blood, which was drawn from these patients, and the obstructed liver, which very frequently accompanies this disease, seems to have led Dr. Mead to suspect the diabetes was owing to a defect of sanguification; and that the schirrosity of the liver was the original cause of it: but as the schirrhus of the liver is most frequently owing to the same causes, that produce the diabetes and dropsies; namely, the great use of fermented liquors; there is no wonder they should exist together, without being the consequence of each other.

5. If the cutaneous branch of absorbents gains a habit of being excited into stronger action, and imbibes greater quantities of moisture from the atmosphere, at the same time that the urinary branch has its motions inverted, another kind of diabetes is formed, which may be termed the aqueous diabetes. In this diabetes the cutaneous absorbents frequently imbibe an amazing quantity of atmospheric moisture; insomuch that there are authentic histories, where many gallons a day, for many weeks together, above the quantity that has been drank, have been discharged by urine.

Dr. Keil, in his Medicina Statica, found that he gained eighteen ounces from the moist air of one night; and Dr. Percival affirms, that one of his hands imbibed, after being well chafed, near an ounce and half of water, in a quarter of an hour. (Transact. of the College, London, vol. ii. p. 102.) Home's Medic. Facts, p. 2. sect. 3.

The pale urine in hysterical women, or which is produced by fear or anxiety, is a temporary complaint of this kind; and it would in reality be the same disease, if it was confirmed by habit.

6. The purging stools, and pale urine, occasioned by exposing the naked body to cold air, or sprinkling it with cold water, originate from a similar cause; for the mouths of the cutaneous lymphatics being suddenly exposed to cold become torpid, and cease, or nearly cease, to act; whilst, by the sympathy above described, not only the lymphatics of the bladder and intestines cease also to absorb the more aqueous and saline part of the fluids secreted into them; but it is probable that these lymphatics invert their motions, and return the fluids, which were previously absorbed, into the intestines and bladder. At the very instant that the body is exposed naked to the cold air, an unusual movement is felt in the bowels; as is experienced by boys going into the cold bath: this could not occur from an obstruction of the perspirable matter, since there is not time, for that to be returned to the bowels by the course of the circulation.

There is also a chronic aqueous diarrhoea, in which the atmospheric moisture, drank up by the cutaneous and pulmonary lymphatics, is poured into the intestines, by the retrograde motions of the lacteals. This disease is most similar to the aqueous diabetes, and is frequently exchanged for it: a distinct instance of this is recorded by Benningerus, Cent. v. Obs. 98. in which an aqueous diarrhoea succeeded an aqueous diabetes, and destroyed the patient. There is a curious example of this, described by Sympson (De Re Medica)--"A young man (says he) was seized with a fever, upon which a diarrhoea came on, with great stupor; and he refused to drink any thing, though he was parched up with excessive heat: the better to supply him with moisture, I directed his feet to be immersed in cold water; immediately I observed a wonderful decrease of water in the vessel, and then an impetuous stream of a fluid, scarcely coloured, was discharged by stool, like a cataract."

7. There is another kind of diarrhoea, which has been called cæliaca; in this disease the chyle, drank up by the lacteals of the small intestines, is probably poured into the large intestines, by the retrograde motions of their lacteals: as in the chyliferous diabetes, the chyle is poured into the bladder, by the retrograde motions of the urinary branch of absorbents.

The chyliferous diabetes, like this chyliferous diarrhoea, produces sudden atrophy; since the nourishment, which ought to supply the hourly waste of the body, is expelled by the bladder, or rectum: whilst the aqueous diabetes, and the aqueous diarrhoea produce excessive thirst; because the moisture, which is obtained from the atmosphere, is not conveyed to the thoracic receptacle, as it ought to be, but to the bladder, or lower intestines; whence the chyle, blood, and whole system of glands, are robbed of their proportion of humidity.

8. There is a third species of diabetes, in which the urine is mucilaginous, and appears ropy in pouring it from one vessel into another; and will sometimes coagulate over the fire. This disease appears by intervals, and ceases again, and seems to be occasioned by a previous dropsy in some part of the body. When such a collection is reabsorbed, it is not always returned into the circulation; but the same irritation that stimulates one lymphatic branch to reabsorb the deposited fluid, inverts the urinary branch, and pours it into the bladder. Hence this mucilaginous diabetes is a cure, or the consequence of a cure, of a worse disease, rather than a disease itself.

Dr. Cotunnius gave half an ounce of cream of tartar, every morning, to a patient, who had the anasarca; and he voided a great quantity of urine; a part of which, put over the fire, coagulated, on the evaporation of half of it, so as to look like the white of an egg. De Ischiade Nervos.

This kind of diabetes frequently precedes a dropsy; and has this remarkable circumstance attending it, that it generally happens in the night; as during the recumbent state of the body, the fluid, that was accumulated in the cellular membrane, or in the lungs, is more readily absorbed, as it is less impeded by its gravity. I have seen more than one instance of this disease. Mr. D. a man in the decline of life, who had long accustomed himself to spirituous liquor, had swelled legs, and other symptoms of approaching anasarca; about once in a week, or ten days, for several months, he was seized, on going to bed, with great general uneasiness, which his attendants resembled to an hysteric fit; and which terminated in a great discharge of viscid urine; his legs became less swelled, and he continued in better health for some days afterwards. I had not the opportunity to try if this urine would coagulate over the fire, when part of it was evaporated, which I imagine would be the criterion of this kind of diabetes; as the mucilaginous fluid deposited in the cells and cysts of the body, which have no communication with the external air, seems to acquire, by stagnation, this property of coagulation by heat, which the secreted mucus of the intestines and bladder do not appear to possess; as I have found by experiment: and if any one should suppose this coagulable urine was separated from the blood by the kidneys, he may recollect, that in the most inflammatory diseases, in which the blood is most replete or most ready to part with the coagulable lymph, none of this appears in the urine.

9. Different kinds of diabetes require different methods of cure. For the first kind, or chyliferous diabetes, after clearing the stomach and intestines, by ipecacuanha and rhubarb, to evacuate any acid material, which may too powerfully stimulate the mouths of the lacteals, repeated and large doses of tincture of cantharides have been much recommended. The specific stimulus of this medicine, on the neck of the bladder, is likely to excite the numerous absorbent vessels, which are spread on that part, into stronger natural actions, and by that means prevent their retrograde ones; till, by persisting in the use of the medicine, their natural habits of motions might again be established. Another indication of cure, requires such medicines, as by lining the intestines with mucilaginous substances, or with such as consist of smooth particles, or which chemically destroy the acrimony of their contents, may prevent the too great action of the intestinal absorbents. For this purpose, I have found the earth precipitated from a solution of alum, by means of fixed alcali, given in the dose of half a dram every six hours, of great advantage, with a few grains of rhubarb, so as to produce a daily evacuation.

The food should consist of materials that have the least stimulus, with calcareous water, as of Bristol and Matlock; that the mouths of the lacteals may be as little stimulated as is necessary for their proper absorption; lest with their greater exertions, should be connected by sympathy, the inverted motions of the urinary lymphatics.

The same method may be employed with equal advantage in the aqueous diabetes, so great is the sympathy between the skin and the stomach. To which, however, some application to the skin might be usefully added; as rubbing the patient all over with oil, to prevent the too great action of the cutaneous absorbents. I knew an experiment of this kind made upon one patient with apparent advantage.

The mucilaginous diabetes will require the same treatment, which is most efficacious in the dropsy, and will be described below. I must add, that the diet and medicines above mentioned, are strongly recommended by various authors, as by Morgan, Willis, Harris, and Etmuller; but more histories of the successful treatment of these diseases are wanting to fully ascertain the most efficacious methods of cure.

In a letter from Mr. Charles Darwin, dated April 24, 1778, Edinburgh, is the subsequent passage:--"A man who had long laboured under a diabetes died yesterday in the clinical ward. He had for some time drank four, and passed twelve pounds of fluid daily; each pound of urine contained an ounce of sugar. He took, without considerable relief, gum kino, sanguis diaconis melted with alum, tincture of cantharides, isinglass, gum arabic, crabs eyes, spirit of hartshorn, and eat ten or fifteen oysters thrice a day. Dr. Home, having read my thesis, bled him, and found that neither the fresh blood nor the serum tasted sweet. His body was opened this morning--every viscus appeared in a sound and natural state, except that the left kidney had a very small pelvis, and that there was a considerable enlargement of most of the mesenteric lymphatic glands. I intend to insert this in my thesis, as it coincides with the experiment, where some asparagus was eaten at the beginning of intoxication, and its smell perceived in the urine, though not in the blood."

The following case of chyliferous diabetes is extracted from some letters of Mr. Hughes, to whose unremitted care the infirmary at Stafford for many years was much indebted. Dated October 10, 1778.

Richard Davis, aged 33, a whitesmith by trade, had drank hard by intervals; was much troubled with sweating of his hands, which incommoded him in his occupation, but which ceased on his frequently dipping them in lime. About seven months ago he began to make large quantities of water; his legs are oedematous, his belly tense, and he complains of a rising in his throat, like the globus hystericus: he eats twice as much as other people, drinks about fourteen pints of small beer a day, besides a pint of ale, some milk-porridge, and a bason of broth, and he makes about eighteen pints of water a day.

He tried alum, dragon's blood, steel, blue vitriol, and cantharides in large quantities, and duly repeated, under the care of Dr. Underhill, but without any effect; except that on the day after he omitted the cantharides, he made but twelve pints of water, but on the next day this good effect ceased again.

November 21.--He made eighteen pints of water, and he now, at Dr. Darwin's request, took a grain of opium every four hours, and five grains of aloes at night; and had a flannel shirt given him.

22.--Made sixteen pints. 23.--Thirteen pints: drinks less.

24.--Increased the opium to a grain and quarter every four hours: he made twelve pints.

25.--Increased the opium to a grain and half: he now makes ten pints; and drinks eight pints in a day.

The opium was gradually increased during the next fortnight, till he took three grains every four hours, but without any further diminution of his water. During the use of the opium he sweat much in the nights, so as to have large drops stand on his face and all over him. The quantity of opium was then gradually decreased, but not totally omitted, as he continued to take about a grain morning and evening.

January 17.--He makes fourteen pints of water a day. Dr. Underhill now directed him two scruples of common rosin triturated with as much sugar, every six hours; and three grains of opium every night.

19.--Makes fifteen pints of water: sweats at night.

21.--Makes seventeen pints of water; has twitchings of his limbs in a morning, and pains of his legs: he now takes a dram of rosin for a dose, and continues the opium.

23.--Water more coloured, and reduced to sixteen pints, and he thinks has a brackish taste.

26.--Water reduced to fourteen pints.

28.--Water thirteen pints: he continues the opium, and takes four scruples of the rosin for a dose.

February 1.--Water twelve pints.

4.--Water eleven pints: twitchings less; takes five scruples for a dose.

8.--Water ten pints: has had many stools.

12.--Appetite less: purges very much.

After this the rosin either purged him, or would not stay on his stomach; and he gradually relapsed nearly to his former condition, and in a few months sunk under the disease.

October 3, Mr. Hughes evaporated two quarts of the water, and obtained from it four ounces and half of a hard and brittle saccharine mass, like treacle which had been some time boiled. Four ounces of blood, which he took from his arm with design to examine it, had the common appearances, except that the serum resembled cheese-whey; and that on the evidence of four persons, two of whom did not know what it was they tasted, _the serum had a saltish taste_.

From hence it appears, that the saccharine matter, with which the urine of these patients so much abounds, does not enter the blood-vessels like the nitre and asparagus mentioned above; but that the process of digestion resembles the process of the germination of vegetables, or of making barley into malt; as the vast quantity of sugar found in the urine must be made from the food which he took (which was double that taken by others), and from the fourteen pints of small beer which he drank. And, secondly, as the serum of the blood was not sweet, the chyle appears to have been conveyed to the bladder without entering the circulation of the blood, since so large a quantity of sugar, as was found in the urine, namely, twenty ounces a day, could not have previously existed in the blood without being perceptible to the taste.

November 1. Mr. Hughes dissolved two drams of nitre in a pint of a decoction of the roots of asparagus, and added to it two ounces of tincture of rhubarb: the patient took a fourth part of this mixture every five minutes, till he had taken the whole.--In about half an hour he made eighteen ounces of water, which was very manifestly tinged with the rhubarb; the smell of asparagus was doubtful.

He then lost four ounces of blood, the serum of which was not so opake as that drawn before, but of a yellowish cast, as the serum of the blood usually appears.

Paper, dipped three or four times in the tinged urine and dried again, did not scintillate when it was set on fire; but when the flame was blown out, the fire ran along the paper for half an inch; which, when the same paper was unimpregnated, it would not do; nor when the same paper was dipped in urine made before he took the nitre, and dried in the same manner.

Paper, dipped in the serum of the blood and dried in the same manner as in the urine, did not scintillate when the flame was blown out, but burnt exactly in the same manner as the same paper dipped in the serum of blood drawn from another person.

This experiment, which is copied from a letter of Mr. Hughes, as well as the former, seems to evince the existence of another passage from the intestines to the bladder, in this disease, besides that of the sanguiferous system; and coincides with the curious experiment related in section the third, except that the smell of the asparagus was not here perceived, owing perhaps to the roots having been made use of instead of the heads.

The rising in the throat of this patient, and the twitchings of his limbs, seem to indicate some similarity between the diabetes and the hysteric disease, besides the great flow of pale urine, which is common to them both.

Perhaps if the mesenteric glands were nicely inspected in the dissections of these patients; and if the thoracic duct, and the larger branches of the lacteals, and if the lymphatics, which arise from the bladder, were well examined by injection, or by the knife, the cause of diabetes might be more certainly understood.

The opium alone, and the opium with the rosin, seem much to have served this patient, and might probably have effected a cure, if the disease had been slighter, or the medicine had been exhibited, before it had been confirmed by habit during the seven months it had continued. The increase of the quantity of water on beginning the large doses of rosin was probably owing to his omitting the morning doses of opium.

V. _The Phænomena of Dropsies explained._

I. Some inebriates have their paroxysms of inebriety terminated by much pale urine, or profuse sweats, or vomiting, or stools; others have their paroxysms terminated by stupor, or sleep, without the above evacuations.

The former kind of these inebriates have been observed to be more liable to diabetes and dropsy; and the latter to gout, gravel, and leprosy. Evoe! attend ye bacchanalians! start at this dark train of evils, and, amid your immodest jests, and idiot laughter, recollect,

Quem Deus vult perdere, prius dementat.

In those who are subject to diabetes and dropsy, the absorbent vessels are naturally more irritable than in the latter; and by being frequently disturbed or inverted by violent stimulus, and by their too great sympathy with each other, they become at length either entirely paralytic, or are only susceptible of motion from the stimulus of very acrid materials; as every part of the body, after having been used to great irritations, becomes less affected by smaller ones. Thus we cannot distinguish objects in the night, for some time after we come out of a strong light, though the iris is presently dilated; and the air of a summer evening appears cold, after we have been exposed to the heat of the day.

There are no cells in the body, where dropsy may not be produced, if the lymphatics cease to absorb that mucilaginous fluid, which is perpetually deposited in them, for the purpose of lubricating their surfaces.

If the lymphatic branch, which opens into the cellular membrane, either does its office imperfectly, or not at all; these cells become replete with a mucilaginous fluid, which, after it has stagnated some time in the cells, will coagulate over the fire; and is erroneously called water. Wherever the seat of this disease is, (unless in the lungs or other pendent viscera) the mucilaginous liquid above mentioned will subside to the most depending parts of the body, as the feet and legs, when those are lower than the head and trunk; for all these cells have communications with each other.

When the cellular absorbents are become insensible to their usual irritations, it most frequently happens, but not always, that the cutaneous branch of absorbents, which is strictly associated with them, suffers the like inability. And then, as no water is absorbed from the atmosphere, the urine is not only less diluted at the time of its secretion, and consequently in less quantity and higher coloured: but great thirst is at the same time induced, for as no water is absorbed from the atmosphere to dilute the chyle and blood, the lacteals and other absorbent vessels, which have not lost their powers, are excited into more constant or more violent action, to supply this deficiency; whence the urine becomes still less in quantity, and of a deeper colour, and turbid like the yolk of an egg, owing to a greater absorption of its thinner parts. From this stronger action of those absorbents, which still retain their irritability, the fat is also absorbed, and the whole body becomes emaciated. This increased exertion of some branches of the lymphatics, while others are totally or partially paralytic, is resembled by what constantly occurs in the hemiplagia; when the patient has lost the use of the limbs on one side, he is incessantly moving those of the other; for the moving power, not having access to the paralytic limbs, becomes redundant in those which are not diseased.

The paucity of urine and thirst cannot be explained from a greater quantity of mucilaginous fluid being deposited in the cellular membrane: for though these symptoms have continued many weeks, or even months, this collection frequently does not amount to more than very few pints. Hence also the difficulty of promoting copious sweats in anasarca is accounted for, as well as the great thirst, paucity of urine, and loss of fat; since, when the cutaneous branch of absorbents is paralytic, or nearly so, there is already too small a quantity of aqueous fluid in the blood: nor can these torpid cutaneous lymphatics be readily excited into retrograde motions.

Hence likewise we understand, why in the ascites, and some other dropsies, there is often no thirst, and no paucity of urine; in these cases the cutaneous absorbents continue to do their office.

Some have believed, that dropsies were occasioned by the inability of the kidneys, from having only observed the paucity of urine; and have thence laboured much to obtain diuretic medicines; but it is daily observable, that those who die of a total inability to make water, do not become dropsical in consequence of it: Fernelius mentions one, who laboured under a perfect suppression of urine during twenty days before his death, and yet had no symptoms of dropsy. Pathol. 1. vi. c. 8. From the same idea many physicians have restrained their patients from drinking, though their thirst has been very urgent; and some cases have been published, where this cruel regimen has been thought advantageous: but others of nicer observation are of opinion, that it has always aggravated the distresses of the patient; and though it has abated his swellings, yet by inducing a fever it has hastened his dissolution. See Transactions of the College, London, vol. ii. p. 235. Cases of Dropsy by Dr. G. Baker.

The cure of anasarca, so far as respects the evacuation of the accumulated fluid, coincides with the idea of the retrograde action of the lymphatic system. It is well known that vomits, and other drugs, which induce sickness or nausea; at the same time that they evacuate the stomach, produce a great absorption of the lymph accumulated in the cellular membrane. In the operation of a vomit, not only the motions of the stomach and duodenum become inverted, but also those of the lymphatics and lacteals, which belong to them; whence a great quantity of chyle and lymph is perpetually poured into the stomach and intestines, during the operation, and evacuated by the mouth. Now at the same time, other branches of the lymphatic system, viz. those which open on the cellular membrane, are brought into more energetic action, by the sympathy above mentioned, and an increase of their absorption is produced.

Hence repeated vomits, and cupreous salts, and small doses of squill or foxglove, are so efficacious in this disease. And as drastic purges act also by inverting the motions of the lacteals; and thence the other branches of lymphatics are induced into more powerful natural action, by sympathy, and drink up the fluids from all the cells of the body; and by their anastomoses, pour them into the lacteal branches; which, by their inverted actions, return them into the intestines; and they are thus evacuated from the body:--these purges also are used with success in discharging the accumulated fluid in anasarca.

II. The following cases are related with design to ascertain the particular kinds of dropsy in which the digitalis purpurea, or common foxglove, is preferable to squill, or other evacuants, and were first published in 1780, in a pamphlet entitled Experiments on mucilaginous and purulent Matter, &c. Cadell. London. Other cases of dropsy, treated with digitalis, were afterwards published by Dr. Darwin in the Medical Transactions, vol. iii. in which there is a mistake in respect to the dose of the powder of foxglove, which should have been from five grains to one, instead of from five grains to ten.

_Anasarca of the Lungs._

1. A lady, between forty and fifty years of age, had been indisposed some time, was then seized with cough and fever, and afterwards expectorated much digested mucus. This expectoration suddenly ceased, and a considerable difficulty of breathing supervened, with a pulse very irregular both in velocity and strength; she was much distressed at first lying down, and at first rising; but after a minute or two bore either of those attitudes with ease. She had no pain or numbness in her arms; she had no hectic fever, nor any cold shiverings, and the urine was in due quantity, and of the natural colour.

The difficulty of breathing was twice considerably relieved by small doses of ipecacuanha, which operated upwards and downwards, but recurred in a few days: she was then directed a decoction of foxglove, (digitalis purpurea) prepared by boiling four ounces of the fresh leaves from two pints of water to one pint; to which was added two ounces of vinous spirit: she took three large spoonfuls of this mixture every two hours, till she had taken it four times; a continued sickness supervened, with frequent vomiting, and a copious flow of urine: these evacuations continued at intervals for two or three days, and relieved the difficulty of breathing--She had some relapses afterwards, which were again relieved by the repetition of the decoction of foxglove.

2. A gentleman, about sixty years of age, who had been addicted to an immoderate use of fermented liquors, and had been very corpulent, gradually lost his strength and flesh, had great difficulty of breathing, with legs somewhat swelled, and a very irregular pulse. He was very much distressed at first lying down, and at first rising from his bed, yet in a minute or two was easy in both those attitudes. He made straw-coloured urine in due quantity, and had no pain or numbness of his arms.

He took a large spoonful of the decoction of foxglove, as above, every hour, for ten or twelve successive hours, had incessant sickness for about two days, and passed a large quantity of urine; upon which his breath became quite easy, and the swelling of his legs subsided; but as his whole constitution was already sinking from the previous intemperance of his life, he did not survive more than three or four months.

_Hydrops Pericardii._

3. A gentleman of temperate life and sedulous application to business, between thirty and forty years of age, had long been subject, at intervals, to an irregular pulse: a few months ago he became weak, with difficulty of breathing, and dry cough. In this situation a physician of eminence directed him to abstain from all animal food and fermented liquor, during which regimen all his complaints increased; he now became emaciated, and totally lost his appetite; his pulse very irregular both in velocity and strength; with great difficulty of breathing, and some swelling of his legs; yet he could lie down horizontally in his bed, though he got little sleep, and passed a due quantity of urine, and of the natural colour: no fullness or hardness could be perceived about the region of the liver; and he had no pain or numbness in his arms.

One night he had a most profuse sweat all over his body and limbs, which quite deluged his bed, and for a day or two somewhat relieved his difficulty of breathing, and his pulse became less irregular: this copious sweat recurred three or four times at the intervals of five or six days, and repeatedly alleviated his symptoms.

He was directed one large spoonful of the above decoction of foxglove every hour, till it procured some considerable evacuation: after he had taken it eleven successive hours he had a few liquid stools, attended with a great flow of urine, which last had a dark tinge, as if mixed with a few drops of blood: he continued sick at intervals for two days, but his breath became quite easy, and his pulse quite regular, the swelling of his legs disappeared, and his appetite and sleep returned.

He then took three grains of white vitriol twice a day, with some bitter medicines, and a grain of opium with five grains of rhubarb every night; was advised to eat flesh meat, and spice, as his stomach would bear it, with small beer, and a few glasses of wine; and had issues made in his thighs; and has suffered no relapse.

4. A lady, about fifty years of age, had for some weeks great difficulty of breathing, with very irregular pulse, and considerable general debility: she could lie down in bed, and the urine was in due quantity and of the natural colour, and she had no pain or numbness of her arms.

She took one large spoonful of the above decoction of foxglove every hour, for ten or twelve successive hours; was sick, and made a quantity of pale urine for about two days, and was quite relieved both of the difficulty of breathing, and the irregularity of her pulse. She then took a grain of opium, and five grains of rhubarb, every night, night, for many weeks; with some slight chalybeate and bitter medicines, and has suffered no relapse.

_Hydrops Thoracis._

5. A tradesman, about fifty years of age, became weak and short of breath, especially on increase of motion, with pain in one arm, about the insertion of the biceps muscle. He observed he sometimes in the night made an unusual quantity of pale water. He took calomel, alum, and peruvian bark, and all his symptoms increased: his legs began to swell considerably; his breath became more difficult, and he could not lie down in bed; but all this time he made a due quantity of straw-coloured water.

The decoction of foxglove was given as in the preceding cases, which operated chiefly by purging, and seemed to relieve his breath for a day or two; but also seemed to contribute to weaken him.--He became after some weeks universally dropsical, and died comatous.

6. A young lady of delicate constitution, with light eyes and hair, and who had perhaps lived too abstemiously both in respect to the quantity and quality of what she eat and drank, was seized with great difficulty of breathing, so as to threaten immediate death. Her extremities were quite cold, and her breath felt cold to the back of one's hand. She had no sweat, nor could be down for a single moment; and had previously, and at present, complained of great weakness and pain and numbness of both her arms; had no swelling of her legs, no thirst, water in due quantity and colour. Her sister, about a year before, was afflicted with similar symptoms, was repeatedly blooded, and died universally dropsical.

A grain of opium was given immediately, and repeated every six hours with evident and amazing advantage; afterwards a blister, with chalybeates, bitters, and essential oils, were exhibited, but nothing had such eminent effect in relieving the difficulty of breathing and coldness of her extremities as opium, by the use of which in a few weeks she perfectly regained her health, and has suffered no relapse.

_Ascites._

7. A young lady of delicate constitution having been exposed to great fear, cold, and fatigue, by the overturn of a chaise in the night, began with pain and tumour in the right hypochondrium: in a few months a fluctuation was felt throughout the whole abdomen, more distinctly perceptible indeed about the region of the stomach; since the integuments of the lower part of the abdomen generally become thickened in this disease by a degree of anasarca. Her legs were not swelled, no thirst, water in due quantity and colour.--She took the foxglove so as to induce sickness and stools, but without abating the swelling, and was obliged at length to submit to the operation of tapping.

8. A man about sixty-seven, who had long been accustomed to spirituous potation, had some time laboured under ascites; his legs somewhat swelled; his breath easy in all attitudes; no appetite; great thirst; urine in exceedingly small quantity, very deep coloured, and turbid; pulse equal. He took the foxglove in such quantity as vomited him, and induced sickness for two days; but procured no flow of urine, or diminution of his swelling; but was thought to leave him considerably weaker.

9. A corpulent man, accustomed to large potation of fermented liquors, had vehement cough, difficult breathing, anasarca of his legs, thighs, and hands, and considerable tumour, with evident fluctuation of his abdomen; his pulse was equal; his urine in small quantity, of deep colour, and turbid. These swellings had been twice considerably abated by drastic cathartics. He took three ounces of a decoction of foxglove (made by boiling one ounce of the fresh leaves in a pint of water) every three hours, for two whole days; it then began to vomit and purge him violently, and promoted a great flow of urine; he was by these evacuations completely emptied in twelve hours. After two or three months all these symptoms returned, and were again relieved by the use of the foxglove; and thus in the space of about three years he was about ten times evacuated, and continued all that time his usual potations: excepting at first, the medicine operated only by urine, and did not appear considerably to weaken him--The last time he took it, it had no effect; and a few weeks afterwards he vomited a great quantity of blood, and expired.

QUERIES.

1. As the first six of these patients had a due discharge of urine, and of the natural colour, was not the feat of the disease confined to some part of the thorax, and the swelling of the legs rather a symptom of the obstructed circulation of the blood, than of a paralysis of the cellular lymphatics of those parts?

2. When the original disease is a general anasarca, do not the cutaneous lymphatics always become paralytic at the same time with the cellular ones, by their greater sympathy with each other? and hence the paucity of urine, and the great thirst, distinguish this kind of dropsy?

3. In the anasarca of the lungs, when the disease is not very great, though the patients have considerable difficulty of breathing at their first lying down, yet after a minute or two their breath becomes easy again; and the same occurs at their first rising. Is not this owing to the time necessary for the fluid in the cells of the lungs to change its place, so as the least to incommode respiration in the new attitude?

4. In the dropsy of the pericardium does not the patient bear the horizontal or perpendicular attitude with equal ease? Does this circumstance distinguish the dropsy of the pericardium from that of the lungs and of the thorax?

5. Do the universal sweats distinguish the dropsy of the pericardium, or of the thorax? and those, which cover the upper parts of the body only, the anasarca of the lungs?

6. When in the dropsy of the thorax, the patient endeavours to lie down, does not the extravasated fluid compress the upper parts of the bronchia, and totally preclude the access of air to every part of the lungs; whilst in the perpendicular attitude the inferior parts of the lungs only are compressed? Does not something similar to this occur in the anasarca of the lungs, when the disease is very great, and thus prevent those patients also from lying down?

7. As a principal branch of the fourth cervical nerve of the left side, after having joined a branch of the third and of the second cervical nerves, descending between the subclavian vein and artery, is received in a groove formed for it in the pericardium, and is obliged to make a considerable turn outwards to go over the prominent part of it, where the point of the heart is lodged, in its course to the diaphragm; and as the other phrenic nerve of the right side has a straight course to the diaphragm; and as many other considerable branches of this fourth pair of cervical nerves are spread on the arms; does not a pain in the left arm distinguish a disease of the pericardium, as in the angina pectoris, or in the dropsy of the pericardium? and does not a pain or weakness in both arms distinguish the dropsy of the thorax?

8. Do not the dropsies of the thorax and pericardium frequently exist together, and thus add to the uncertainty and fatality of the disease?

9. Might not the foxglove be serviceable in hydrocephalus internus, in hydrocele, and in white swellings of the joints?

VI. _Of cold Sweats._

There have been histories given of chronical immoderate sweatings, which bear some analogy to the diabetes. Dr. Willis mentions a lady then living, whose sweats where for many years so profuse, that all her bed-clothes were not only moistened, but deluged with them every night; and that many ounces, and sometimes pints, of this sweat, were received in vessels properly placed, as it trickled down her body. He adds, that she had great thirst, had taken many medicines, and submitted to various rules of life, and changes of climate, but still continued to have these immoderate sweats. Pharmac. ration. de sudore anglico.

Dr. Willis has also observed, that the sudor anglicanus which appeared in England, in 1483, and continued till 1551, was in some respects similar to the diabetes; and as Dr. Caius, who saw this disease, mentions the viscidity, as well as the quantity of these sweats, and adds, that the extremities were often cold, when the internal parts were burnt up with heat and thirst, with great and speedy emaciation and debility: there is great reason to believe, that the fluids were absorbed from the cells of the body by the cellular and cystic branches of the lymphatics, and poured on the skin by the retrograde motions of the cutaneous ones.

Sydenham has recorded, in the stationary fever of the year 1685, the viscid sweats flowing from the head, which were probably from the same source as those in the sweating plague above mentioned.