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A Course of Lectures IN GENERAL PATHOLOGY;
JUNE
A Course of Lectures IN
GENERAL
PATHOLOGY;
Delivered at St. Thomas’s Hospital, BY JOHN SIMON, ESQ., F.R.S., ONE OF THE SURGICAL STAFF OF THAT HOSPITAL.
LECTURE II. simply a chemical question; physiological according according to their of blood blood analysis, distinguishing elements of statioaa in its development-whether mature, progressive, or re-
Blood in disease;
not
analysis, similar gressive;
principle in classifying morbid phenomenaarising in morbid ingestion; com-
viz.: 1. Diseased conditions
mon poisons; limitations to their power of infecting the blood; morbid poisons foreign bodies, cancer-cells, pus.- 2. Diseased conditions arising in errors of excretion; (a) Retention of what ought to be excretedcarbonic acid, bile, urea. (b) Drain of what ought to be retained ;j’ effects of diabetes cholera hœmorrhage, serous discharges, and parasitic animal growths ; secondary results of inspissation and attenuation of the blood. GENTLEMEN,—I propose devoting the present lecture to a consideration of the blood in disease. It is neither my business nor my intention to say much about the healthy condition of that fluid. I may safely take for granted that in the Physiological Lectures you have acquired the information which will enable you with facility to follow such details as I have now to offer you on the chief morbid affections of the blood. On the diagram-board, you see a table* from which you can refresh your memory on the particulars of its composition in health; and I will very briefly recal to you the physiological points which it is most important you should recollect. In a person whose growth is stationary, the quantity of food passing into the body in a given time is exactly equivalent to the quantity of matter passing away in various excretions; the daily six pounds, more or less, of meat, bread, coffee, fish, wine, salad, condiments, water, &c., exactly correspond to the
what ought to be retained; effects of diabetes,cholera,hæmor-
*
Analysis of the Composition of Healthy Venous Blood.
No. 1398.
15, 1850.
A cerof fseces, urine, sweat, expired carbon, &c. tain small proportion of these matters passes quite unaltered through the intestinal canal; appearing at one terminus of the canal in exactly the same form as it entered at the other one; but nearly all the substances taken into the stomach undergo solution there, or in the duodenum, are absorbed into the circulation, and make their re-appearance eventually in some new combination, in which few or none of their original properties survive. Leaving out of account that small proportion which, as I have said, passes unchanged through the canals, (such as the woody matter of vegetables, indigestible bits of smoked meat, &c.,) putting these out of account, it may be said that the true excreta correspond exactly to what is absorbed from the food. Food, I need hardly tell you, is not taken for the sake of the excreta, or in order to furnish them;. it is taken to renew the body; and unless it be supplied to the system in considerable excess, none of it passes into an excretion till after having entered into the construction of the body-till after having been part of some one tissue or another. The blood, as it circulates, gives to each organ the means of repairing itself; first, by furnishing it with material of new growth; secondly, by washing away from it in a dissolved state, whatever elements of its tissue have become worn out and useless. Thus, e. g., with the brain; the carotid artery carries blood to that organ; the jugular vein carries it back; and therefore, theoretically speaking, there must be this difference between the contents of the two vessels-that the blood of the jugular vein will be destitute (comparatively) of the materials necessary for renovation of the brain, (the phosphorus, the fat, &c.,) and will contain, instead of them, the effete I, products, or waste of the brain formed in the progress of its function-chiefly, perhaps, consisting of carbonic acid, the phosphates, water, and other oxydized elements of its constitution ; and then, as a final result of this process, the blood which has traversed the brain, and undergone the change in: question, presently goes to other organs-organs of excretion, such as the lungs or kidney, where the phosphates and carbonic acid get eliminated from the system. If this were the whole history of the blood, its investigation in disease would be comparatively easy. But a chief difficulty in the study is this; that the blood undergoes changes of its own-undergoes what I can hardly call anything else than a process of growth. In addition to receiving new matter from the food, and old matter from the tissues,-in addition to feeding the several organs, and supplying the several excretions of the body, it does also itself undergo, as I have said, progressive changes of its own, analogous to the growth of the solid tissues. For the new materials which are derived to it from the food are not blood at the time of their addition, but are crude, immature products, which subsequently ripen within the stream of the circulation, under the influence of the maturer blood, and conformably to its composition. To some of you, perhaps, the view here suggested, of the blood undergoing development akin to growth, may be new and strange. There is an early prejudice, which makes us consider solidity of structure an indispensable preliminary for the residence and manifestation of life. Still, in spite of that prejudice, and in spite of the fluidity of the blood, you may securely believe that that red fluid is a living, growing mass; that the process of blood-formation is not the mere infusion of certain ready- made materials from without, but is as truly a process of growth as the development of cartilage or muscle. If the power of resisting change-if the power of converting things to its own type, and perpetuating its own constitutionbe signs of life in an element or portion of the body, I know none which possesses these qualities in a higher, if in so high, And further, in recalling its anatomy, a degree as the blood. you will be confirmed in this view. You will remember, that in all other elements of the body the abundance of celldevelopment which you meet with measures the activity and constancy of growth; and if you put a drop of blood under the microscope, and compare it with a patch of equal size of liver, or of brain, you are at once enabled to judge how immeasurably greater is the developmental activity in the blood; or if you look at a drop of fluid from the thoracic duct, you observe myriads of cell-germs there-germs which it is the chief, and perhaps the only, object of the lacteal and lymphatic systems to provide, and which attain their maturity, and fulfil their purpose, only when received into the blood. And not only does the blood live and grow; but, in the mature animal, its life and growth must precede all other life and growth in the body; for first it grows, next other organs grow at its expense.
quantity
.. A
710 What I have said will suggest to you how many liabilitiei by the poison, the symptoms were almost indefinitely post to disease are included in the circumstances to which thc poned; he found, however, that directly he loosened his liga blood is exposed; how easily morbid ingesta may become com. ture on the vein, the poison (having passed on into the circu mingled with it as causes of change; how easily matters ma3 lation) began to operate, and soon produced its characteristi be retained in it, which various distant organs ought to elimi- fatal results. He invented, too, an ingenious way of demon nate; how easily its own progressive development may be in’ strating this still more strikingly; he would amputate a dog’! terfered with, arrested, or deranged. leg, all but artery and vein, so that the vessels should be thf The enumeration, too, that I have given of its functions in only medium of connexion; or, more than this, he woulc health, will show you sufficiently what particular diflicultiee divide these vessels, and join their upper to their lower sec. of quill or of catheter, still letting the blood flovi belong to any investigation of its changes in disease : in the tions by bits the severed limb by means of these artificial first place, the extreme rapidity with which all it3 changes on through occur, the consequent transientness of the phenomena, and pipes; and, not the less, did the symptoms of poison arise the minute quantities in which several of the ingredients when there was no continuity of living tissue, no communica exist, oppose great obstacles to the research; but still greater tion whatever except the flowing contaminated blood. The same is true in respect of cases of slower operation :embarrassment is caused by the extreme complication of the fluid. By " complication," I do not mean merely that it con- in a peasant, who has been eating diseased rye-bread for some tains a large number of ingredients; but that those ingredients weeks, and who presently, in consequence, has dry-gangrene oi correspond to different dates of time, to different degrees of the extremities; or in a painter, who for months or years has development, to different organs of formation. Mentally, we been exposed to the poisonous contact of lead, and who has can see with perfect distinctness that in every porringer of got paralysis of the extensor muscles of his wrist, with perblood drawn by the phlebotomist there do in really co-exist haps other nervous injury beside; or in a gilder who has three forms of blood-viz., 1st, blood not yet ripe, but in been for a similarly long period inhaling the vapours of mer. course of development-perhaps I should rather call it matter cury, and is palsied in consequence; in any such case, I say, in a transition state from food to blood ; 2ndly, blood which you must not forget that the lesion of the blood is the first is already perfect, and which, at the moment of its abstrac- link in the chain of cause and effect, and that the local affection, was actually doing the work of the economy; 3rdly, tion, the excitement of brain, or the paralysis of muscles, or blood which had done its work and was worn out, or, to speak the obliteration of bloodvessels in the cases I have cited, or more exactly, the waste material of those various organs and indeed any other morbid affection of a tissue or organ under tissues which the blood had previously nourished. Mentally, similar circumstances, depends on that tissue or organ being I say, we can separate these three kinds of blood, but experi- nourished by a previously contaminated blood. If you take mentally we cannot. They are mixed together-past, present, into the stomach a little rhubarb or iodide of potass, and and future, (the blood of yesterday, the blood of to-day, and the find traces of the drug in a few minutes in the urine, you blood of to-morrow,) and we have no method of separating them. know that before arriving at the kidney this material must In all human probability, the fibrin and extractive matters have traversed the circulation; that it must have been absorbed represent the waste products of the active elements of the : from the intestinal canal, have been dissolved in the serum, body, and exist in the blood as effete material in the way to and literally have formed part of the blood during the time be eliminated; representing what just now, by a figure of that elapsed between its absorption and its discharge. You speech, I called the blood of yesterday. Of the fibrin, I shall see that this is pretty nearly the same thing as occurs in the have plenty to say presently, and shall then explain to you natural processes of organic conversion. The urea, which the why I consider it as an effete product in the blood. Of the kidney naturally secretes, has not been developed in that extractive matters I know too little for me to dare to say organ, but has been formed at a distance from it-has been much; hardly an endeavour has yet been made by any com- formed, in all probability, as a part of the series of chemical petent physiological chemist to refer them to the several changes which occur in the active tissues of the body during organs in which they probably originate. Dr. Franz Simon, the performance of their functions; then, in order to reach who has done with them more than any other chemist, divides the kidney, has formed part of the stream of circulating them according to their respective menstrua into water- blood, dissolved in its serum, and detectible there by chemical extract, alcohol-extract, proof spirit-extract ; but, as I need procedure. While on this subject, too, I may take the opportunity of hardly suggest to you, that is not the sort of division likely to be useful to us in our present subject; the only physiological mentioning,-though I shall again have occasion to recur to it, division would be one referring them severally to the organs - that the organs which display these secondary affections whose effete products they represent: showing such an one to under the influence of poisons in the blood will always have be brain-extract., another muscle-extract, &c. &c. appropriated a certain proportion of the poison into their It is desirable, gentlemen, as far as may be possible in substance, and will generally display it, under chemical treattreating of blood-diseases, to contemplate them in the manner ment, even more strikingly than the blood itself. Thus, for suggested in the physiological retrospect I have made, and to instance, in the post-mortem examination of a paralytic looktake them in some such order as the following:-First, diseases ing-glass silverer, you may have the certainty of discovering depending on morbid ingestion; secondly, diseases depending traces of mercury in the substance of the nervous centres, &c. on increase, arrest, or alteration of the excretions; thirdly, Now, to the affection of the blood by morbid ingesta, there diseases depending on modification of the blood’s own growth are limitations set by nature which it may be well to consider. 1. A variety of poisons which would prove instantaneously and development. I. Morbid Ingestion.-This is, in fact, known to you under fatal, if they could enter the blood, are precluded from the other name of poisoning. But when we have a patient entering it - at all events rapidly. The mineral acids, Suddenly dying or presenting symptoms under the effects of For instance, would at once coagulate the albumen and an active drug, we are sometimes apt to forget how important lestroy the fluidity of the blood; but this act is impossible in reality; for, their first chemical action being exerted on a part the blood plays in the production of phenomena. The symptoms of blood-disease are, in fact, generally quite lost in :he tissue with which they come into primary contact, those of some secondary local affection: where alcohol has ;hey begin by disorganising this, coagulating all the albumen been taken, the remarkable cerebral phenomena induce one n its capillaries, arresting its circulation, and thus opposing to say that " it has got into the patient’s head;"--and so it m effectual barrier to their own direct action on the blood of has; but its presence there has been preceded by its solution he general circulation. I think it little less than certain, in the blood; and if a, quantity of blood should be withdrawn hough I have not the means of demonstrating it to you, that he action of corrosive sublimate is very importantly limited at the time when alcoholic excitement is at its height, the process of distillation would conclusively attest the presence nd retarded by this process; and I may suggest it, as a very of the agent in question. You are, I dare say, aware of )roper subject for inquiry, whether the pneumonia which so Magendie’s celebrated experiments with poisons, particu- ften follows the action of corrosive poisons, may not, in some larly of those which he undertook to illustrate the trans- nstances, depend on a mechanical stasis, or interference with ference of poisons by the blood. There are certain strong he capillary circulation in the lungs, by means of coagulated poisons, such as the wourali, which very rapidly diffuse lbumen which has been conveyed in the blood from the seat f the primary lesion, and has become arrested in the next their action over the entire system if a small portion be inserted into a recent wound. A little wourali thus inserted nsuing minute vessels to which the circulation had hurried hem. into an incision in a dog’s foot would very rapidly prove There is another limit to the possibility of the blood’s being all ordinary circumstances; but Magendie found fatal, under that if he previously tied the femoral vein, so as to prevent oisoned, and this one acts almost or quite universally. I althe general system of the circulation being contaminated Jde to the extreme rapidity of excretion, and I may inform
711 forms an all-important provisionI whether the admission of pus into the stream of blood have of the blood, constitutes likewise arisen in one way or the other, the results are uniform: the pusmay conceive) a main source of difficulty in all clie- cells are larger than the Mood-corpuscles ; they consequently (as yeuendeavours to demonstrate the passage of drugs and become fixed in the smaller capillaries at which they next poisons through the circulation. I have already stated to) arrive, and give origin to what are called secondary abscesses. It will be obvious to you that these secondary formations of you (and you may easily illustrate it for yourselves), that the elimination of a matter by one organ or surface of the body is pus and cancer (tor both follow the same law) will be apt to sometimes quite as rapid as its absorption by another. Wet occur in the lungs, when the primary disease has been in connexion with some systemic vein; and that, on the contrary, are unable to decide what effect might be produced by the presence of a drachm of iodide of potassium in the blood, be- they will present themselves in the liver, when some vein of cause, as soon as a few grains are absorbed from the stomach,, the chylopoietic system has been the channel of infection. the kidney and various mucous membranes begin to secrete; When secondary deposits have occurred in the lung, there is fluids, which are impregnated into the drug, and which rapidlyliability to the formation of innumerable tertiary deposits in remove every trace of it from the circulation. Prussiate of: other parts of the body: and, in regard of pus, this liability is potash has been detected in the urine two minutes after its extreme. I cannot tell you with certainty whether these introduction into the stomach. I can give you a striking in- ulterior formations depend on the diseased lung furnishing stance of the completeness with which these transferences are materials de novo for the contamination of the system; or effected without disorganization of the blood. An ounce of whether, on the contrary, they arise from some of the original lactic acid was injected into the pleura of a dog, daily, for inflammatory products having (from their smaller size) escaped several days; twenty-four hours after the last injection, not detention in the capillaries of the lung, and having subseonly had the blood its normal reaction, but the serous effusion quently (perhaps meanwhile grown larger) got entangled in the capillaries of the systemic circulation. The latter supin the pleural cavity was likewise alkaline. I must not leave the subject of morbid ingestion without position is, on the whole, most accordant with the facts of the two other allusions. In the first place, let me remind you of case; but I may tell you that it has never happened to me to the ingestion of the so-called morbid poisons-the materials see these scattered abscesses in the course of the aortic circuof infection in the specific communicable diseases. As I shall lation, except where the lung itself has likewise been in a devote a lecture to the separate consideration of these in- stateof suppuration. There is, you see, a very striking difference between the fluences, I may content myself now with indicating to you the of contact between that subject and our present one,and effects observed when these living things, these germs of pus with telling you, that undoubtedly it is by absorption into the and cancer, get into the circulating blood, and the derangeblood, and by ulterior changes produced in that fluid, that the ments which arise (at first mechanical, and afterwards, to a virus of scarlatina, of hydrophobia, of typhus, of syphilis &c., ob- very limited extent, inflammatory) when inorganic foreign tain their power of infecting and injuring the whole economy. bodies have found their way into the stream. The essential Secondly, let me advert to the abnormal passage into the difference lies in the immense reproduction which follows the circulation of materials not having the fluid form-materials intra-vascular stasis of the former class of bodies. In the which act primarily as foreign bodies within the bloodvessels. present state of our knowledge, it is impossible to decide with I have already glanced at the possibility of coagulated alhu- confidence as to the manner in which this occurs; but there are good grounds for believing that the transplanted germs men being transferred from one part of the circulating system to another, and presently forming plugs, and giving rise to (like the founders of a colony) become, in their new site, the congestions of blood in the part to which it has been con- agents of this multiplication; and it seems at the least proveyed. Starch, sawdust, sand, mercury, injected for the sake bable that the process occurs at their expense; that it is an of experiment into the systemic veins of the lower animals, actual development out of them; and that (by endogenous presently get their particles impacted in the capillaries of generation, or by some analogous method of breeding) the the lung, and produce pneumonia there. This inflammation transplanted cells of pus or cancer stand in a parental relation is often not very intense, and is circumscribed to the imme- to the secondary deposits which they occasion. II. Having thus touched on the most important sources for diate vicinity of the foreign irritant or obstruent: after such an experiment, you will find a globule of mercury, or a few contamination of the blood by ingestion of abnormal products, granules of silica, forming the centre of a little circle of in- I now proceed to enumerate, under our second head, those flammatory condensation in the lung, or perhaps of a little diseased conditions of the blood which arise in errors of abscess, which, if left to itself, would presently have burst egestion or excretion. into any neighbouring bronchus, and would then have healed. 1. Foremost among such morbid conditions we may consider, Sometimes the foreign materials thus introduced into the as a class, the retention and accumulation in the blood of circulation are things having life, and susceptible of ulterior matters which ought to be excreted. a. Of all excretions, that of carbonic acid seems the most changes of their own; such as the growing germs of pus and essential to the continuance of life, and any sudden interrupcancer. In the practice of surgery, we very frequently have the opportunity of witnessing the effects of their presence in tion to its progress proves, as you know, immediately fatal. the blood, and the manner in which that presence is occa- In warm-blooded animals. where the waste of tissue is incomsioned. In the progress of cancerous tumours, veins get laid i parably more rapid than in the lower vertebrata, constant open, often in such a manner that a portion of the morbid renewal of oxygen is indispensable to the function of the growth blocks the ulcerated opening of the vein, suffers the nervous centres, and privation of this gas proves per se a rapid circulation for a while to pass on uninterruptedly, and from cause of death ; but in cold-blooded animals (where the need time to time sheds a batch of cells into the blood which washes for oxygen is less urgent) we are able to observe, experimenover its surface. Suppose this to be a systemic vein, and you tally, that asphyxia results not so much from the absence of will know that presently this blood, with cancer-germs sus- oxygen as from the accumulation of carbonic acid in the blood, pended in it, must reach the right side of the heart, and and that such animals live (comparatively speaking) a long thence be transmitted to the lungs: there-in capillaries which time, if placed in an atmosphere of nitrogen or hydrogen gas, are adapted only for the corpuscles of the blood, the larger which (though destitute of oxygen) enables them, according foreign cells are at once arrested, as on a filter, and become to the well-known laws for the diffusion of gases, to eliminate the nucleus of secondary cancerous growths. Similarly with their carbonic acid as fast as it is formed. Wehave many pus, suppuration may have occurred in some tissue which opportunities of recognising the influence of carbonic acid on (like the cancellated structure of bone) abounds with large animal life as that of a poison, positively; and we can trace veins, and some of these may have ulcerated and have given all degrees of this agency from that minor amount of inconentrance to the pus-cells; or, in another case, the vein may venience and injury sustained as we breathe an ill-ventilated itself have been the seat of suppurative inflammation, and atmosphere (that of an ordinary ball-room, for instance, or of have suffered the products of this process to make way through the theatre at the College of Surgeons), up to the dramatic the lining membrane into the blood; or (as very frequently French suicides effected by the vapours of burning charcoal, happens in surgical operations) large veins may have been or the rapid extinction of life in animals forced to respire the freely opened in immediate connexion with surfaces likely to exhalations of the soil in the celebrated Grotta del Cane, near undergo acute suppuration; or (as I have seen in two in- Naples. The state of blood brought about by any of these stances) a small abscess in the muscular substance of the means is one in which the distinction of venous and arterial heart may discharge itself into the auricle or ventricle; or is more or less completely lost : the blood tends to become finally (as I have lately had occasion to witness), there may uniformly venous in its qualities ; that is to say (whether be the passage of pus from diseased lymphatics into the taken from artery or vein), it has a dark colour, and an imthoracic duct, and thence into the subclavian vein; and then, paired coagulability.
you that this facultv, which for the
safety and integrity
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mical
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’
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,
point
712
Defective exhalation of carbonic acid attends a great variety from the retention of urea, whenever the kidneyshave become of diseases in the human subject;--all, namely, in which the incapable of discharging that product from the system. It is extent of respiratory surface is diminished by any organic dis- thus that patients die with acute suppression of urine, or with the chronic effects of Bright’s disease, poisoned by their own ease of lung, or by a straitened capacity of chest; or in which the access of fresh air is hindered by an obstruction of the urea. The blood, loaded with this material, acts on the brain larger air-tubes, or by a paralysis of the inspiratory muscles; as a narcotic, and terminates life by coma and convulsions. or in which the heart is unable to maintain an active circulaVery often (especially where its accumulation in the blood tion through the lungs, so as to expose all parts of the blood is gradual, as in slow cases of kidney degeneration) the urea with sufficient frequency to the influence of the atmosphere. will act as an irritant of various tissues, especially of the Chronic venosity of the blood (as it occurs in dependence serous membranes: the patients will be carried offby pleurisy on congenital malformations of the heart) is called cyanosis ; or peritonitis, or sometimes by pneumonia. Many fatal attacks and the blueness of surface from which this class of cases of inflammation, which at first might appear idiopathic, prove, derives its name, depends on the insufficient exhalation of car- on more careful inquiry, to be secondary effects of the state bonic acid. The heart (owing to its mechanical imperfections) under consideration. In all cases where a large inflammatory cannot circulate the blood rapidly enough, cannot expose it effusion has occurred under the influence of an urinous contaoften enough to the action of the air; thus the carbonic acid mination of the blood, you can demonstrate,by proper chemical accumulates, and maintains the blood in a venous condition; tests, the presence of urea in that effusion, and can thus while, at the same time, the malformed organ, by delaying connect the fatal disease with the true cause of death. The the systemic circulation and causing great congestion of the vomiting and diarrhoea, which so frequently occur in concarbonated blood in the general capillary system, renders the nexion with Bright’s disease, have the same pathological unhealthy tint of the blood more apparent to the eye than it origin: they consist in an irritation of the gastro-intestinal would be in any simple case of poisoning by carbonic acid. If mucous membrane, by the morbid blood, and their tendency the subjects of such diseases delay to die (as sometimes they is to work off the poison by that secreting surface: a point to do for years) they vegetate with a general torpor and feeble- which I shall hereafter have occasion to recur. 2. A second, and a very important class of errors relative ness of vitality, with an incapacity for muscular or even mental exertion, with an extreme susceptibility of fatigue, and with to egestion from the blood, is the opposite to that just spoken a defective resistance to cold, which sufficiently mark the of,-a class of diseases, namely, in which the blood is demorbid chemistry of their blood. ranged by the occurrence of certain new, artificial, or otherThere is one signal peculiarity which attends this chronic wise abnormal excretions. Now these morbid drains from the venous condition of the blood, and which I must not leave un- system modify the blood chiefly in respect of its proportion mentioned. Not only in extreme cases of cyanosis, but in all of solid to fluid ingredients : they affect its dilution, making chronic diseases where, from any cause whatever, there is de- it more or less watery than it should be ; and, in doing this, fective arterialisation of the blood, the patient enjoys one they alter its specific gravity. a. Inspissation of the blood, under such circumstances, is privilege. He is exempt (perhaps absolutely, but at least, all but absolutely exempt) from tubercular diseases. And as the rare. You might at first think it would cccur in diabetes, circumstances which interfere with due aeration of the blood where the flux of water is so great ; but when you remember the high specific gravity of the urine, and the vast quantity of are of the most various kinds (some of them acting merely mechanically), so we are justified in inferring, from the exemption solid matter running to waste in that excretion, you will be just specified, that the condition of system in which tubercle prepared to believe the contrary. And such is the case: the solids of the blood are relatively diminished in diabetes. is deposited is incompatible with venosity of the blood. b. You are familiar with another illustration of retained Nothing can illustrate the waste of the economy in that dis. excretion in the blood, as constituting the disease of jaundice: ease, and the extreme degree in which nourishment is derived the phenomena of which depend, first, on the saturation of the from its due course, more clearly than the fact, that despite liquor sanguinis by the colouring matter of the bile, subse- the immense elimination of water, the specific gravity of the quently on the deposition of this colouring matter in various ’ blood is below its standard. The only disease (so far I know) in which the excretions tissues, and its admixture with various secretions. In the urine, especially, you see a large quantity carried off. As gain on the fluidity of the blood, so as to inspissate it, is soon as the mechanical impediment to the flow of bile has cholera. Lecanu made several experiments upon the constibeen removed, and the secretion again takes its natural course tution of the blood in this disease, and found the water always into the duodenum, the urine rapidly recovers its natural hue, materially reduced, in one case even to less than half the total of the blood examined. The following are his numand so likewise (we may presume) does the serum of the blood. The skin is more permanently dyed, and recovers it- bers :— self slowly: probably the colouring material is deposited there in a solid and scantily-soluble form. Vogel has noticed, in the tissues of persons who have died with jaundice, the presence of coarse granular deposits of an intensely yellow-red and in a separate analysis of the serum in cholera, which colour. In such cases, too, you may expect to find the colour- O’Shaughnessy published, the solid ingredients are given as ing matter deposited in the nucleated cells of the glands more than 17 per cent. of the serum, instead of being 9 or 10 which have been excreting it: in those of the kidney, for per cent. This inspissation of the blood in cholera has, no doubt, example, I have often observed it. Of the real condition and changes of the blood in jaundice we know very little. We much to do with the production of symptoms: the dulness can in most instances account for the occurrence of the dis- and flaccidity of the cornea, the shrinking of the extremities, ease, either by finding evidence of a mechanical impediment the imperfect aeration of the blood, and especially the stagnato the passage of the secretion; or by having reason to believe tion of the blood-corpuscles in the Malpighian capillaries of the that the secretion has been formed in sudden temporary kidney, with the conseqnent suppression of urine, would all be excess, so as to flood the ducts and lobules of the liver: and in probable physical results of so important a change in the either of these cases we can understand the blood being fluidity and circulability of the blood. As regards the origin of tainted with bile. And we easily, with the eye, trace the that change in the blood, I need hardly tell you that the excreapparent diffusion of the retained product in all parts to which tions, which pour by pailfuls from the intestinal canal with a the blood has access; but this is only as regards the colouring, rapidity unparalleled in disease,furnishasufficient explanation. b. Attenuation of the blood marks all other diseases which matter, for in respect of the essential constituent (bilin) we have little certain information. Sometimes this ingredientare attended by exhaustive discharges, and is their almost has been discovered in the urine bv means of Pettenkofer’s’ immediate result. First among these may be counted haemorrhage. Ten of test, but by no means invariably; and yet it does not seem to’ accumulate in the blood. The subject derives great additionalL Cruveilhier’s patients were bled three times. The mean coninterest from the insignificance of the symptoms which oftenL dition of their blood, after each bleeding, was as follows :attend jaundice, and which we can scarcely suppose consistent with the suppression of so large an excretion. Whether the bilin may undergo decomposition in the blood, and may thus be brought within the excreting power of other organs, is a as yet quite undecided, and on which accurate knowledge point is very much required. c. The most important disease under our present head is that deadly contamination, which the blood is liable to derive
weight
713 And MM.
Becquerel and Rodier, who give these particulars, state that the effect of bleeding in impoverishing the blood increases with every venesection. This is likewise well illustrated in many of the tables which accompany the work of MM. Andral and Gavarret.*" In their striking array of facts you will observe that the attenuation of the blood occurs almost exclusively at the expense of the corpuscles, the other constituents of the blood undergoing little change, in their proportion either to each other or to the entire mass. This law prevails in respect of all haemorrhagic affections, and of some exhaustive diseases besides. The albumen, for instance, you will observe, remains stationary, or nearly so. The physiological explanation of this fact appears to be as follows: - After the abstraction of a considerable mass of blood, the volame of the circulation is restored by an increased absorption through the veins : the materials absorbed consist of those which had previously been exhaled from the capillaries into the interstices of the several organs, and into the areolar tissue of the body, a flilid so nearly identical with serum, (differing only in its concentration,) that this constituent of the blood is soon replaced; but as the corpuscles can only be regenerated by a slower process of growth, each bleeding appears to have been made especially at their expense. But still there are certain drains or excretions from the system which occur chiefly at the expense of the serum of the blood, and by which the albumen is consequently much re duced in its proportions. Protracted and extensive suppuration, or the discharge from large cancerous sores, or continued serous evacuations from the bowels, would act directly in diminishing the albuminous contents of the blood, as well as indirectly interfere with the regeneration of its corpuscles. In Bright’s disease, where so much serum passes off with the urine, the same effect is observed; in three cases, where Andral analyzed the blood, he found that the organic matters of the serum had fallen from their normal proportion (72 in 1000) to 61.5, 60.8, and 57.9 respectively. The development of hydatids in the liver (as it occurs in the rot of sheep) is attended by a similar result as regards the albumen; and Andral, who first drew attention to the fact, states that sheep are liable to two distinct forms of ansemia, contrasted with each other in this particular: in the one form (analogous to ,chlorosis of the human subject) the corpuscles alone are diminished; in the other (that which depends on the parasitic growth) the albumen, equally with the corpuscles, undergoes a marked diminution. The attenuated condition of the blood, arising under any of these circumstances, produces an important secondary * Proportion ofthe severaL Ingredients of the Blood in Cases of Rheumatic Fever, illustrating the Changes effected by Bleeding.
worthy of notice. You know that naturally limitary membrane of the capillaries is a transudable tissue; that it lets a certain quantity of the liquor sanguinis sweat through it; and no doubt there is a definite proportion observed by nature in the construction of the body (according to its various local necessities), between the fluidity of the blood and the thickness and transudability of that limitary membrane, in the several organs where it is distributed. Now, in excessive attenuation of the blood this proportion is destroyed; the fluid is too penetrating for the tissue, and in consequence the membrane becomes too easily transuded by its effect which is
the
contents. Such is the origin of those effusions into the areolar tissue (oedema) and into serous cavities, which are apt to occur when the serum of the blood is much de-albuminised. They do not arise in cases (of haemorrhage, for instance, or of chlo rosis) where merely the corpuscles of the blood are relatively diminished; but only when the liquor sanguinis has undergone some considerable reduction of density by the loss of its dis. solved albumen. Their origin is purely physical : the animal membrane, under the same amount of pressure, suffering the partial transudation of its fluid contents with greater facility in proportion to the limpidity and low specific gravity of £ those contents. Of the composition of the fluids exhaled under these circumstances I shall have other opportunities of
speaking.
_
NOTES FROM
A Course of Lectures Delivered BY GILBERT
at
St. Thomas’s
Hospital.
MACKMURDO, ESQ., F.R.S.,
SURGEON TO THAT HOSPITAL, AND TO THE ROYAL LONDON OPHTHALMIC HOSPITAL.
(Reported by his Son.)
LECTURE VI.
Conjunctivitis Scrofulosa, or Phlyctenular Ophtlialmia; Pustular Ophthalmia; Ophthalmia Morbillosa; Scarlatinosa Variolosa; Rheumatic Ophthalmia and Catarrho-rheumatic Ophthalmia. GENTLEMEN,-From the name assigned to the affection of the eye which comes next under our notice, you will at once perceive that it is an affection of that organ in persons of scrofulous constitutions. This term, scrofula, so objectionable to the world, has been described as signifying a peculiar set of diseases in a constitution, which, from its particular characters, is likely to suffer from such diseases under circumstances calculated to call them forth. The chief symptoms of this form of ophthalmia are, great intolerance of light, small elevations over the cornea, termed phlyctense, in the epithelia layer of the conjunctiva, which I have sometimes seen opposite the very centre, but more generally nearer its circumference, or at a little distance from it over the sclerotic; the under surface of the eyelids generally present patches of a reddish colour, but the membrane over the eyeball is not very red at first. The phlyctenæ are in some cases clear vesicles, and at other times they are white and opaque. Frequently we observe a number of small vessels, distended with blood, directing their course towards one of these elevations at th edge of the cornea, or on its surface. The lids are spasmodically closed by the orbicularis muscle to protect the eye from the light, which is most distressing in these cases. The
eyebrows are contracted, and the muscles of the face are called into excessive action, giving a very peculiar appearancQ to the patient. He will seek the darkest corner of the room, or bury his face under the bed-clothes, or when brought out for examination, he will cover his face with his hands, and resist violently your attempts to examine properly his eyes. Very generally excessive sneezing accompanies this affection; the tears will gush down the cheek violently when the lids are opened by the surgeon, the eyelids become swollen, and frequently excoriation of the cheek, and even a pustular eruption, as crusta lactea, will follow from the irritation of the tears, and from the child rubbing its eyelids and face on aocount of the itching produced by the flow of tears. The photophobia has generally been considered to result from a sympathetic affection of the retina, but not from absolute disease of the nerve. Very generally there is but little
A Course of Lectures IN
GENERAL
PATHOLOGY;
Delivered at St. Thomas’s Hospital, BY JOHN SIMON, ESQ., F.R.S., ONE OF THE SURGICAL STAFF OF THAT HOSPITAL.
LECTURE II. simply a chemical question; physiological according according to their of blood blood analysis, distinguishing elements of statioaa in its development-whether mature, progressive, or re-
Blood in disease;
not
analysis, similar gressive;
principle in classifying morbid phenomenaarising in morbid ingestion; com-
viz.: 1. Diseased conditions
mon poisons; limitations to their power of infecting the blood; morbid poisons foreign bodies, cancer-cells, pus.- 2. Diseased conditions arising in errors of excretion; (a) Retention of what ought to be excretedcarbonic acid, bile, urea. (b) Drain of what ought to be retained ;j’ effects of diabetes cholera hœmorrhage, serous discharges, and parasitic animal growths ; secondary results of inspissation and attenuation of the blood. GENTLEMEN,—I propose devoting the present lecture to a consideration of the blood in disease. It is neither my business nor my intention to say much about the healthy condition of that fluid. I may safely take for granted that in the Physiological Lectures you have acquired the information which will enable you with facility to follow such details as I have now to offer you on the chief morbid affections of the blood. On the diagram-board, you see a table* from which you can refresh your memory on the particulars of its composition in health; and I will very briefly recal to you the physiological points which it is most important you should recollect. In a person whose growth is stationary, the quantity of food passing into the body in a given time is exactly equivalent to the quantity of matter passing away in various excretions; the daily six pounds, more or less, of meat, bread, coffee, fish, wine, salad, condiments, water, &c., exactly correspond to the
what ought to be retained; effects of diabetes,cholera,hæmor-
*
Analysis of the Composition of Healthy Venous Blood.
No. 1398.
15, 1850.
A cerof fseces, urine, sweat, expired carbon, &c. tain small proportion of these matters passes quite unaltered through the intestinal canal; appearing at one terminus of the canal in exactly the same form as it entered at the other one; but nearly all the substances taken into the stomach undergo solution there, or in the duodenum, are absorbed into the circulation, and make their re-appearance eventually in some new combination, in which few or none of their original properties survive. Leaving out of account that small proportion which, as I have said, passes unchanged through the canals, (such as the woody matter of vegetables, indigestible bits of smoked meat, &c.,) putting these out of account, it may be said that the true excreta correspond exactly to what is absorbed from the food. Food, I need hardly tell you, is not taken for the sake of the excreta, or in order to furnish them;. it is taken to renew the body; and unless it be supplied to the system in considerable excess, none of it passes into an excretion till after having entered into the construction of the body-till after having been part of some one tissue or another. The blood, as it circulates, gives to each organ the means of repairing itself; first, by furnishing it with material of new growth; secondly, by washing away from it in a dissolved state, whatever elements of its tissue have become worn out and useless. Thus, e. g., with the brain; the carotid artery carries blood to that organ; the jugular vein carries it back; and therefore, theoretically speaking, there must be this difference between the contents of the two vessels-that the blood of the jugular vein will be destitute (comparatively) of the materials necessary for renovation of the brain, (the phosphorus, the fat, &c.,) and will contain, instead of them, the effete I, products, or waste of the brain formed in the progress of its function-chiefly, perhaps, consisting of carbonic acid, the phosphates, water, and other oxydized elements of its constitution ; and then, as a final result of this process, the blood which has traversed the brain, and undergone the change in: question, presently goes to other organs-organs of excretion, such as the lungs or kidney, where the phosphates and carbonic acid get eliminated from the system. If this were the whole history of the blood, its investigation in disease would be comparatively easy. But a chief difficulty in the study is this; that the blood undergoes changes of its own-undergoes what I can hardly call anything else than a process of growth. In addition to receiving new matter from the food, and old matter from the tissues,-in addition to feeding the several organs, and supplying the several excretions of the body, it does also itself undergo, as I have said, progressive changes of its own, analogous to the growth of the solid tissues. For the new materials which are derived to it from the food are not blood at the time of their addition, but are crude, immature products, which subsequently ripen within the stream of the circulation, under the influence of the maturer blood, and conformably to its composition. To some of you, perhaps, the view here suggested, of the blood undergoing development akin to growth, may be new and strange. There is an early prejudice, which makes us consider solidity of structure an indispensable preliminary for the residence and manifestation of life. Still, in spite of that prejudice, and in spite of the fluidity of the blood, you may securely believe that that red fluid is a living, growing mass; that the process of blood-formation is not the mere infusion of certain ready- made materials from without, but is as truly a process of growth as the development of cartilage or muscle. If the power of resisting change-if the power of converting things to its own type, and perpetuating its own constitutionbe signs of life in an element or portion of the body, I know none which possesses these qualities in a higher, if in so high, And further, in recalling its anatomy, a degree as the blood. you will be confirmed in this view. You will remember, that in all other elements of the body the abundance of celldevelopment which you meet with measures the activity and constancy of growth; and if you put a drop of blood under the microscope, and compare it with a patch of equal size of liver, or of brain, you are at once enabled to judge how immeasurably greater is the developmental activity in the blood; or if you look at a drop of fluid from the thoracic duct, you observe myriads of cell-germs there-germs which it is the chief, and perhaps the only, object of the lacteal and lymphatic systems to provide, and which attain their maturity, and fulfil their purpose, only when received into the blood. And not only does the blood live and grow; but, in the mature animal, its life and growth must precede all other life and growth in the body; for first it grows, next other organs grow at its expense.
quantity
.. A
710 What I have said will suggest to you how many liabilitiei by the poison, the symptoms were almost indefinitely post to disease are included in the circumstances to which thc poned; he found, however, that directly he loosened his liga blood is exposed; how easily morbid ingesta may become com. ture on the vein, the poison (having passed on into the circu mingled with it as causes of change; how easily matters ma3 lation) began to operate, and soon produced its characteristi be retained in it, which various distant organs ought to elimi- fatal results. He invented, too, an ingenious way of demon nate; how easily its own progressive development may be in’ strating this still more strikingly; he would amputate a dog’! terfered with, arrested, or deranged. leg, all but artery and vein, so that the vessels should be thf The enumeration, too, that I have given of its functions in only medium of connexion; or, more than this, he woulc health, will show you sufficiently what particular diflicultiee divide these vessels, and join their upper to their lower sec. of quill or of catheter, still letting the blood flovi belong to any investigation of its changes in disease : in the tions by bits the severed limb by means of these artificial first place, the extreme rapidity with which all it3 changes on through occur, the consequent transientness of the phenomena, and pipes; and, not the less, did the symptoms of poison arise the minute quantities in which several of the ingredients when there was no continuity of living tissue, no communica exist, oppose great obstacles to the research; but still greater tion whatever except the flowing contaminated blood. The same is true in respect of cases of slower operation :embarrassment is caused by the extreme complication of the fluid. By " complication," I do not mean merely that it con- in a peasant, who has been eating diseased rye-bread for some tains a large number of ingredients; but that those ingredients weeks, and who presently, in consequence, has dry-gangrene oi correspond to different dates of time, to different degrees of the extremities; or in a painter, who for months or years has development, to different organs of formation. Mentally, we been exposed to the poisonous contact of lead, and who has can see with perfect distinctness that in every porringer of got paralysis of the extensor muscles of his wrist, with perblood drawn by the phlebotomist there do in really co-exist haps other nervous injury beside; or in a gilder who has three forms of blood-viz., 1st, blood not yet ripe, but in been for a similarly long period inhaling the vapours of mer. course of development-perhaps I should rather call it matter cury, and is palsied in consequence; in any such case, I say, in a transition state from food to blood ; 2ndly, blood which you must not forget that the lesion of the blood is the first is already perfect, and which, at the moment of its abstrac- link in the chain of cause and effect, and that the local affection, was actually doing the work of the economy; 3rdly, tion, the excitement of brain, or the paralysis of muscles, or blood which had done its work and was worn out, or, to speak the obliteration of bloodvessels in the cases I have cited, or more exactly, the waste material of those various organs and indeed any other morbid affection of a tissue or organ under tissues which the blood had previously nourished. Mentally, similar circumstances, depends on that tissue or organ being I say, we can separate these three kinds of blood, but experi- nourished by a previously contaminated blood. If you take mentally we cannot. They are mixed together-past, present, into the stomach a little rhubarb or iodide of potass, and and future, (the blood of yesterday, the blood of to-day, and the find traces of the drug in a few minutes in the urine, you blood of to-morrow,) and we have no method of separating them. know that before arriving at the kidney this material must In all human probability, the fibrin and extractive matters have traversed the circulation; that it must have been absorbed represent the waste products of the active elements of the : from the intestinal canal, have been dissolved in the serum, body, and exist in the blood as effete material in the way to and literally have formed part of the blood during the time be eliminated; representing what just now, by a figure of that elapsed between its absorption and its discharge. You speech, I called the blood of yesterday. Of the fibrin, I shall see that this is pretty nearly the same thing as occurs in the have plenty to say presently, and shall then explain to you natural processes of organic conversion. The urea, which the why I consider it as an effete product in the blood. Of the kidney naturally secretes, has not been developed in that extractive matters I know too little for me to dare to say organ, but has been formed at a distance from it-has been much; hardly an endeavour has yet been made by any com- formed, in all probability, as a part of the series of chemical petent physiological chemist to refer them to the several changes which occur in the active tissues of the body during organs in which they probably originate. Dr. Franz Simon, the performance of their functions; then, in order to reach who has done with them more than any other chemist, divides the kidney, has formed part of the stream of circulating them according to their respective menstrua into water- blood, dissolved in its serum, and detectible there by chemical extract, alcohol-extract, proof spirit-extract ; but, as I need procedure. While on this subject, too, I may take the opportunity of hardly suggest to you, that is not the sort of division likely to be useful to us in our present subject; the only physiological mentioning,-though I shall again have occasion to recur to it, division would be one referring them severally to the organs - that the organs which display these secondary affections whose effete products they represent: showing such an one to under the influence of poisons in the blood will always have be brain-extract., another muscle-extract, &c. &c. appropriated a certain proportion of the poison into their It is desirable, gentlemen, as far as may be possible in substance, and will generally display it, under chemical treattreating of blood-diseases, to contemplate them in the manner ment, even more strikingly than the blood itself. Thus, for suggested in the physiological retrospect I have made, and to instance, in the post-mortem examination of a paralytic looktake them in some such order as the following:-First, diseases ing-glass silverer, you may have the certainty of discovering depending on morbid ingestion; secondly, diseases depending traces of mercury in the substance of the nervous centres, &c. on increase, arrest, or alteration of the excretions; thirdly, Now, to the affection of the blood by morbid ingesta, there diseases depending on modification of the blood’s own growth are limitations set by nature which it may be well to consider. 1. A variety of poisons which would prove instantaneously and development. I. Morbid Ingestion.-This is, in fact, known to you under fatal, if they could enter the blood, are precluded from the other name of poisoning. But when we have a patient entering it - at all events rapidly. The mineral acids, Suddenly dying or presenting symptoms under the effects of For instance, would at once coagulate the albumen and an active drug, we are sometimes apt to forget how important lestroy the fluidity of the blood; but this act is impossible in reality; for, their first chemical action being exerted on a part the blood plays in the production of phenomena. The symptoms of blood-disease are, in fact, generally quite lost in :he tissue with which they come into primary contact, those of some secondary local affection: where alcohol has ;hey begin by disorganising this, coagulating all the albumen been taken, the remarkable cerebral phenomena induce one n its capillaries, arresting its circulation, and thus opposing to say that " it has got into the patient’s head;"--and so it m effectual barrier to their own direct action on the blood of has; but its presence there has been preceded by its solution he general circulation. I think it little less than certain, in the blood; and if a, quantity of blood should be withdrawn hough I have not the means of demonstrating it to you, that he action of corrosive sublimate is very importantly limited at the time when alcoholic excitement is at its height, the process of distillation would conclusively attest the presence nd retarded by this process; and I may suggest it, as a very of the agent in question. You are, I dare say, aware of )roper subject for inquiry, whether the pneumonia which so Magendie’s celebrated experiments with poisons, particu- ften follows the action of corrosive poisons, may not, in some larly of those which he undertook to illustrate the trans- nstances, depend on a mechanical stasis, or interference with ference of poisons by the blood. There are certain strong he capillary circulation in the lungs, by means of coagulated poisons, such as the wourali, which very rapidly diffuse lbumen which has been conveyed in the blood from the seat f the primary lesion, and has become arrested in the next their action over the entire system if a small portion be inserted into a recent wound. A little wourali thus inserted nsuing minute vessels to which the circulation had hurried hem. into an incision in a dog’s foot would very rapidly prove There is another limit to the possibility of the blood’s being all ordinary circumstances; but Magendie found fatal, under that if he previously tied the femoral vein, so as to prevent oisoned, and this one acts almost or quite universally. I althe general system of the circulation being contaminated Jde to the extreme rapidity of excretion, and I may inform
711 forms an all-important provisionI whether the admission of pus into the stream of blood have of the blood, constitutes likewise arisen in one way or the other, the results are uniform: the pusmay conceive) a main source of difficulty in all clie- cells are larger than the Mood-corpuscles ; they consequently (as yeuendeavours to demonstrate the passage of drugs and become fixed in the smaller capillaries at which they next poisons through the circulation. I have already stated to) arrive, and give origin to what are called secondary abscesses. It will be obvious to you that these secondary formations of you (and you may easily illustrate it for yourselves), that the elimination of a matter by one organ or surface of the body is pus and cancer (tor both follow the same law) will be apt to sometimes quite as rapid as its absorption by another. Wet occur in the lungs, when the primary disease has been in connexion with some systemic vein; and that, on the contrary, are unable to decide what effect might be produced by the presence of a drachm of iodide of potassium in the blood, be- they will present themselves in the liver, when some vein of cause, as soon as a few grains are absorbed from the stomach,, the chylopoietic system has been the channel of infection. the kidney and various mucous membranes begin to secrete; When secondary deposits have occurred in the lung, there is fluids, which are impregnated into the drug, and which rapidlyliability to the formation of innumerable tertiary deposits in remove every trace of it from the circulation. Prussiate of: other parts of the body: and, in regard of pus, this liability is potash has been detected in the urine two minutes after its extreme. I cannot tell you with certainty whether these introduction into the stomach. I can give you a striking in- ulterior formations depend on the diseased lung furnishing stance of the completeness with which these transferences are materials de novo for the contamination of the system; or effected without disorganization of the blood. An ounce of whether, on the contrary, they arise from some of the original lactic acid was injected into the pleura of a dog, daily, for inflammatory products having (from their smaller size) escaped several days; twenty-four hours after the last injection, not detention in the capillaries of the lung, and having subseonly had the blood its normal reaction, but the serous effusion quently (perhaps meanwhile grown larger) got entangled in the capillaries of the systemic circulation. The latter supin the pleural cavity was likewise alkaline. I must not leave the subject of morbid ingestion without position is, on the whole, most accordant with the facts of the two other allusions. In the first place, let me remind you of case; but I may tell you that it has never happened to me to the ingestion of the so-called morbid poisons-the materials see these scattered abscesses in the course of the aortic circuof infection in the specific communicable diseases. As I shall lation, except where the lung itself has likewise been in a devote a lecture to the separate consideration of these in- stateof suppuration. There is, you see, a very striking difference between the fluences, I may content myself now with indicating to you the of contact between that subject and our present one,and effects observed when these living things, these germs of pus with telling you, that undoubtedly it is by absorption into the and cancer, get into the circulating blood, and the derangeblood, and by ulterior changes produced in that fluid, that the ments which arise (at first mechanical, and afterwards, to a virus of scarlatina, of hydrophobia, of typhus, of syphilis &c., ob- very limited extent, inflammatory) when inorganic foreign tain their power of infecting and injuring the whole economy. bodies have found their way into the stream. The essential Secondly, let me advert to the abnormal passage into the difference lies in the immense reproduction which follows the circulation of materials not having the fluid form-materials intra-vascular stasis of the former class of bodies. In the which act primarily as foreign bodies within the bloodvessels. present state of our knowledge, it is impossible to decide with I have already glanced at the possibility of coagulated alhu- confidence as to the manner in which this occurs; but there are good grounds for believing that the transplanted germs men being transferred from one part of the circulating system to another, and presently forming plugs, and giving rise to (like the founders of a colony) become, in their new site, the congestions of blood in the part to which it has been con- agents of this multiplication; and it seems at the least proveyed. Starch, sawdust, sand, mercury, injected for the sake bable that the process occurs at their expense; that it is an of experiment into the systemic veins of the lower animals, actual development out of them; and that (by endogenous presently get their particles impacted in the capillaries of generation, or by some analogous method of breeding) the the lung, and produce pneumonia there. This inflammation transplanted cells of pus or cancer stand in a parental relation is often not very intense, and is circumscribed to the imme- to the secondary deposits which they occasion. II. Having thus touched on the most important sources for diate vicinity of the foreign irritant or obstruent: after such an experiment, you will find a globule of mercury, or a few contamination of the blood by ingestion of abnormal products, granules of silica, forming the centre of a little circle of in- I now proceed to enumerate, under our second head, those flammatory condensation in the lung, or perhaps of a little diseased conditions of the blood which arise in errors of abscess, which, if left to itself, would presently have burst egestion or excretion. into any neighbouring bronchus, and would then have healed. 1. Foremost among such morbid conditions we may consider, Sometimes the foreign materials thus introduced into the as a class, the retention and accumulation in the blood of circulation are things having life, and susceptible of ulterior matters which ought to be excreted. a. Of all excretions, that of carbonic acid seems the most changes of their own; such as the growing germs of pus and essential to the continuance of life, and any sudden interrupcancer. In the practice of surgery, we very frequently have the opportunity of witnessing the effects of their presence in tion to its progress proves, as you know, immediately fatal. the blood, and the manner in which that presence is occa- In warm-blooded animals. where the waste of tissue is incomsioned. In the progress of cancerous tumours, veins get laid i parably more rapid than in the lower vertebrata, constant open, often in such a manner that a portion of the morbid renewal of oxygen is indispensable to the function of the growth blocks the ulcerated opening of the vein, suffers the nervous centres, and privation of this gas proves per se a rapid circulation for a while to pass on uninterruptedly, and from cause of death ; but in cold-blooded animals (where the need time to time sheds a batch of cells into the blood which washes for oxygen is less urgent) we are able to observe, experimenover its surface. Suppose this to be a systemic vein, and you tally, that asphyxia results not so much from the absence of will know that presently this blood, with cancer-germs sus- oxygen as from the accumulation of carbonic acid in the blood, pended in it, must reach the right side of the heart, and and that such animals live (comparatively speaking) a long thence be transmitted to the lungs: there-in capillaries which time, if placed in an atmosphere of nitrogen or hydrogen gas, are adapted only for the corpuscles of the blood, the larger which (though destitute of oxygen) enables them, according foreign cells are at once arrested, as on a filter, and become to the well-known laws for the diffusion of gases, to eliminate the nucleus of secondary cancerous growths. Similarly with their carbonic acid as fast as it is formed. Wehave many pus, suppuration may have occurred in some tissue which opportunities of recognising the influence of carbonic acid on (like the cancellated structure of bone) abounds with large animal life as that of a poison, positively; and we can trace veins, and some of these may have ulcerated and have given all degrees of this agency from that minor amount of inconentrance to the pus-cells; or, in another case, the vein may venience and injury sustained as we breathe an ill-ventilated itself have been the seat of suppurative inflammation, and atmosphere (that of an ordinary ball-room, for instance, or of have suffered the products of this process to make way through the theatre at the College of Surgeons), up to the dramatic the lining membrane into the blood; or (as very frequently French suicides effected by the vapours of burning charcoal, happens in surgical operations) large veins may have been or the rapid extinction of life in animals forced to respire the freely opened in immediate connexion with surfaces likely to exhalations of the soil in the celebrated Grotta del Cane, near undergo acute suppuration; or (as I have seen in two in- Naples. The state of blood brought about by any of these stances) a small abscess in the muscular substance of the means is one in which the distinction of venous and arterial heart may discharge itself into the auricle or ventricle; or is more or less completely lost : the blood tends to become finally (as I have lately had occasion to witness), there may uniformly venous in its qualities ; that is to say (whether be the passage of pus from diseased lymphatics into the taken from artery or vein), it has a dark colour, and an imthoracic duct, and thence into the subclavian vein; and then, paired coagulability.
you that this facultv, which for the
safety and integrity
-
mical
’
’
’
.
,
point
712
Defective exhalation of carbonic acid attends a great variety from the retention of urea, whenever the kidneyshave become of diseases in the human subject;--all, namely, in which the incapable of discharging that product from the system. It is extent of respiratory surface is diminished by any organic dis- thus that patients die with acute suppression of urine, or with the chronic effects of Bright’s disease, poisoned by their own ease of lung, or by a straitened capacity of chest; or in which the access of fresh air is hindered by an obstruction of the urea. The blood, loaded with this material, acts on the brain larger air-tubes, or by a paralysis of the inspiratory muscles; as a narcotic, and terminates life by coma and convulsions. or in which the heart is unable to maintain an active circulaVery often (especially where its accumulation in the blood tion through the lungs, so as to expose all parts of the blood is gradual, as in slow cases of kidney degeneration) the urea with sufficient frequency to the influence of the atmosphere. will act as an irritant of various tissues, especially of the Chronic venosity of the blood (as it occurs in dependence serous membranes: the patients will be carried offby pleurisy on congenital malformations of the heart) is called cyanosis ; or peritonitis, or sometimes by pneumonia. Many fatal attacks and the blueness of surface from which this class of cases of inflammation, which at first might appear idiopathic, prove, derives its name, depends on the insufficient exhalation of car- on more careful inquiry, to be secondary effects of the state bonic acid. The heart (owing to its mechanical imperfections) under consideration. In all cases where a large inflammatory cannot circulate the blood rapidly enough, cannot expose it effusion has occurred under the influence of an urinous contaoften enough to the action of the air; thus the carbonic acid mination of the blood, you can demonstrate,by proper chemical accumulates, and maintains the blood in a venous condition; tests, the presence of urea in that effusion, and can thus while, at the same time, the malformed organ, by delaying connect the fatal disease with the true cause of death. The the systemic circulation and causing great congestion of the vomiting and diarrhoea, which so frequently occur in concarbonated blood in the general capillary system, renders the nexion with Bright’s disease, have the same pathological unhealthy tint of the blood more apparent to the eye than it origin: they consist in an irritation of the gastro-intestinal would be in any simple case of poisoning by carbonic acid. If mucous membrane, by the morbid blood, and their tendency the subjects of such diseases delay to die (as sometimes they is to work off the poison by that secreting surface: a point to do for years) they vegetate with a general torpor and feeble- which I shall hereafter have occasion to recur. 2. A second, and a very important class of errors relative ness of vitality, with an incapacity for muscular or even mental exertion, with an extreme susceptibility of fatigue, and with to egestion from the blood, is the opposite to that just spoken a defective resistance to cold, which sufficiently mark the of,-a class of diseases, namely, in which the blood is demorbid chemistry of their blood. ranged by the occurrence of certain new, artificial, or otherThere is one signal peculiarity which attends this chronic wise abnormal excretions. Now these morbid drains from the venous condition of the blood, and which I must not leave un- system modify the blood chiefly in respect of its proportion mentioned. Not only in extreme cases of cyanosis, but in all of solid to fluid ingredients : they affect its dilution, making chronic diseases where, from any cause whatever, there is de- it more or less watery than it should be ; and, in doing this, fective arterialisation of the blood, the patient enjoys one they alter its specific gravity. a. Inspissation of the blood, under such circumstances, is privilege. He is exempt (perhaps absolutely, but at least, all but absolutely exempt) from tubercular diseases. And as the rare. You might at first think it would cccur in diabetes, circumstances which interfere with due aeration of the blood where the flux of water is so great ; but when you remember the high specific gravity of the urine, and the vast quantity of are of the most various kinds (some of them acting merely mechanically), so we are justified in inferring, from the exemption solid matter running to waste in that excretion, you will be just specified, that the condition of system in which tubercle prepared to believe the contrary. And such is the case: the solids of the blood are relatively diminished in diabetes. is deposited is incompatible with venosity of the blood. b. You are familiar with another illustration of retained Nothing can illustrate the waste of the economy in that dis. excretion in the blood, as constituting the disease of jaundice: ease, and the extreme degree in which nourishment is derived the phenomena of which depend, first, on the saturation of the from its due course, more clearly than the fact, that despite liquor sanguinis by the colouring matter of the bile, subse- the immense elimination of water, the specific gravity of the quently on the deposition of this colouring matter in various ’ blood is below its standard. The only disease (so far I know) in which the excretions tissues, and its admixture with various secretions. In the urine, especially, you see a large quantity carried off. As gain on the fluidity of the blood, so as to inspissate it, is soon as the mechanical impediment to the flow of bile has cholera. Lecanu made several experiments upon the constibeen removed, and the secretion again takes its natural course tution of the blood in this disease, and found the water always into the duodenum, the urine rapidly recovers its natural hue, materially reduced, in one case even to less than half the total of the blood examined. The following are his numand so likewise (we may presume) does the serum of the blood. The skin is more permanently dyed, and recovers it- bers :— self slowly: probably the colouring material is deposited there in a solid and scantily-soluble form. Vogel has noticed, in the tissues of persons who have died with jaundice, the presence of coarse granular deposits of an intensely yellow-red and in a separate analysis of the serum in cholera, which colour. In such cases, too, you may expect to find the colour- O’Shaughnessy published, the solid ingredients are given as ing matter deposited in the nucleated cells of the glands more than 17 per cent. of the serum, instead of being 9 or 10 which have been excreting it: in those of the kidney, for per cent. This inspissation of the blood in cholera has, no doubt, example, I have often observed it. Of the real condition and changes of the blood in jaundice we know very little. We much to do with the production of symptoms: the dulness can in most instances account for the occurrence of the dis- and flaccidity of the cornea, the shrinking of the extremities, ease, either by finding evidence of a mechanical impediment the imperfect aeration of the blood, and especially the stagnato the passage of the secretion; or by having reason to believe tion of the blood-corpuscles in the Malpighian capillaries of the that the secretion has been formed in sudden temporary kidney, with the conseqnent suppression of urine, would all be excess, so as to flood the ducts and lobules of the liver: and in probable physical results of so important a change in the either of these cases we can understand the blood being fluidity and circulability of the blood. As regards the origin of tainted with bile. And we easily, with the eye, trace the that change in the blood, I need hardly tell you that the excreapparent diffusion of the retained product in all parts to which tions, which pour by pailfuls from the intestinal canal with a the blood has access; but this is only as regards the colouring, rapidity unparalleled in disease,furnishasufficient explanation. b. Attenuation of the blood marks all other diseases which matter, for in respect of the essential constituent (bilin) we have little certain information. Sometimes this ingredientare attended by exhaustive discharges, and is their almost has been discovered in the urine bv means of Pettenkofer’s’ immediate result. First among these may be counted haemorrhage. Ten of test, but by no means invariably; and yet it does not seem to’ accumulate in the blood. The subject derives great additionalL Cruveilhier’s patients were bled three times. The mean coninterest from the insignificance of the symptoms which oftenL dition of their blood, after each bleeding, was as follows :attend jaundice, and which we can scarcely suppose consistent with the suppression of so large an excretion. Whether the bilin may undergo decomposition in the blood, and may thus be brought within the excreting power of other organs, is a as yet quite undecided, and on which accurate knowledge point is very much required. c. The most important disease under our present head is that deadly contamination, which the blood is liable to derive
weight
713 And MM.
Becquerel and Rodier, who give these particulars, state that the effect of bleeding in impoverishing the blood increases with every venesection. This is likewise well illustrated in many of the tables which accompany the work of MM. Andral and Gavarret.*" In their striking array of facts you will observe that the attenuation of the blood occurs almost exclusively at the expense of the corpuscles, the other constituents of the blood undergoing little change, in their proportion either to each other or to the entire mass. This law prevails in respect of all haemorrhagic affections, and of some exhaustive diseases besides. The albumen, for instance, you will observe, remains stationary, or nearly so. The physiological explanation of this fact appears to be as follows: - After the abstraction of a considerable mass of blood, the volame of the circulation is restored by an increased absorption through the veins : the materials absorbed consist of those which had previously been exhaled from the capillaries into the interstices of the several organs, and into the areolar tissue of the body, a flilid so nearly identical with serum, (differing only in its concentration,) that this constituent of the blood is soon replaced; but as the corpuscles can only be regenerated by a slower process of growth, each bleeding appears to have been made especially at their expense. But still there are certain drains or excretions from the system which occur chiefly at the expense of the serum of the blood, and by which the albumen is consequently much re duced in its proportions. Protracted and extensive suppuration, or the discharge from large cancerous sores, or continued serous evacuations from the bowels, would act directly in diminishing the albuminous contents of the blood, as well as indirectly interfere with the regeneration of its corpuscles. In Bright’s disease, where so much serum passes off with the urine, the same effect is observed; in three cases, where Andral analyzed the blood, he found that the organic matters of the serum had fallen from their normal proportion (72 in 1000) to 61.5, 60.8, and 57.9 respectively. The development of hydatids in the liver (as it occurs in the rot of sheep) is attended by a similar result as regards the albumen; and Andral, who first drew attention to the fact, states that sheep are liable to two distinct forms of ansemia, contrasted with each other in this particular: in the one form (analogous to ,chlorosis of the human subject) the corpuscles alone are diminished; in the other (that which depends on the parasitic growth) the albumen, equally with the corpuscles, undergoes a marked diminution. The attenuated condition of the blood, arising under any of these circumstances, produces an important secondary * Proportion ofthe severaL Ingredients of the Blood in Cases of Rheumatic Fever, illustrating the Changes effected by Bleeding.
worthy of notice. You know that naturally limitary membrane of the capillaries is a transudable tissue; that it lets a certain quantity of the liquor sanguinis sweat through it; and no doubt there is a definite proportion observed by nature in the construction of the body (according to its various local necessities), between the fluidity of the blood and the thickness and transudability of that limitary membrane, in the several organs where it is distributed. Now, in excessive attenuation of the blood this proportion is destroyed; the fluid is too penetrating for the tissue, and in consequence the membrane becomes too easily transuded by its effect which is
the
contents. Such is the origin of those effusions into the areolar tissue (oedema) and into serous cavities, which are apt to occur when the serum of the blood is much de-albuminised. They do not arise in cases (of haemorrhage, for instance, or of chlo rosis) where merely the corpuscles of the blood are relatively diminished; but only when the liquor sanguinis has undergone some considerable reduction of density by the loss of its dis. solved albumen. Their origin is purely physical : the animal membrane, under the same amount of pressure, suffering the partial transudation of its fluid contents with greater facility in proportion to the limpidity and low specific gravity of £ those contents. Of the composition of the fluids exhaled under these circumstances I shall have other opportunities of
speaking.
_
NOTES FROM
A Course of Lectures Delivered BY GILBERT
at
St. Thomas’s
Hospital.
MACKMURDO, ESQ., F.R.S.,
SURGEON TO THAT HOSPITAL, AND TO THE ROYAL LONDON OPHTHALMIC HOSPITAL.
(Reported by his Son.)
LECTURE VI.
Conjunctivitis Scrofulosa, or Phlyctenular Ophtlialmia; Pustular Ophthalmia; Ophthalmia Morbillosa; Scarlatinosa Variolosa; Rheumatic Ophthalmia and Catarrho-rheumatic Ophthalmia. GENTLEMEN,-From the name assigned to the affection of the eye which comes next under our notice, you will at once perceive that it is an affection of that organ in persons of scrofulous constitutions. This term, scrofula, so objectionable to the world, has been described as signifying a peculiar set of diseases in a constitution, which, from its particular characters, is likely to suffer from such diseases under circumstances calculated to call them forth. The chief symptoms of this form of ophthalmia are, great intolerance of light, small elevations over the cornea, termed phlyctense, in the epithelia layer of the conjunctiva, which I have sometimes seen opposite the very centre, but more generally nearer its circumference, or at a little distance from it over the sclerotic; the under surface of the eyelids generally present patches of a reddish colour, but the membrane over the eyeball is not very red at first. The phlyctenæ are in some cases clear vesicles, and at other times they are white and opaque. Frequently we observe a number of small vessels, distended with blood, directing their course towards one of these elevations at th edge of the cornea, or on its surface. The lids are spasmodically closed by the orbicularis muscle to protect the eye from the light, which is most distressing in these cases. The
eyebrows are contracted, and the muscles of the face are called into excessive action, giving a very peculiar appearancQ to the patient. He will seek the darkest corner of the room, or bury his face under the bed-clothes, or when brought out for examination, he will cover his face with his hands, and resist violently your attempts to examine properly his eyes. Very generally excessive sneezing accompanies this affection; the tears will gush down the cheek violently when the lids are opened by the surgeon, the eyelids become swollen, and frequently excoriation of the cheek, and even a pustular eruption, as crusta lactea, will follow from the irritation of the tears, and from the child rubbing its eyelids and face on aocount of the itching produced by the flow of tears. The photophobia has generally been considered to result from a sympathetic affection of the retina, but not from absolute disease of the nerve. Very generally there is but little