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ESSAYS ON GENERAL PATHOLOGY.
730 ESSAYS ON GENERAL PATHOLOGY. By J. BOWER HARRISON, Esq., M.R.C.S.L., &c., late Surgeon to the Ardwick and Ancoats Dispensary, and formerly one of the Resident Medical Officers of the Manchester Royal Infirmary. No. VI. OF MORBID CONDITIONS OF THE VASCULAR SYSTEM.
speak of the more active or progressive states of derangement, those which seem to have a disposition to extend ’, themselves, and some of which appear to have a definite course. Amongst these, the disorders of the vascular system are of the utmost importance; in fact, there are few trains of disorder in I
SHALL now
which the vascular system is not intimately concerned. It would be amazing indeed, if, among the immense number of capillary vessels which are intricately arranged in structures which are themselves the subjects of complicated operations, the circulation was not
occasionally impeded or deranged.
What is called the balance of the circulation may be destroyed, that is to say, the blood may be unequally distributed throughout the system. This leads to what is called congestion, or the undue accumulation of blood in particular parts of the body. Of course, congestion may be either local or general, according to the nature of its cause. In the latter case, the whole system suffers, and the epithet congestive has been applied to those fevers in which this particular condition is an important feature. It might be thought that the term congestive would in every instance be inappropriately used in conjunction with that of fever ; but if we only consider the enlarged sense in which the word fever is now employed, and that it has long since ceased to be restricted to its primitive signification,* it seems needless to object to it. The word asphyxia, and many others in common use, has acquired, in like manner, a conventional meaning, which is very different from their etymological signification. General congestion is known by a great embarrassment of the circulation ; we have a small, weak, and sometimes irregular pulse, a laborious state of the breathing, an oppressed state of the brain, a loss of muscular power, and comp,ete prostration of the strength. To these may be added a coldness of the suriace, and a blue appearance of the bloodvessels, especially in those parts which are ordinarily of a vivid red. These effects arise from a diminution of the heart’s action, which is occasioned by causes operating on the nervous centres, for it does not appear that the mere accumulation of blood in the large vessels would itself be sufficient to Other symptoms besides those account for all the phenomena. which we have enumerated, are, of course, produced by the disturbance of the functions of var:ous organs, as the brain, the mucous surface of the bronchiae, and the liver. The various occasions of congestion probably operate mainly, as we have stated, by their peculiar action on the nervous system causing a kind of partial syncope, so that the blood is no longer propelled with its usual force and freedom. This condition forms an element of many of those specific fevers which are of a malignant and fatal character, as the plague and yellow fever; the epidemic cholera of our own country is also distinguished by this general congestion. In other instances, it is a more transient, but still important condition, yet it scarcely merits the same at ention in the train of morbid changes. The collapse which follows the more serious accidents. and which sometimes arises from the presence of indifood in the stomach, may be instanced as a state of temporary congestion. Long and imprudent exposure to cold, especially to cold bathing, partly by its effect on the skin, but more particularly on the nervous system, is likewise an occasion of a general depression of the circulation, and a consequent withdrawal of blood from the surface. General congestion is, of course, best removed by the re-establishment of the cutaneous circulation, and this is well promoted (as was remarked by Dr. Armstrong) by the use of that simple contrivance, the hot air-hatli. The use of diffusible stimulants tc restore the nervous agency is, in many instances, a valuable auxiliary, if not carried beyond its legitimate extent. When congestion is of a less general character, it is commonly ascribahle to mechanical causes, which directly impede the transmission of the blood. Disease affecting the valves of the heart. especially the aortic and mitral valves, prevents the healthy returr of the blood from the lungs, which, in consequence, become inordinately loaded. Obstruction in the large vessels produces very serious effects on the system, and is commonly ultimately fatal Sometimes many small vessels are impeded by structural change; in the surrounding tissues, and when this takes place in sucha situation as the liver, where the ramifications of the vena port: are considerable, it is of the most serious consequence. Conges
gestible
*
Ferveo-to be hot.
local nature arise from lesions which onlymembers or bloodvessels. In this case the blood stagnates, and assumes a more decidedly venous character the temperature falls, and the function of the part is greatly disturbed. In some instances local congestion arises from a deficiency of power in the arterial capillaries, so that they become dilated and unable to sustain the column of the blood. There can be no doubt that the capillaries have an influence on the circulation distinct from that of the heart, and that a stagnation may proceed from a want of capillary tonicity. Andral exemplifies this state by allusion to the violet colour often seen on the anterior surface of the legs of old people; and he mentions also the sanguineous congestions of the pulmonary tissue, which attend the last stages of fatal diseases. There has been too much readiness to attribute all such changes to inflammation ; but if that word be allowed to have anv signification, it cannot surely be considered to represent states which are so diametrically opposite. We may now proceed to speak of another condition of the vascular system, in which we have not simply an inordinate collection of blood, but a particular series of phenomena of a more complicated nature. This is inflammation. The subject of inflammation has at all times excited very considerable attention, and there is, perhaps, no morbid condition which is so important, and so frequently found to form an element of disease. It is true that the disciples of the great Hunter may have given too exclusive an attention to this condition, but it must yet be granted that there are few trains of disorder in which inflammation does not form a part ; and, modified by other derangements, or existing in an insidious and chronic form, it mixes itself with disease in every possible variety. The attention which the celebrated Hunter paid to this subject may be viewed at once as a proof of the greatness of his mind and the importance of the investigation. The valuable researches of continental writers on the subject of general anatomy have shown the manner in which this action is modified by the structure in which it occurs, and this mode of examination has thrown a new light on the inquiry, and been, as it were, a key to the arcana of pathology. It is proper to say that one of our own countrymen, Mr. Carmichael Smith, has the merit of having been one of the first to direct the profession to this line of inquiry. It would be impossible, in the space we can devote to the purpose, to do anything like justice to the subject of inflammation ; and it must be remembered that our principal object is to show the reciprocal bearing of different conditions, and the manner in which complicated derangements are formed, and not to bring together all that can be collected respecting each individual condition. On this account, we must refer, for more detailed information, to the more elaborate treatises, and more especially to the recent and able work of Dr. Alison, on the practice of medicine. The presence of inflammation is inferred from the combination of the following symptoms, though they are not always found in conjunction, even where it must be allowed to exist—namely. redness, heat, pain, and swelling, and a disturbance of the function of the affected organ. Internal inflammation is inferred, in the language of Cullen, from the union of " fever with fixed pain in We stated that all these symptoms were some internal organ." not necessarily present, nor does the existence of any one, singly, lead us to suspect inflammation. Redness, it is well known, may be occasioned by various other causes, and pain may exist without the bloodvessels being materially disturbed. Again, inflammation may exist with little or no appreciable redness ; and even pain may be absent altogether, as in the examples of suppurative inflammation, which supervene on paralytic affections and iujuries of the nerves. Thus it must be a certain combination of symptoms which leads us to infer the presence of inflammation, and, probably, the most certain evidence is to be derived fr<:m its effects, which are presently to be considered. Inflammation gives rise to various changes, which have been called the terminations of inflammation, because they certainly conduce to relieve the action ; but as they rather attend its progress than necessarily occur on its cessation, the words resolution and moi tiJication are alone properly applicable in this sense. One of the most common accompaniments of inflammation is the effusion of serum, which is especially liable to be produced in those tissues which naturally secrete a watery discharge. The crepitant rattle which indicates the early stage of pneumonia is to be ascribed to the effusion of’ serum in the air-cells of the lungs. ’1 he escape of the adhesive matter called fibrine, mostly succeeds or attends this serous exhalation. Thus (to take the example already adduced) in a more advanced stage of pneumonia, fibrine is secreted in combination with the serum, and the latter being afterwards absorbed, the coagulable lymph not unfrequently remains as the nidus of structural alteration. The formation of what is called pus is another pro-’ tions of
a
concern
particular
still
more
731 duct of the inflammatory action. Pus is probably produced by a less highly vitalized process than that of fibrine, since it is not found to take place so near the vivifying influence of the surface of the wound, and is favoured by many circumstances which would seem destructive of vitality. Dr. Alison observes, that one use of suppuration may be, to rid the system of blood which has received an irremediable injury from the inflammatory action. Pus seems at least to be formed by a transformation of the globules of the blood, which have stagnated either in the interior of bloodvessels, or in the exudations which are surrounded by inflammamatory action. Of the latter we have an instance in the case of pneumonia to which we have already adverted : the fibrine effused in the air-cells of the lungs may be further changed into a thick, bland fluid, constituting what is called the purulent infiltration. This alteration appears, in a great measure, ascribable to the influence of the air. It has been remarked, that those cases of pleurisy which follow the admission of air into the chest, more surely lead to purulent effusion than the other instances where the inflammatory action is differently produced. When pus is once formed, it appears (as it has been well observed) to act like a leaven in the production of more purulent fluid. Its effect in softening the structures in which it is effused is also deserving of notice, and this is well observed in the purulent infiltration of the lungs. Mortification may arise independently of inflammation, and perhaps mainly depends on the cessation of the circulation, and those reciprocal changes which occur between the vessels and their contents. Inflammation may produce mortification, as well by injuring the vitality of the blood, as by impeding its circulation. Motion is in some degree essential to the life of the blood, and stagnation is followed by the death of the affected part. The reciprocal action which is constantly maintained between the circulating fluid and the molecules of the body, is interfered with by whatever impedes or arrests the transmission of the blood. In this manner, a change of consistence and softening of structure are likewise occasioned. The process of ulceration, and its connexion with inflammation, is not yet properly understood. It has of late been questioned by many respectable authorities, amongst which I may include my friend Mr. Gaskell, whether it be, in reality, produced by absorption. The discussion would be here manifestly out of place; it may be remarked, however, that there is at least gooll reason to suppose that ulceration is in part attributable to the mechanical removal of matter in combination with the external discharge, and this is particularly the case where the ulcer is of a sloughing character. Though so much has been written on the subject of inflammation, obscurity still prevails as to its intimate nature, and we are obliged to express ourselves on the subject by having recourse to the epithet, " vital." It seems, from microscopical that inflammation is attended, in the first instance, by an increased tonicity of the capillary vessels, with an augmented speed in the circulation of the blood, but that this is succeeded by an actual retardation, at least in the parts which are the immediate seat of the process. The inflammatory action seems brought about by an influence which is best compared to one of attraction acting at the extremities of the vessels, and drawing the blood towards the seat of disorder. In what way this arises is a subject of difficulty, but that it is occasioned by some changes in the affinities of the blood, seems to be the most probable conjecture. That the blood is altered in inflammation is well known, by the buffy coat which presents itself on the surface of the blood drawn during its existence, but as this also occurs in pregnancy and other states of the system, it ought not to be allowed an undue degree of importance. The modifications which inflammation receives from differences of physical structure, form a most importantand interesting subject, and one which should now constitute a large part of all pathological inquiries. This is not, however, the place to enter on the subject, and we shall therefore pass on to speak of the other morbid conditions of the vascular system. The circulation of the blood may be generally disturbed by causes which increase the action of the heart, and the state which is thereby occasioned may also be considered as an element of disease. The word fever, in its primitive application, was no doubt used as expressive of this condition, but it is now employed in so much more comprehensive a manner, that it becomes necessary to adopt a new term, or have recourse to a more phraseology. The state of simple febrile disturbance lengthened is characterized by a hot skin, a quick pulse, and a flushed countenance. In some caes, the eyes have a ferrety appearance, ’, and the skin is pink on the surface; the respiration is hurried, and there is generally beadach and thirst. The augmented speed of the respiration is directly attributable to the state of the lungs, which seek to relieve themselves from the unpleasant sensation which is experienced. This condition is so
observations,
gorged
of as a part of a more complex combination, that it may appear singular to speak of it abstractedly; but as it admits of many associations, it deserves an isolated consideration. The febrile disturbance arises immediately from an impression acting on the nerves, and in this inseparable connexion with what is called irritation, it resembles many other derangements in which there is a synchronous disturbance of the In inflammation, strictly speaking, we have an nervous centres. error in the nervous as well as in the vascular system, but yet it is always thought expedient to view the whole as a simple condition. Referring to what we formerly said as to the difficulties of all artificial distinctions, we may be allowed to pursue our analysis only so far as it may seem to be useful for practical purposes. For many reasons, as we shall afterwards see, it is desirable to regard the condition of general vascular disturbance apart from its immediate causes. We have already observed, that inflammation may exist without producing f’ds common excitement of the circulation; and, on the other hand, it will be shortly seen, that the febrile derangement is found in combination with many other conditions. It may not be necessary, however, to speak more at tength on this condition at the present, as it will again come under consideration when we come to speak of the associations of morbid states; and, for a similar reason, we shall speak somewhat cursorily of the remaining morbid states to which the vascular system is liable. Besides the derangements we have noticed, the bloodvessels may be disordered in the performance of those functions which affect the nutrition of the body. Fortunately, these processes are not easily disturbed, and when any disorder does ensue. it is
commonly spoken
referrible to other morbid conditions which influence the minute capillaries in a secondary manner. These morbid states, therefore, like many others, are principally interesting in their pathological relations. It is not easy to say how far the nutrition of the body is dependent on the agency of the nerves, because we find in plants, where we have no proof of any analogous system, that similar changes are constantly being performed. It is at least evident, that causes which operate on the nervous system greatly influence the functions of the capillary blood vessels. In many cases it is very difficult to assign any reason for these aberrations of nutrition. Occasionally, extraordinary changes will arise without any apparent cause; but we can rest in the general assertion, that all depressing causes, and particularly mental uneasiness, contribute to their production. There has, perhaps, been too ready a disposition to consider all abnormal actions as the result of inflammation, and it must be granted that a large proportion of them are, in some way or other, connected with it; others are more intimately associated with changes in the quality of the blood. Some time ago, I had an opportunity of witnessing a very remarkable instance of departure from the ordinary process of nutrition. It happened in a young girl who resided in Ancoats, in the neighbourhood of Manchester. She was about twentytwo years of age. The muscular tissue, in a great part of the body, was replaced by bone; the spine was curved, and the chest much diminished; the neck was quite rigid ; the jaws could scarcely be opened, and the arms were quite fixed at the shoulderjoints. Mr. Dumville, my colleague at the Ancoats Dispensary, took much interest in the case, and when the girl died he sent for me to be present at the inspection. The pectoralis on each side was completely ossified, forming radii, converging to a point at its insertion ; the latissimus dorsi and teres major at their conjoined tendons were quite bony; the tendons at the bend of the arm were also bony; the scaleni and deep muscles of the neck were bony; the spine was distorted, and the muscles a mass of bone; the pelvis was of a natural size; the heart was not in any way affected, and the viscera generally natural; the inferior extremities were free from bone ; the uterus was very small, and scarcely distinguishable, except by its triangular shape, from the surrounding membranes. Altogether, I never saw so singular a case. Mr. Dumville was successful in obtaining an interesting specimen of the disease, in procuring which he displayed no little zeal and determination. I believe there is a similar instance recorded in the Philosophical Transactions, where the whole skeleton was affected, and the motions of all the joints stopped by bony productions of the most fantastic shapes. Nutrition may simply be over-active in degree, as though the formative principle, which has been figuratively supposed to preside over the distribution of the molecules, had ceased to exercise its restrictive influence. The production of tumours cannot always be traced to any known source of irritation, nor can their formation be with so much propriety regarded as an inflammatory action, as an aberration of the nutrient function. The ordinary process of growth is performed by the minute
commonly
bony
732
capillaries,
and it is reasonable to suppose that those circum-
IPECACUANHA,
give them an increased quantity of blood, must in expedite the deposition of matter. It thus happens inordinate exercise, which appears (as Dr. Alison justly
stances
which
that
IN EMETIC
DOSES,
AS A
some measure
POWERFUL RESTORATIVE IN SOME CASES OF EXHAUSTION AND SINKING.
kind of attractive influence, must induce Various states which favour By JOHN HIGGINBOTTOM, F.R.C.S., Nottingham. the accumulation of blood will be seen hereafter associated with (Read before the Nottingham Medico-Chirurgical Society, May 23, 1845.) this condition. For the same reason that over-exercise is attended with in- IN the year 1814, I was first led to see the extraordinary bene. creased nutrition, it may be inferred that an opposite state would ficial effects of ipecacuanha as an emetic, in a female forty years be the result of deficient action. As the supply of blood to of age, who was in a sinking state, in the last stage of cholera; different structures is required to be constantly replenished, to her countenance was shrunk, extremities cold, cramp in the legs, balance a corresponding process of waste and removal, whatever and other symptoms of approaching dissolution. I had previously retards the former or accelerates the latter may be attended with attended two similar cases, where I had given opium, brandy, and Besides the changes ex- medicinal cordials, and both patients died. I was induced, in this a diminution of the affected organ. to give a scruple of ipecacuanha, from having frequently perienced in the growth of the body by the common loss which instance, is constantly sustained, there seems also a kind of modelling seen the good effects of it in the early stage of the disease. After lapse of two or three hours, I again visited my patient, fearing capbility in the resources of nature which is not simply a process the I should find her dead, but, to my great pleasure and surprise, so of absorption, but an adaptation of the nutrient function to the wants of the occasion. John Hunter named it the molelling process, great a change for the better had taken place as to appear almost incredible; the whole of her body was of a natural warmth, the and perhaps no term can be found more expressive of this action. The vascular system may be further deranged in its secretory dangerous symptoms had disappeared, and she made no complaint, was very weak. She had no further unfavourable functions; indeed, secretion must be viewed as accessory to nu- except thatofshe the disease, and was soon convalescent. symptom trition. A disturbance of the secerning process is for the most confidence in the ipecacuanha, as a remedy in such cases, My will to other and therefore be alluded conditions, part secondary now been confirmed during the practice of thirty years ; the to again in the progress of our inquiries: occasionally it would has and cramp, often entirely cease after the purging, appear to be a primary affection. The quantity of fluid separated emetic vomiting, operation of the ipecacuanha, but I have thought it proper from the blood by this action is known to be much influenced by the caliber of the vessels interested, and it is probably on this to give, in about two or three hours after the emetic, a pill, with a of opium and five grains of the blue pill, to allay any reaccount that variations of temperature and moisture are capable ofgrain irritation of the stomach and intestines, and an aperient, ’ maining in an alteration. It is well that some countries known, effecting with one scruple of rhubarb and two of the sulphate of potash, to the females make use of a small heated apparatus, to promote the menstrual flux, which they use under their petticoats to promote. assist the natural action of the bowels, and a simple saline effervescing draught every two or three hours afterwards; weak tea, an agreeable warmth. The other day, a servant girl called to consult me, who had formerly resided in the West Indies for a well-boiled gruel, milk, with sago or arrow-root as nutriment, and number of years. She informed me, that during her stay in that diluents. UTERINE HÆMORRHAGE. climate she menstruated regularly every fortnight, but since her return she had passed many months without any appearance of The next case which attracted my particular observation, was the catamenial discharge. The speed of the circulation is also the utility of ipecacuanha in severe uterine haemorrhage. I at.infin"t1tial on the quantity and quality of the secretions, and this tended the patient three times in labour, in the years 1821, 1823, is obviously under the control of accidentalcircumstances. A and 1826, and each time with most severe flooding immediately still more frequent cause of secretory derangement is to be found after the separation of the placenta. I employed the usual remedies, in a primary disturbance of the nervous system. There can be such as the sudden application of cold water to the abdomen, .no possible doubt but that the different secretions may be greatly pressure to cause contraction of the uterus, with the administraimpaired by causes acting on the nervous system, though this is far tion of opiates, wine, and brandy, which were at that times from proving that all the healthy functions of the bloodvessels are common remedies. These were cases of great anxiety, and I had maintained by the nervous agency. The celebrated John Hunter to remain with my patient several hours before it was safe to did not, perhaps, attach so much importance to the influence of the leave her. In her third confinement, I was afraid she would die. After nerves in organic processes as some of his successors have done. " Much more," says he, " has been given to the nerves than they having used all my remedies, and having given her half a pint of deserve; they have been thought to be the cause of every property brandy and a pint of port wine, which was of no avail, it occurred in an animal body; that independently of them the body was a to me, that in the former cases in which I had attended her, when I dead machine, and that it was only put in action by them. But, had used the same means to check the haemorrhage, that there was although their actions are absolutely necessary in the machine, no amendment until she had ejected the contents of the stomach. they are not so universally so as has been imagined. They I was, then, most anxious that vomiting should take place, in hope are not the cause of growth, nor do they even preserve a part from of relief, as she was rapidly sinking. I thought that as vomiting death, although the whole, as a whole, cannot livewithout them."’ had been so beneficial to her before, I was in this case justified in Lastly, the explanation of various morbid phenomena, which producing it by giving an emetic. I directly gave her half a cannot be referred to the changes we have mentioned, has been drachm of ipecacuanha; a full vomiting soon succeeded, and a attempted by the supposition that the affected parts are the sub- large quantity of fluid was ejected. I was much struck with an ject of peculiar actions, but I do not think we have any precise expression of my patient, which I had several times heard before ideas respecting these actions. It would be an interesting inquiry in similar cases, after vomiting. After a deep sigh, she said, to endeavour to ascertain how far those diseases which are called "O! I’m better; I’m better now." The haemorrhage ceased malignant have a local origin. We know, at least, that the ex- directly, and did not return; the symptoms of sinking abated, tension of many diseases is checked by applications of a topical and the patient appeared in her natural state of body, but very nature. We speak of changing the action of a part, and setting feeble. A little plain gruel was all the nutriment given her, and up a new action; but I conceive there are no precise ideas enter- she recovered gradually from her weak state. I attended the same tained as to what these actions are, or how they are brought about. patient three times afterwards, in the years 1827,1829, and 1831, The word action expresses a change, but it does not explain it. and what is very satisfactory in favour of the secale cornutum, Some actions are probably of a strictly chemical nature, as the which was about that time becoming more used in this locality, extension of sloughs may go on by the actual decomposition ofIgave, in every case, half a drachm of the powder before the the tissues. We have got so accustomed to the word action, that birth of the child, a second such dose after the birth, before the we perhaps conceive we attach a more definite idea to it than separation of the placenta. This remedy had the desired effect of we in reality do, but it seems that this was not always the case. preventing the haemorrhage, so that I had no further need of the There is an amusing note amongst the MSS. of the late Sir Astley ipecacuanha, or, indeed, of any other remedy. Several years ago, I had a patient, ou whom the secale cornutum Cooper: it runs as follows:" Although Mr. Hunter and his opinions were so much esteemed after his death, yet I rememberhad no effect in preventing the hæmorrhage, and I gave the that the surgeons and physicians of his day thought him a mere ipecacuanha with a favourable result. For nearly twenty years, I have lost all confidence in the imaginative speculator, and any one who believed in him a blockhead and a black sheep in the profession. I have heard surgeons! diffusible stimulants, such as wine, brandy, &c., in uterine say, ’ What do you mean by action, and all such nonsense?’ andl haemorrhage, from a conviction that they increase the arterial men, too, who now extol him to the skies." circulation, and, consequently, the haemorrhage, and I find that Broughton, near Manchester. opinion corroborated by the writings of Di’s. Clutterbuck and Ramsbotham. * Lectures on Surgery. Palmer’s Edit. p. 260.
remarks) a
state
to
occasion
a
of superabundant nutrition.
,
,
.
,
,
.
-
speak of the more active or progressive states of derangement, those which seem to have a disposition to extend ’, themselves, and some of which appear to have a definite course. Amongst these, the disorders of the vascular system are of the utmost importance; in fact, there are few trains of disorder in I
SHALL now
which the vascular system is not intimately concerned. It would be amazing indeed, if, among the immense number of capillary vessels which are intricately arranged in structures which are themselves the subjects of complicated operations, the circulation was not
occasionally impeded or deranged.
What is called the balance of the circulation may be destroyed, that is to say, the blood may be unequally distributed throughout the system. This leads to what is called congestion, or the undue accumulation of blood in particular parts of the body. Of course, congestion may be either local or general, according to the nature of its cause. In the latter case, the whole system suffers, and the epithet congestive has been applied to those fevers in which this particular condition is an important feature. It might be thought that the term congestive would in every instance be inappropriately used in conjunction with that of fever ; but if we only consider the enlarged sense in which the word fever is now employed, and that it has long since ceased to be restricted to its primitive signification,* it seems needless to object to it. The word asphyxia, and many others in common use, has acquired, in like manner, a conventional meaning, which is very different from their etymological signification. General congestion is known by a great embarrassment of the circulation ; we have a small, weak, and sometimes irregular pulse, a laborious state of the breathing, an oppressed state of the brain, a loss of muscular power, and comp,ete prostration of the strength. To these may be added a coldness of the suriace, and a blue appearance of the bloodvessels, especially in those parts which are ordinarily of a vivid red. These effects arise from a diminution of the heart’s action, which is occasioned by causes operating on the nervous centres, for it does not appear that the mere accumulation of blood in the large vessels would itself be sufficient to Other symptoms besides those account for all the phenomena. which we have enumerated, are, of course, produced by the disturbance of the functions of var:ous organs, as the brain, the mucous surface of the bronchiae, and the liver. The various occasions of congestion probably operate mainly, as we have stated, by their peculiar action on the nervous system causing a kind of partial syncope, so that the blood is no longer propelled with its usual force and freedom. This condition forms an element of many of those specific fevers which are of a malignant and fatal character, as the plague and yellow fever; the epidemic cholera of our own country is also distinguished by this general congestion. In other instances, it is a more transient, but still important condition, yet it scarcely merits the same at ention in the train of morbid changes. The collapse which follows the more serious accidents. and which sometimes arises from the presence of indifood in the stomach, may be instanced as a state of temporary congestion. Long and imprudent exposure to cold, especially to cold bathing, partly by its effect on the skin, but more particularly on the nervous system, is likewise an occasion of a general depression of the circulation, and a consequent withdrawal of blood from the surface. General congestion is, of course, best removed by the re-establishment of the cutaneous circulation, and this is well promoted (as was remarked by Dr. Armstrong) by the use of that simple contrivance, the hot air-hatli. The use of diffusible stimulants tc restore the nervous agency is, in many instances, a valuable auxiliary, if not carried beyond its legitimate extent. When congestion is of a less general character, it is commonly ascribahle to mechanical causes, which directly impede the transmission of the blood. Disease affecting the valves of the heart. especially the aortic and mitral valves, prevents the healthy returr of the blood from the lungs, which, in consequence, become inordinately loaded. Obstruction in the large vessels produces very serious effects on the system, and is commonly ultimately fatal Sometimes many small vessels are impeded by structural change; in the surrounding tissues, and when this takes place in sucha situation as the liver, where the ramifications of the vena port: are considerable, it is of the most serious consequence. Conges
gestible
*
Ferveo-to be hot.
local nature arise from lesions which onlymembers or bloodvessels. In this case the blood stagnates, and assumes a more decidedly venous character the temperature falls, and the function of the part is greatly disturbed. In some instances local congestion arises from a deficiency of power in the arterial capillaries, so that they become dilated and unable to sustain the column of the blood. There can be no doubt that the capillaries have an influence on the circulation distinct from that of the heart, and that a stagnation may proceed from a want of capillary tonicity. Andral exemplifies this state by allusion to the violet colour often seen on the anterior surface of the legs of old people; and he mentions also the sanguineous congestions of the pulmonary tissue, which attend the last stages of fatal diseases. There has been too much readiness to attribute all such changes to inflammation ; but if that word be allowed to have anv signification, it cannot surely be considered to represent states which are so diametrically opposite. We may now proceed to speak of another condition of the vascular system, in which we have not simply an inordinate collection of blood, but a particular series of phenomena of a more complicated nature. This is inflammation. The subject of inflammation has at all times excited very considerable attention, and there is, perhaps, no morbid condition which is so important, and so frequently found to form an element of disease. It is true that the disciples of the great Hunter may have given too exclusive an attention to this condition, but it must yet be granted that there are few trains of disorder in which inflammation does not form a part ; and, modified by other derangements, or existing in an insidious and chronic form, it mixes itself with disease in every possible variety. The attention which the celebrated Hunter paid to this subject may be viewed at once as a proof of the greatness of his mind and the importance of the investigation. The valuable researches of continental writers on the subject of general anatomy have shown the manner in which this action is modified by the structure in which it occurs, and this mode of examination has thrown a new light on the inquiry, and been, as it were, a key to the arcana of pathology. It is proper to say that one of our own countrymen, Mr. Carmichael Smith, has the merit of having been one of the first to direct the profession to this line of inquiry. It would be impossible, in the space we can devote to the purpose, to do anything like justice to the subject of inflammation ; and it must be remembered that our principal object is to show the reciprocal bearing of different conditions, and the manner in which complicated derangements are formed, and not to bring together all that can be collected respecting each individual condition. On this account, we must refer, for more detailed information, to the more elaborate treatises, and more especially to the recent and able work of Dr. Alison, on the practice of medicine. The presence of inflammation is inferred from the combination of the following symptoms, though they are not always found in conjunction, even where it must be allowed to exist—namely. redness, heat, pain, and swelling, and a disturbance of the function of the affected organ. Internal inflammation is inferred, in the language of Cullen, from the union of " fever with fixed pain in We stated that all these symptoms were some internal organ." not necessarily present, nor does the existence of any one, singly, lead us to suspect inflammation. Redness, it is well known, may be occasioned by various other causes, and pain may exist without the bloodvessels being materially disturbed. Again, inflammation may exist with little or no appreciable redness ; and even pain may be absent altogether, as in the examples of suppurative inflammation, which supervene on paralytic affections and iujuries of the nerves. Thus it must be a certain combination of symptoms which leads us to infer the presence of inflammation, and, probably, the most certain evidence is to be derived fr<:m its effects, which are presently to be considered. Inflammation gives rise to various changes, which have been called the terminations of inflammation, because they certainly conduce to relieve the action ; but as they rather attend its progress than necessarily occur on its cessation, the words resolution and moi tiJication are alone properly applicable in this sense. One of the most common accompaniments of inflammation is the effusion of serum, which is especially liable to be produced in those tissues which naturally secrete a watery discharge. The crepitant rattle which indicates the early stage of pneumonia is to be ascribed to the effusion of’ serum in the air-cells of the lungs. ’1 he escape of the adhesive matter called fibrine, mostly succeeds or attends this serous exhalation. Thus (to take the example already adduced) in a more advanced stage of pneumonia, fibrine is secreted in combination with the serum, and the latter being afterwards absorbed, the coagulable lymph not unfrequently remains as the nidus of structural alteration. The formation of what is called pus is another pro-’ tions of
a
concern
particular
still
more
731 duct of the inflammatory action. Pus is probably produced by a less highly vitalized process than that of fibrine, since it is not found to take place so near the vivifying influence of the surface of the wound, and is favoured by many circumstances which would seem destructive of vitality. Dr. Alison observes, that one use of suppuration may be, to rid the system of blood which has received an irremediable injury from the inflammatory action. Pus seems at least to be formed by a transformation of the globules of the blood, which have stagnated either in the interior of bloodvessels, or in the exudations which are surrounded by inflammamatory action. Of the latter we have an instance in the case of pneumonia to which we have already adverted : the fibrine effused in the air-cells of the lungs may be further changed into a thick, bland fluid, constituting what is called the purulent infiltration. This alteration appears, in a great measure, ascribable to the influence of the air. It has been remarked, that those cases of pleurisy which follow the admission of air into the chest, more surely lead to purulent effusion than the other instances where the inflammatory action is differently produced. When pus is once formed, it appears (as it has been well observed) to act like a leaven in the production of more purulent fluid. Its effect in softening the structures in which it is effused is also deserving of notice, and this is well observed in the purulent infiltration of the lungs. Mortification may arise independently of inflammation, and perhaps mainly depends on the cessation of the circulation, and those reciprocal changes which occur between the vessels and their contents. Inflammation may produce mortification, as well by injuring the vitality of the blood, as by impeding its circulation. Motion is in some degree essential to the life of the blood, and stagnation is followed by the death of the affected part. The reciprocal action which is constantly maintained between the circulating fluid and the molecules of the body, is interfered with by whatever impedes or arrests the transmission of the blood. In this manner, a change of consistence and softening of structure are likewise occasioned. The process of ulceration, and its connexion with inflammation, is not yet properly understood. It has of late been questioned by many respectable authorities, amongst which I may include my friend Mr. Gaskell, whether it be, in reality, produced by absorption. The discussion would be here manifestly out of place; it may be remarked, however, that there is at least gooll reason to suppose that ulceration is in part attributable to the mechanical removal of matter in combination with the external discharge, and this is particularly the case where the ulcer is of a sloughing character. Though so much has been written on the subject of inflammation, obscurity still prevails as to its intimate nature, and we are obliged to express ourselves on the subject by having recourse to the epithet, " vital." It seems, from microscopical that inflammation is attended, in the first instance, by an increased tonicity of the capillary vessels, with an augmented speed in the circulation of the blood, but that this is succeeded by an actual retardation, at least in the parts which are the immediate seat of the process. The inflammatory action seems brought about by an influence which is best compared to one of attraction acting at the extremities of the vessels, and drawing the blood towards the seat of disorder. In what way this arises is a subject of difficulty, but that it is occasioned by some changes in the affinities of the blood, seems to be the most probable conjecture. That the blood is altered in inflammation is well known, by the buffy coat which presents itself on the surface of the blood drawn during its existence, but as this also occurs in pregnancy and other states of the system, it ought not to be allowed an undue degree of importance. The modifications which inflammation receives from differences of physical structure, form a most importantand interesting subject, and one which should now constitute a large part of all pathological inquiries. This is not, however, the place to enter on the subject, and we shall therefore pass on to speak of the other morbid conditions of the vascular system. The circulation of the blood may be generally disturbed by causes which increase the action of the heart, and the state which is thereby occasioned may also be considered as an element of disease. The word fever, in its primitive application, was no doubt used as expressive of this condition, but it is now employed in so much more comprehensive a manner, that it becomes necessary to adopt a new term, or have recourse to a more phraseology. The state of simple febrile disturbance lengthened is characterized by a hot skin, a quick pulse, and a flushed countenance. In some caes, the eyes have a ferrety appearance, ’, and the skin is pink on the surface; the respiration is hurried, and there is generally beadach and thirst. The augmented speed of the respiration is directly attributable to the state of the lungs, which seek to relieve themselves from the unpleasant sensation which is experienced. This condition is so
observations,
gorged
of as a part of a more complex combination, that it may appear singular to speak of it abstractedly; but as it admits of many associations, it deserves an isolated consideration. The febrile disturbance arises immediately from an impression acting on the nerves, and in this inseparable connexion with what is called irritation, it resembles many other derangements in which there is a synchronous disturbance of the In inflammation, strictly speaking, we have an nervous centres. error in the nervous as well as in the vascular system, but yet it is always thought expedient to view the whole as a simple condition. Referring to what we formerly said as to the difficulties of all artificial distinctions, we may be allowed to pursue our analysis only so far as it may seem to be useful for practical purposes. For many reasons, as we shall afterwards see, it is desirable to regard the condition of general vascular disturbance apart from its immediate causes. We have already observed, that inflammation may exist without producing f’ds common excitement of the circulation; and, on the other hand, it will be shortly seen, that the febrile derangement is found in combination with many other conditions. It may not be necessary, however, to speak more at tength on this condition at the present, as it will again come under consideration when we come to speak of the associations of morbid states; and, for a similar reason, we shall speak somewhat cursorily of the remaining morbid states to which the vascular system is liable. Besides the derangements we have noticed, the bloodvessels may be disordered in the performance of those functions which affect the nutrition of the body. Fortunately, these processes are not easily disturbed, and when any disorder does ensue. it is
commonly spoken
referrible to other morbid conditions which influence the minute capillaries in a secondary manner. These morbid states, therefore, like many others, are principally interesting in their pathological relations. It is not easy to say how far the nutrition of the body is dependent on the agency of the nerves, because we find in plants, where we have no proof of any analogous system, that similar changes are constantly being performed. It is at least evident, that causes which operate on the nervous system greatly influence the functions of the capillary blood vessels. In many cases it is very difficult to assign any reason for these aberrations of nutrition. Occasionally, extraordinary changes will arise without any apparent cause; but we can rest in the general assertion, that all depressing causes, and particularly mental uneasiness, contribute to their production. There has, perhaps, been too ready a disposition to consider all abnormal actions as the result of inflammation, and it must be granted that a large proportion of them are, in some way or other, connected with it; others are more intimately associated with changes in the quality of the blood. Some time ago, I had an opportunity of witnessing a very remarkable instance of departure from the ordinary process of nutrition. It happened in a young girl who resided in Ancoats, in the neighbourhood of Manchester. She was about twentytwo years of age. The muscular tissue, in a great part of the body, was replaced by bone; the spine was curved, and the chest much diminished; the neck was quite rigid ; the jaws could scarcely be opened, and the arms were quite fixed at the shoulderjoints. Mr. Dumville, my colleague at the Ancoats Dispensary, took much interest in the case, and when the girl died he sent for me to be present at the inspection. The pectoralis on each side was completely ossified, forming radii, converging to a point at its insertion ; the latissimus dorsi and teres major at their conjoined tendons were quite bony; the tendons at the bend of the arm were also bony; the scaleni and deep muscles of the neck were bony; the spine was distorted, and the muscles a mass of bone; the pelvis was of a natural size; the heart was not in any way affected, and the viscera generally natural; the inferior extremities were free from bone ; the uterus was very small, and scarcely distinguishable, except by its triangular shape, from the surrounding membranes. Altogether, I never saw so singular a case. Mr. Dumville was successful in obtaining an interesting specimen of the disease, in procuring which he displayed no little zeal and determination. I believe there is a similar instance recorded in the Philosophical Transactions, where the whole skeleton was affected, and the motions of all the joints stopped by bony productions of the most fantastic shapes. Nutrition may simply be over-active in degree, as though the formative principle, which has been figuratively supposed to preside over the distribution of the molecules, had ceased to exercise its restrictive influence. The production of tumours cannot always be traced to any known source of irritation, nor can their formation be with so much propriety regarded as an inflammatory action, as an aberration of the nutrient function. The ordinary process of growth is performed by the minute
commonly
bony
732
capillaries,
and it is reasonable to suppose that those circum-
IPECACUANHA,
give them an increased quantity of blood, must in expedite the deposition of matter. It thus happens inordinate exercise, which appears (as Dr. Alison justly
stances
which
that
IN EMETIC
DOSES,
AS A
some measure
POWERFUL RESTORATIVE IN SOME CASES OF EXHAUSTION AND SINKING.
kind of attractive influence, must induce Various states which favour By JOHN HIGGINBOTTOM, F.R.C.S., Nottingham. the accumulation of blood will be seen hereafter associated with (Read before the Nottingham Medico-Chirurgical Society, May 23, 1845.) this condition. For the same reason that over-exercise is attended with in- IN the year 1814, I was first led to see the extraordinary bene. creased nutrition, it may be inferred that an opposite state would ficial effects of ipecacuanha as an emetic, in a female forty years be the result of deficient action. As the supply of blood to of age, who was in a sinking state, in the last stage of cholera; different structures is required to be constantly replenished, to her countenance was shrunk, extremities cold, cramp in the legs, balance a corresponding process of waste and removal, whatever and other symptoms of approaching dissolution. I had previously retards the former or accelerates the latter may be attended with attended two similar cases, where I had given opium, brandy, and Besides the changes ex- medicinal cordials, and both patients died. I was induced, in this a diminution of the affected organ. to give a scruple of ipecacuanha, from having frequently perienced in the growth of the body by the common loss which instance, is constantly sustained, there seems also a kind of modelling seen the good effects of it in the early stage of the disease. After lapse of two or three hours, I again visited my patient, fearing capbility in the resources of nature which is not simply a process the I should find her dead, but, to my great pleasure and surprise, so of absorption, but an adaptation of the nutrient function to the wants of the occasion. John Hunter named it the molelling process, great a change for the better had taken place as to appear almost incredible; the whole of her body was of a natural warmth, the and perhaps no term can be found more expressive of this action. The vascular system may be further deranged in its secretory dangerous symptoms had disappeared, and she made no complaint, was very weak. She had no further unfavourable functions; indeed, secretion must be viewed as accessory to nu- except thatofshe the disease, and was soon convalescent. symptom trition. A disturbance of the secerning process is for the most confidence in the ipecacuanha, as a remedy in such cases, My will to other and therefore be alluded conditions, part secondary now been confirmed during the practice of thirty years ; the to again in the progress of our inquiries: occasionally it would has and cramp, often entirely cease after the purging, appear to be a primary affection. The quantity of fluid separated emetic vomiting, operation of the ipecacuanha, but I have thought it proper from the blood by this action is known to be much influenced by the caliber of the vessels interested, and it is probably on this to give, in about two or three hours after the emetic, a pill, with a of opium and five grains of the blue pill, to allay any reaccount that variations of temperature and moisture are capable ofgrain irritation of the stomach and intestines, and an aperient, ’ maining in an alteration. It is well that some countries known, effecting with one scruple of rhubarb and two of the sulphate of potash, to the females make use of a small heated apparatus, to promote the menstrual flux, which they use under their petticoats to promote. assist the natural action of the bowels, and a simple saline effervescing draught every two or three hours afterwards; weak tea, an agreeable warmth. The other day, a servant girl called to consult me, who had formerly resided in the West Indies for a well-boiled gruel, milk, with sago or arrow-root as nutriment, and number of years. She informed me, that during her stay in that diluents. UTERINE HÆMORRHAGE. climate she menstruated regularly every fortnight, but since her return she had passed many months without any appearance of The next case which attracted my particular observation, was the catamenial discharge. The speed of the circulation is also the utility of ipecacuanha in severe uterine haemorrhage. I at.infin"t1tial on the quantity and quality of the secretions, and this tended the patient three times in labour, in the years 1821, 1823, is obviously under the control of accidentalcircumstances. A and 1826, and each time with most severe flooding immediately still more frequent cause of secretory derangement is to be found after the separation of the placenta. I employed the usual remedies, in a primary disturbance of the nervous system. There can be such as the sudden application of cold water to the abdomen, .no possible doubt but that the different secretions may be greatly pressure to cause contraction of the uterus, with the administraimpaired by causes acting on the nervous system, though this is far tion of opiates, wine, and brandy, which were at that times from proving that all the healthy functions of the bloodvessels are common remedies. These were cases of great anxiety, and I had maintained by the nervous agency. The celebrated John Hunter to remain with my patient several hours before it was safe to did not, perhaps, attach so much importance to the influence of the leave her. In her third confinement, I was afraid she would die. After nerves in organic processes as some of his successors have done. " Much more," says he, " has been given to the nerves than they having used all my remedies, and having given her half a pint of deserve; they have been thought to be the cause of every property brandy and a pint of port wine, which was of no avail, it occurred in an animal body; that independently of them the body was a to me, that in the former cases in which I had attended her, when I dead machine, and that it was only put in action by them. But, had used the same means to check the haemorrhage, that there was although their actions are absolutely necessary in the machine, no amendment until she had ejected the contents of the stomach. they are not so universally so as has been imagined. They I was, then, most anxious that vomiting should take place, in hope are not the cause of growth, nor do they even preserve a part from of relief, as she was rapidly sinking. I thought that as vomiting death, although the whole, as a whole, cannot livewithout them."’ had been so beneficial to her before, I was in this case justified in Lastly, the explanation of various morbid phenomena, which producing it by giving an emetic. I directly gave her half a cannot be referred to the changes we have mentioned, has been drachm of ipecacuanha; a full vomiting soon succeeded, and a attempted by the supposition that the affected parts are the sub- large quantity of fluid was ejected. I was much struck with an ject of peculiar actions, but I do not think we have any precise expression of my patient, which I had several times heard before ideas respecting these actions. It would be an interesting inquiry in similar cases, after vomiting. After a deep sigh, she said, to endeavour to ascertain how far those diseases which are called "O! I’m better; I’m better now." The haemorrhage ceased malignant have a local origin. We know, at least, that the ex- directly, and did not return; the symptoms of sinking abated, tension of many diseases is checked by applications of a topical and the patient appeared in her natural state of body, but very nature. We speak of changing the action of a part, and setting feeble. A little plain gruel was all the nutriment given her, and up a new action; but I conceive there are no precise ideas enter- she recovered gradually from her weak state. I attended the same tained as to what these actions are, or how they are brought about. patient three times afterwards, in the years 1827,1829, and 1831, The word action expresses a change, but it does not explain it. and what is very satisfactory in favour of the secale cornutum, Some actions are probably of a strictly chemical nature, as the which was about that time becoming more used in this locality, extension of sloughs may go on by the actual decomposition ofIgave, in every case, half a drachm of the powder before the the tissues. We have got so accustomed to the word action, that birth of the child, a second such dose after the birth, before the we perhaps conceive we attach a more definite idea to it than separation of the placenta. This remedy had the desired effect of we in reality do, but it seems that this was not always the case. preventing the haemorrhage, so that I had no further need of the There is an amusing note amongst the MSS. of the late Sir Astley ipecacuanha, or, indeed, of any other remedy. Several years ago, I had a patient, ou whom the secale cornutum Cooper: it runs as follows:" Although Mr. Hunter and his opinions were so much esteemed after his death, yet I rememberhad no effect in preventing the hæmorrhage, and I gave the that the surgeons and physicians of his day thought him a mere ipecacuanha with a favourable result. For nearly twenty years, I have lost all confidence in the imaginative speculator, and any one who believed in him a blockhead and a black sheep in the profession. I have heard surgeons! diffusible stimulants, such as wine, brandy, &c., in uterine say, ’ What do you mean by action, and all such nonsense?’ andl haemorrhage, from a conviction that they increase the arterial men, too, who now extol him to the skies." circulation, and, consequently, the haemorrhage, and I find that Broughton, near Manchester. opinion corroborated by the writings of Di’s. Clutterbuck and Ramsbotham. * Lectures on Surgery. Palmer’s Edit. p. 260.
remarks) a
state
to
occasion
a
of superabundant nutrition.
,
,
.
,
,
.
-