1666.] It has been supposed, that the absorption performed by the extremities of lympathics may be interrupted by an obstruction of these vessels, or at least of the conglobate glands through which these vessels pass. This, however, is very doubtful. As the lymphatics have branches frequently communicating with one another, it is not probable that the obstruction of any one, or even several of these, can have any considerable effect in interrupting the absorption of their extremities.

And for the same reason it is as little probable that the obstruction of conglobate glands can have such an effect: at least it is only an obstruction of the glands of the mesentery, through which so considerable a portion of the lymph passes, that can possibly have the effect of interrupting absorption. But even this we should not readily suppose, there being reason to believe that these glands, even in a considerably tumefied state, are not entirely obstructed: and accordingly I have known several instances of the most part of the mesenteric glands being considerably tumefied, without either interrupting the transmission of fluids to the blood-vessels, or occasioning any dropsy.

An hydropic swelling, indeed, seems often to affect the arm from a tumor of the axillary gland: but it seems to me doubtful, whether the tumor of the arm may not be owing to some compression of the axillary vein, rather than to an obstruction of the lymphatics.

1667.] A particular interruption of absorption may be supposed to take place in the brain. As no lymphatic vessels have yet very certainly been discovered in that organ, it may be thought that the absorption, which certainly takes place there, is performed by the extremities of veins, or by vessels that carry the fluid directly into the veins; so that any impediment to the free motion of the blood in the veins of the brain, may interrupt the absorption there, and occasion that accumulation of serous fluid which so frequently occurs from a congestion of blood in these veins. But I give all this as a matter of conjecture only.

1668.] Having thus explained the general causes of dropsy, I should proceed, in the next place, to mention the several parts of the body in which serous collections take place, and so to mark the different species of dropsy: but I do not think it necessary for me to enter into any minute detail upon this subject. In many cases, these collections, are not to be ascertained by any external symp

toms and therefore cannot be the objects of practice; and many of them, though in some measure discernible, do not seem to be curable by our art. I the more especially avoid mentioning very particularly the several species, because that has already been sufficiently done by Dr. D. Monro, and other writers in every body's hands. I must confine myself here to the consideration of those species which are the most frequently occurring and the most common objects of our practice; which are, the Anasarca, Hydrothorax, and Ascites and each of these I shall treat of in so many separate sections.

SECTION I.

Of Anasarca.

1669.] THE Anasarca is a swelling upon the surface of the body, at first commonly appearing in particular parts only, but at length frequently appearing over the whole. So far as it extends, it is an uniform swelling over the whole member, at first always soft, and readily receiving the pressure of the finger, which forms a hollow that remains for some little time after the pressure is removed, but at length rises again to its former fulness. This swelling generally appears, first, upon the lower extremities: and there too only in the evening, disappearing again in the morning. It is usually more considerable as the person has been more in an erect posture during the day; but there are many instances of the exercise of walking preventing altogether its otherwise usual coming on. Although this swelling appears at first only upon the feet and about the ankles; yet if the causes producing it continue to act, it gradually extends upwards, occupying the legs, thighs, and trunk of the body, and sometimes even the head. Commonly the swelling of the lower extremities diminishes during the night; and in the morning, the swelling of the face is most considerable, which again generally disappears almost entirely in the course of the day.

1670.] The terms of Anasarca and Leucophlegmatia have been commonly considered as synonymous: but some authors have proposed to consider them as denoting dis tinct diseases. The authors who are of this last opinion employ the name of Anasarca for that disease which begins

in the lower extremities, and is from thence gradually extended upwards in the manner I have just now described; while the term Leucophlematia, that in which the same kind of swelling appears even at first very generally over the whole body. They seem to think also, that the two diseases proceed from different causes; and that, while the anasarca may arise from the several causes in 16491660, the leucophlegmatia proceeds especially from a deficiency of red blood, as we have mentioned in 1661, et seq. I cannot, however, find any proper foundation for this distinction. For although in dropsies proceeding from the causes mentioned in 1661, et seq. the disease арpears in some cases more immediately affecting the whole body; yet that does not establish a difference from the common case of anasarca: for the disease, in all its circumstances, comes at length to be entirely the same; and in cases ocasioned by a deficiency of red blood, I have frequently observed it to come on exactly in the manner of an anasarca, as above described.

1671.] An anasarca is evidently a preternatural collection of serous fluid in the cellular texture immediately under the skin. Sometimes pervading the skin itself, it oozes out through the pores of the cuticle; and sometimes, too gross to pass by these, it raises the cuticle in blisters. Sometimes the skin, not allowing the water to pervade it, is compressed and hardened, and at the same time so much distended, as to give anasarcous tumors an unusual firmness. It is in these last circumstances also that an erythematic inflammation is ready to come upon anasarcous swellings.

1672.] An anasarca may immediately arise from any of the several causes of dropsy which act more generally upon the system and even when other species of dropsy, from particular circumstances, appear first; yet whenever these proceed from any causes more generally affecting the system, an anasarca sooner or later comes always to be joined with them.

1673.]. The manner in which this disease commonly first appears, will be readily explained by what I have said in 1651, respecting the effects of the posture of the body. Its gradual progress, and its affecting, after some time, not only the cellular texture under the skin, but probably also much of the same texture in the internal parts, will be understood partly from the communication that is readily made between the several parts of the cellular texture; but especially from

the same general causes of the disease producing their effects in every part of the body. It appears to me, that the water of anasarcous swellings is more readily communicated to the cavity of the thorax, and to the lungs, than to the cavity of the abdomen, or to the viscera contained in it.

1674.] An anasarca is almost always attended with a scarcity of urine; and the urine voided, is, from its scarcity, always of a high color; and from the same cause, after cooling, readily lets fall a copious reddish sediment. This scarcity of urine may sometimes be owing to an obstruction of the kidneys; but probably is generally occasioned by the watery parts of the blood running off into the cellular texture, and being thereby prevented from passing in the usual quantity to the kidneys.

The disease is also generally attended with an unusual degree of thirst; a circumstance I would attribute to a like abstraction of fluid from the tongue and fauces, which are extremely sensible to every diminution of the fluid in these parts.

1675.] The cure of anasarca is to be attempted upon three general indications.

1. The removing the remote causes of the disease.

2. The evacuation of the serous fluid already collected in the cellular texture.

3. The restoring the tone of the system, the loss of which may be considered in many cases as the proximate cause of the disease.

1676.] The remote causes are very often such as had not only been applied, but had also been removed* long before the disease came on. Although, therefore, their ef fects remain, the causes themselves cannot be the objects of practice; but if the causes still continue to be applied, such as intemperance, indolence, and some others, they must be removed. For the most part, the remote causes are certain diseases previous to the dropsy, which are to be cured by the remedies particularly adapted to them, and cannot be treated of here. The curing of these, indeed, may be often difficult; but it was proper to lay down the present indication, in order to show, that when these remote causes cannot be removed, the cure of the dropsy must be difficult, or perhaps impossible. In may cases, therefore, the following indications will be to little pur

These are large evacuations of different kinds, but especially hæmorrhagies, which have ceased before the dropsy came on.

pose; and particularly, that often the execution of the second, will not only give the patient a great deal of fruitless trouble, but commonly also hurry on his fate.

1677.] The second indication for evacuating the collected serum, may be sometimes executed with advantage, and often, at least, with temporary relief. It may be performed in two ways. First, by drawing off the water directly from the dropsical part, by openings made into it for that purpose: or, secondly, by exciting certain serous excretions; in consequence of which, an absorption may be excited in the dropsical parts, and thereby the serum absorbed and carried into the blood-vessels may afterwards be directed to run out, or may spontaneously pass out, by one or other of the common excretions.

1678.] In an anasarca, the openings into the dropsical part are commonly to be made in some part of the lower extremities; and will be most properly made by many small punctures reaching the cellular texture. Formerly, considerable incisions were employed for this purpose: but as any wound made in dropsical parts, which, in order to their healing, must necessarily inflame and suppurate, are liable* to become gangrenous; so it is found to be much safer to make the openings by small punctures only, which may heal up by the first intention. At the same time, even with respect to these punctures, it is proper to observe, that they should be made at some distance from one another, and that care should be taken to avoid making them in the most depending parts.

1679.] The water of anasarcous limbs may be sometimes drawn off by pea-issues, made by caustic a little below the knees: for as the great swelling of the lower extremities is chiefly occasioned by the serous fluid exhaled into the upper parts constantly falling down to the lower; so the issues now mentioned, by evacuating the water from the upper parts, may very much relieve the whole of the disease. Unless, however, the issues be put in before the disease is far advanced, and before the parts have very much lost their tone, the places of the issues are ready to become affected with gangrene.

Some practical writers have advised the employment of setons, for the same purpose that I have proposed issues;

Peculiarly liable in this disease on account of the diminished tone, and consequently the diminished strength of the parts.

1