OF HÆMORRHAGES.
I. The veins are absorbent vessels. 1. Hæmorrhages from inflammation. Case of hæmorrhage from the kidney cured by cold bathing. Case of hæmorrhage from the nose cured by cold immersion. II. Hæmorrhage from venous paralysis. Of Piles. Black stools. Petechiæ. Consumption. Scurvy of the lungs. Blackness of the face and eyes in epileptic fits. Cure of hæmorrhages from venous inability.
I. As the imbibing mouths of the absorbent system already described open on the surface, and into the larger cavities of the body, so there is another system of absorbent vessels, which are not commonly esteemed such, I mean the veins, which take up the blood from the various glands and capillaries, after their proper fluids or secretions have been separated from it.
The veins resemble the other absorbent vessels; as the progression of their contents is carried on in the same manner in both, they alike absorb their appropriated fluids, and have valves to prevent its regurgitation by the accidents of mechanical violence. This appears first, because there is no pulsation in the very beginnings of the veins, as is seen by microscopes; which must happen, if the blood was carried into them by the actions of the arteries. For though the concurrence of various venous streams of blood from different distances must prevent any pulsation in the larger branches, yet in the very beginnings of all these branches a pulsation must unavoidably exist, if the circulation in them was owing to the intermitted force of the arteries. Secondly, the venous absorption of blood from the penis, and from the teats of female animals after their erection, is still more similar to the lymphatic absorption, as it is previously poured into cells, where all arterial impulse must cease.
There is an experiment, which seems to evince this venous absorption, which consists in the external application of a stimulus to the lips, as of vinegar, by which they become instantly pale; that is, the bibulous mouths of the veins by this stimulus are excited to absorb the blood faster, than it can be supplied by the usual arterial exertion. See Sect. XXIII. 5.
There are two kinds of hæmorrhages frequent in diseases, one is where the glandular or capillary action is too powerfully exerted, and propels the blood forwards more hastily, than the veins can absorb it; and the other is, where the absorbent power of the veins is diminished, or a branch of them is become totally paralytic.
1. The former of these cases is known by the heat of the part, and the general fever or inflammation that accompanies the hæmorrhage. An hæmorrhage from the nose or from the lungs is sometimes a crisis of inflammatory diseases, as of the hepatitis and gout, and generally ceases spontaneously, when the vessels are considerably emptied. Sometimes the hæmorrhage recurs by daily periods accompanying the hot fits of fever, and ceasing in the cold fits, or in the intermissions; this is to be cured by removing the febrile paroxysms, which will be treated of in their place. Otherwise it is cured by venesection, by the internal or external preparations of lead, or by the application of cold, with an abstemious diet, and diluting liquids, like other inflammations. Which by inducing a quiescence on those glandular parts, that are affected, prevents a greater quantity of blood from being protruded forwards, than the veins are capable of absorbing.
Mr. B—— had an hæmorrhage from his kidney, and parted with not less than a pint of blood a day (by conjecture) along with his urine for above a fortnight: venesections, mucilages, balsams, preparations of lead, the bark, alum, and dragon's blood, opiates, with a large blister on his loins, were separately tried, in large doses, to no purpose. He was then directed to bathe in a cold spring up to the middle of his body only, the upper part being covered, and the hæmorrhage diminished at the first, and ceased at the second immersion.
In this case the external capillaries were rendered quiescent by the coldness of the water, and thence a less quantity of blood was circulated through them; and the internal capillaries, or other glands, became quiescent from their irritative associations with the external ones; and the hæmorrhage was stopped a sufficient time for the ruptured vessels to contract their apertures, or for the blood in those apertures to coagulate.
Mrs. K—— had a continued haemorrhage from her nose for some days; the ruptured vessel was not to be reached by plugs up the nostrils, and the sensibility of her fauces was such that nothing could be born behind the uvula. After repeated venesection, and other common applications, she was directed to immerse her whole head into a pail of water, which was made colder by the addition of several handfuls of salt, and the hæmorrhage immediately ceased, and returned no more; but her pulse continued hard, and she was necessitated to lose blood from the arm on the succeeding day.
Query, might not the cold bath instantly stop hæmorrhages from the lungs in inflammatory cases?—for the shortness of breath of those, who go suddenly into cold water, is not owing to the accumulation of blood in the lungs, but to the quiescence of the pulmonary capillaries from association, as explained in Section XXXII. 3. 2.
II. The other kind of hæmorrhage is known from its being attended with a weak pulse, and other symptoms of general debility, and very frequently occurs in those, who have diseased livers, owing to intemperance in the use of fermented liquors. These constitutions are shewn to be liable to paralysis of the lymphatic absorbents, producing the various kinds of dropsies in Section XXIX. 5. Now if any branch of the venous system loses its power of absorption, the part swells, and at length bursts and discharges the blood, which the capillaries or other glands circulate through them.
It sometimes happens that the large external veins of the legs burst, and effuse their blood; but this occurs most frequently in the veins of the intestines, as the vena portarum is liable to suffer from a schirrus of the liver opposing the progression of the blood, which is absorbed from the intestines. Hence the piles are a symptom of hepatic obstruction, and hence the copious discharges downwards or upwards of a black material, which has been called melancholia, or black bile; but is no other than the blood, which is probably discharged from the veins of the intestines.
J.F. Meckel, in his Experimenta de Finibus Vasorum, published at Berlin, 1772, mentions his discovery of a communication of a lymphatic vessel with the gastric branch of the vena portarum. It is possible, that when the motion of the lymphatic becomes retrograde in some diseases, that blood may obtain a passage into it, where it anastomoses with the vein, and thus be poured into the intestines. A discharge of blood with the urine sometimes attends diabetes, and may have its source in the same manner.
Mr. A——, who had been a hard drinker, and had the gutta rosacea on his face and breast, after a stroke of the palsy voided near a quart of a black viscid material by stool: on diluting it with water it did not become yellow, as it must have done if it had been inspissated bile, but continued black like the grounds of coffee.
But any other part of the venous system may become quiescent or totally paralytic as well as the veins of the intestines: all which occur more frequently in those who have diseased livers, than in any others. Hence troublesome bleedings of the nose, or from the lungs with a weak pulse; hence hæmorrhages from the kidneys, too great menstruation; and hence the oozing of blood from every part of the body, and the petechiæ in those fevers, which are termed putrid, and which is erroneously ascribed to the thinness of the blood: for the blood in inflammatory diseases is equally fluid before it coagulates in the cold air.
Is not that hereditary consumption, which occurs chiefly in dark-eyed people about the age of twenty, and commences with slight pulmonary hæmorrhages without fever, a disease of this kind?—These hæmorrhages frequently begin during sleep, when the irritability of the lungs is not sufficient in these patients to carry on the circulation without the assistance of volition; for in our waking hours, the motions of the lungs are in part voluntary, especially if any difficulty of breathing renders the efforts of volition necessary. See Class I. 2. 1. 3. and Class III. 2. 1. 12. Another species of pulmonary consumption which seems more certainly of scrophulous origin is described in the next Section, No. 2.
I have seen two cases of women, of about forty years of age, both of whom were seized with quick weak pulse, with difficult respiration, and who spit up by coughing much viscid mucus mixed with dark coloured blood. They had both large vibices on their limbs, and petechiæ; in one the feet were in danger of mortification, in the other the legs were œdematous. To relieve the difficult respiration, about six ounces of blood were taken from one of them, which to my surprise was sizy, like inflamed blood: they had both palpitations or unequal pulsations of the heart. They continued four or five weeks with pale and bloated countenances, and did not cease spitting phlegm mixed with black blood, and the pulse seldom slower than 130 or 135 in a minute. This blood, from its dark colour, and from the many vibices and petechiæ, seems to have been venous blood; the quickness of the pulse, and the irregularity of the motion of the heart, are to be ascribed to debility of that part of the system; as the extravasation of blood originated from the defect of venous absorption. The approximation of these two cases to sea-scurvy is peculiar, and may allow them to be called scorbutus pulmonalis. Had these been younger subjects, and the paralysis of the veins had only affected the lungs, it is probable the disease would have been a pulmonary consumption.
Last week I saw a gentleman of Birmingham, who had for ten days laboured under great palpitation of his heart, which was so distinctly felt by the hand, as to discountenance the idea of there being a fluid in the pericardium. He frequently spit up mucus stained with dark coloured blood, his pulse very unequal and very weak, with cold hands and nose. He could not lie down at all, and for about ten days past could not sleep a minute together, but waked perpetually with great uneasiness. Could those symptoms be owing to very extensive adhesions of the lungs? or is this a scorbutus pulmonalis? After a few days he suddenly got so much better as to be able to sleep many hours at a time by the use of one grain of powder of foxglove twice a day, and a grain of opium at night. After a few days longer, the bark was exhibited, and the opium continued with some wine; and the palpitations of his heart became much relieved, and he recovered his usual degree of health, but died suddenly some months afterwards.
In epileptic fits the patients frequently become black in the face, from the temporary paralysis of the venous system of this part. I have known two instances where the blackness has continued many days. M. P——, who had drank intemperately, was seized with the epilepsy when he was in his fortieth year; in one of these fits the white part of his eyes was left totally black with effused blood; which was attended with no pain or heat, and was in a few weeks gradually absorbed, changing colour as is usual with vibices from bruises.
The hæmorrhages produced from the inability of the veins to absorb the refluent blood, is cured by opium, the preparations of steel, lead, the bark, vitriolic acid, and blisters; but these have the effect with much more certainty, if a venesection to a few ounces, and a moderate cathartic with four or six grains of calomel be premised, where the patient is not already too much debilitated; as one great means of promoting the absorption of any fluid consists in previously emptying the vessels, which are to receive it.
OF THE PARALYSIS OF THE ABSORBENT SYSTEM.
The term paralysis has generally been used to express the loss of voluntary motion, as in the hemiplagia, but may with equal propriety be applied to express the disobediency of the muscular fibres to the other kinds of stimulus; as to those of irritation or sensation.
I. There is a species of atrophy, which has not been well understood; when the absorbent vessels of the stomach and intestines have been long inured to the stimulus of too much spirituous liquor, they at length, either by the too sudden omission of fermented or spirituous potation, or from the gradual decay of nature, become in a certain degree paralytic; now it is observed in the larger muscles of the body, when one side is paralytic, the other is more frequently in motion, owing to the less expenditure of sensorial power in the paralytic limbs; so in this case the other part of the absorbent system acts with greater force, or with greater perseverance, in consequence of the paralysis of the lacteals; and the body becomes greatly emaciated in a small time.
I have seen several patients in this disease, of which the following are the circumstances. 1. They were men about fifty years of age, and had lived freely in respect to fermented liquors. 2. They lost their appetite to animal food. 3. They became suddenly emaciated to a great degree. 4. Their skins were dry and rough. 5. They coughed and expectorated with difficulty a viscid phlegm. 6. The membrane of the tongue was dry and red, and liable to become ulcerous.
The inability to digest animal food, and the consequent distaste to it, generally precedes the dropsy, and other diseases, which originate from spirituous potation. I suppose when the stomach becomes inirritable, that there is at the same time a deficiency of gastric acid; hence milk seldom agrees with these patients, unless it be previously curdled, as they have not sufficient gastric acid to curdle it; and hence vegetable food, which is itself acescent, will agree with their stomachs longer than animal food, which requires more of the gastric acid for its digestion.
In this disease the skin is dry from the increased absorption of the cutaneous lymphatics, the fat is absorbed from the increased absorption of the cellular lymphatics, the mucus of the lungs is too viscid to be easily spit up by the increased absorption of the thinner parts of it, the membrana sneideriana becomes dry, covered with hardened mucus, and at length becomes inflamed and full of aphthæ, and either these sloughs, or pulmonary ulcers, terminate the scene.
II. The immediate cause of dropsy is the paralysis of some other branches of the absorbent system, which are called lymphatics, and which open into the larger cavities of the body, or into the cells of the cellular membrane; whence those cavities or cells become distended with the fluid, which is hourly secreted into them for the purpose of lubricating their surfaces. As is more fully explained in No. 5. of the next Section.
As those lymphatic vessels consist generally of a long neck or mouth, which drinks up its appropriated fluid, and of a conglobate gland, in which this fluid undergoes some change, it happens, that sometimes the mouth of the lymphatic, and sometimes the belly or glandular part of it, becomes totally or partially paralytic. In the former case, where the mouths of the cutaneous lymphatics become torpid or quiescent, the fluid secreted on the skin ceases to be absorbed, and erodes the skin by its saline acrimony, and produces eruptions termed herpes, the discharge from which is as salt, as the tears, which are secreted too fast to be reabsorbed, as in grief, or when the puncta lacrymalia are obstructed, and which running down the cheek redden and inflame the skin.
When the mouths of the lymphatics, which open on the mucous membrane of the nostrils, become torpid, as on walking into the air in a frosty morning; the mucus, which continues to be secreted, has not its aqueous and saline part reabsorbed, which running over the upper lip inflames it, and has a salt taste, if it falls on the tongue.
When the belly, or glandular part of these lymphatics, becomes torpid, the fluid absorbed by its mouth stagnates, and forms a tumour in the gland. This disease is called the scrophula. If these glands suppurate externally, they gradually heal, as those of the neck; if they suppurate without an opening on the external habit, as the mesenteric glands, a hectic fever ensues, which destroys the patient; if they suppurate in the lungs, a pulmonary consumption ensues, which is believed thus to differ from that described in the preceding Section, in respect to its seat or proximate cause.
It is remarkable, that matter produced by suppuration will lie concealed in the body many weeks, or even months, without producing hectic fever; but as soon as the wound is opened, so as to admit air to the surface of the ulcer, a hectic fever supervenes, even in very few hours, which is probably owing to the azotic part of the atmosphere rather than to the oxygene; because those medicines, which contain much oxygene, as the calces or oxydes of metals, externally applied, greatly contribute to heal ulcers, of these are the solutions of lead and mercury, and copper in acids, or their precipitates.
Hence when wounds are to be healed by the first intention, as it is called, it is necessary carefully to exclude the air from them. Hence we have one cause, which prevents pulmonary ulcers from healing, which is their being perpetually exposed to the air.
Both the dark-eyed patients, which are affected with pulmonary ulcers from deficient venous absorption, as described in Section. XXVII. 2. and the light-eyed patients from deficient lymphatic absorption, which we are now treating of, have generally large apertures of the iris; these large pupils of the eyes are a common mark of want of irritability; and it generally happens, that an increase of sensibility, that is, of motions in consequence of sensation, attends these constitutions. See Sect. XXXI. 2. Whence inflammations may occur in these from stagnated fluids more frequently than in those constitutions, which possess more irritability and less sensibility.
Great expectations in respect to the cure of consumptions, as well as of many other diseases, are produced by the very ingenious exertions of DR. BEDDOES; who has established an apparatus for breathing various mixtures of airs or gasses, at the hot-wells near Bristol, which well deserves the attention of the public.
DR. BEDDOES very ingeniously concludes, from the florid colour of the blood of consumptive patients, that it abounds in oxygene; and that the redness of their tongues, and lips, and the fine blush of their cheeks shew the presence of the same principle, like flesh reddened by nitre. And adds, that the circumstance of the consumptions of pregnant women being stopped in their progress during pregnancy, at which time their blood may be supposed to be in part deprived of its oxygene, by oxygenating the blood of the fœtus, is a forceable argument in favour of this theory; which must soon be confirmed or confuted by his experiments. See Essay on Scurvy, Consumption, &c. by Dr. Beddoes. Murray. London. Also Letter to Dr. Darwin, by the same. Murray. London.
ON THE RETROGRADE MOTIONS OF THE ABSORBENT SYSTEM.
I. Account of the absorbent system. II. The valves of the absorbent vessels may suffer their fluids to regurgitate in some diseases. III. Communication from the alimentary canal to the bladder by means of the absorbent vessels. IV. The phenomena of diabetes explained. V. 1. The phenomena of dropsies explained. 2. Cases of the use of foxglove. VI. Of cold sweats. VII. Translations of matter, of chyle, of milk, of urine, operation of purging drugs applied externally. VIII. Circumstances by which the fluids, that are effused by the retrograde motions of the absorbent vessels, are distinguished. IX. Retrograde motions of vegetable juices. X. Objections answered. XI. The causes, which induce the retrograde motions of animal vessels, and the medicines by which the natural motions are restored.
N.B. The following Section is a translation of a part of a Latin thesis written by the late Mr. Charles Darwin, which was printed with his prize-dissertation on a criterion between matter and mucus in 1780. Sold by Cadell, London.
I. Account of the Absorbent System.
1. The absorbent system of vessels in animal bodies consists of several branches, differing in respect to their situations, and to the fluids, which they absorb.
The intestinal absorbents open their mouths on the internal surfaces of the intestines; their office is to drink up the chyle and the other fluids from the alimentary canal; and they are termed lacteals, to distinguish them from the other absorbent vessels, which have been termed lymphatics.
Those, whose mouths are dispersed on the external skin, imbibe a great quantity of water from the atmosphere, and a part of the perspirable matter, which does not evaporate, and are termed cutaneous absorbents.
Those, which arise from the internal surface of the bronchia, and which imbibe moisture from the atmosphere, and a part of the bronchial mucus, are called pulmonary absorbents.
Those, which open their innumerable mouths into the cells of the whole cellular membrane; and whose use is to take up the fluid, which is poured into those cells, after it has done its office there; may be called cellular absorbents.
Those, which arise from the internal surfaces of the membranes, which line the larger cavities of the body, as the thorax, abdomen, scrotum, pericardium, take up the mucus poured into those cavities; and are distinguished by the names of their respective cavities.
Whilst those, which arise from the internal surfaces of the urinary bladder, gall-bladder, salivary ducts, or other receptacles of secreted fluids, may take their names from those fluids; the thinner parts of which it is their office to absorb: as urinary, bilious, or salivary absorbents.
2. Many of these absorbent vessels, both lacteals and lymphatics, like some of the veins, are replete with valves: which seem designed to assist the progress of their fluids, or at least to prevent their regurgitation; where they are subjected to the intermitted pressure of the muscular, or arterial actions in their neighbourhood.
These valves do not however appear to be necessary to all the absorbents, any more than to all the veins; since they are not found to exist in the absorbent system of fish; according to the discoveries of the ingenious, and much lamented Mr. Hewson. Philos. Trans. v. 59, Enquiries into the Lymph. Syst. p. 94.
3. These absorbent vessels are also furnished with glands, which are called conglobate glands; whose use is not at present sufficiently investigated; but it is probable that they resemble the conglomerate glands both in structure and in use, except that their absorbent mouths are for the conveniency of situation placed at a greater distance from the body of the gland. The conglomerate glands open their mouths immediately into the sanguiferous vessels, which bring the blood, from whence they absorb their respective fluids, quite up to the gland: but these conglobate glands collect their adapted fluids from very distant membranes, or cysts, by means of mouths furnished with long necks for this purpose; and which are called lacteals, or lymphatics.
4. The fluids, thus collected from various parts of the body, pass by means of the thoracic duct into the left subclavian near the jugular vein; except indeed that those collected from the right side of the head and neck, and from the right arm, are carried into the right subclavian vein: and sometimes even the lymphatics from the right side of the lungs are inserted into the right subclavian vein; whilst those of the left side of the head open but just into the summit of the thoracic duct.
5. In the absorbent system there are many anastomoses of the vessels, which seem of great consequence to the preservation of health. These anastomoses are discovered by dissection to be very frequent between the intestinal and urinary lymphatics, as mentioned by Mr. Hewson, (Phil. Trans. v. 58.)
6. Nor do all the intestinal absorbents seem to terminate in the thoracic duct, as appears from some curious experiments of D. Munro, who gave madder to some animals, having previously put a ligature on the thoracic duct, and found their bones, and the serum of their blood, coloured red.
II. The Valves of the Absorbent System may suffer their Fluids to regurgitate in some Diseases.
1. The many valves, which occur in the progress of the lymphatic and lacteal vessels, would seem insuperable obstacles to the regurgitation of their contents. But as these valves are placed in vessels, which are indued with life, and are themselves indued with life also; and are very irritable into those natural motions, which absorb, or propel the fluids they contain; it is possible, in some diseases, where these valves or vessels are stimulated into unnatural exertions, or are become paralytic, that during the diastole of the part of the vessel to which the valve is attached, the valve may not so completely close, as to prevent the relapse of the lymph or chyle. This is rendered more probable, by the experiments of injecting mercury, or water, or suet, or by blowing air down these vessels: all which pass the valves very easily, contrary to the natural course of their fluids, when the vessels are thus a little forcibly dilated, as mentioned by Dr. Haller, Elem. Physiol. t. iii. s. 4.
"The valves of the thoracic duct are few, some assert they are not more than twelve, and that they do not very accurately perform their office, as they do not close the whole area of the duct, and thence may permit chyle to repass them downwards. In living animals, however, though not always, yet more frequently than in the dead, they prevent the chyle from returning. The principal of these valves is that, which presides over the insertion of the thoracic duct, into the subclavian vein; many have believed this also to perform the office of a valve, both to admit the chyle into the vein, and to preclude the blood from entering the duct; but in my opinion it is scarcely sufficient for this purpose." Haller, Elem. Phys. t. vii. p. 226.
2. The mouths of the lymphatics seem to admit water to pass through them after death, the inverted way, easier than the natural one; since an inverted bladder readily lets out the water with which it is filled; whence it may be inferred, that there is no obstacle at the mouths of these vessels to prevent the regurgitation of their contained fluids.
I was induced to repeat this experiment, and having accurately tied the ureters and neck of a fresh ox's bladder, I made an opening at the fundus of it; and then, having turned it inside outwards, filled it half full with water, and was surprised to see it empty itself so hastily. I thought the experiment more apposite to my purpose by suspending the bladder with its neck downwards, as the lymphatics are chiefly spread upon this part of it, as shewn by Dr. Watson, Philos. Trans. v. 59. p. 392.
3. In some diseases, as in the diabetes and scrophula, it is probable the valves themselves are diseased, and are thence incapable of preventing the return of the fluids they should support. Thus the valves of the aorta itself have frequently been found schirrous, according to the dissections of Mons. Lieutaud, and have given rise to an interrupted pulse, and laborious palpitations, by suffering a return of part of the blood into the heart. Nor are any parts of the body so liable to schirrosity as the lymphatic glands and vessels, insomuch that their schirrosities have acquired a distinct name, and been termed scrophula.
4. There are valves in other parts of the body, analogous to those of the absorbent system, and which are liable, when diseased, to regurgitate their contents: thus the upper and lower orifices of the stomach are closed by valves, which, when too great quantities of warm water have been drank with a design to promote vomiting, have sometimes resisted the utmost efforts of the abdominal muscles, and diaphragm: yet, at other times, the upper valve, or cardia, easily permits the evacuation of the contents of the stomach; whilst the inferior valve, or pylorus, permits the bile, and other contents of the duodenum, to regurgitate into the stomach.
5. The valve of the colon is well adapted to prevent the retrograde motion of the excrements; yet, as this valve is possessed of a living power, in the iliac passion, either from spasm, or other unnatural exertions, it keeps itself open, and either suffers or promotes the retrograde movements of the contents of the intestines below; as in ruminating animals the mouth of the first stomach seems to be so constructed, as to facilitate or assist the regurgitation of the food; the rings of the œsophagus afterwards contracting themselves in inverted order. De Haeu, by means of a syringe, forced so much water into the rectum intestinum of a dog, that he vomited it in a full stream from his mouth; and in the iliac passion above mentioned, excrements and clyster are often evacuated by the mouth. See Section XXV. 15.
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 Diarrhœas.
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 œsophagus 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 œsophagus 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 diarrhœa, 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 diarrhœa 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 diarrhœa 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 diarrhœa, 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 diarrhœa, 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 diarrhœa 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 œdematous, 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,