Part 8

When the lungs are inflamed, is it the red blood of the bronchial artery that flows to the irritated place, or the black blood of the pulmonary artery? I think that it is difficult to decide this question by experiment; but examination after death appears to prove that the second performs an important part in it. In fact, this viscus is often crowded so suddenly, that we can hardly believe that the first would be able to furnish the blood. Sometimes, though it is not always the case, we can trace as it were, the progress of this crowding by percussion, which is infinitely less sonorous in the evening than the morning. There died a short time since a patient under my care in the hospital, in whom this difference was perceptible from hour to hour. The progress is much less rapid, no doubt, in the greatest number of cases; but in those the black blood has undoubtedly contributed to the crowding of the lungs.

No organ in the animal economy acquires by inflammation, so great a size in so short a time, and such excessive weight, as the lungs. All who open dead bodies know this. Observe the lungs of one dead of pneumonia; cut them, and you would say at first that they were solid; they often look like liver, they exhibit the appearance of such a heavy mass; but macerate them and soon the whole will escape in fluids. Now examine comparatively the skin, the stomach, the liver, the kidnies, &c. when they have been the seat of acute inflammation, that has destroyed the patient; they have nothing approaching to this enormous increase of fluid, which is seen in the substance of inflamed lungs. Not only the cavity of the cells is full, but the organ is also much dilated. I have often had occasion to open those who have died of pneumonia, in whom one of the lungs was entirely sound; now, the disproportion of weight between it and the affected one, was incomparably greater than that between an inflamed kidney and a sound one.

This phenomenon evidently arises from the fact, that the lungs alone receive as much blood as the whole body, so that when an inflammation of this viscus interrupts the course of the fluids, a very great quantity of them can accumulate there in a given time. It is not however, properly speaking, the blood that is found crowding the lungs in pneumonia; the fluid appears whitish when pressed out; we should say that it was a kind of pus. Much has been said of vomicæ after pneumonia; but they are extremely rare; there is almost always effusion in the lungs; the fluid is not collected in a sac.

In pulmonary inflammation, does the blood pass through vessels that do not ordinarily circulate it, as happens so evidently upon the serous surfaces, or conjunctiva, &c. when inflamed? I do not think it does, for we do not know any vessels in the lungs, except the sanguineous. It appears evident that the blood or the other fluids are effused into the pulmonary texture, in which they are deposited by exhalation. There is no doubt that in some phlegmons, this fluid passes, as I shall say, into the cells of the cellular texture; now it appears that it happens here in the same way. By breaking or cutting inflamed lungs, we see clearly that its whole texture is crowded, and filled; whereas in examining an inflamed serous surface, we see that the blood is evidently contained in the capillaries.

It is a great mistake to try to represent inflammation as being everywhere the same, as exhibiting always the fluids, like their vessels, in the same state. Boerhaave for example thought, that there could be no inflammation without an error loci. There is according to the state of the parts, their structure, their vital properties, a thousand different modifications in the new anatomical order that this affection gives to the organs.

What constitutes the essence of inflammation is, 1st, the irritation of the inflamed part; 2d, the new modifications that its vital forces have taken in consequence of that irritation; 3d, the consequent stagnation of the fluids around it. But in what manner the fluids are arrested; how they stop in the capillary system; how they are taken up by the exhalants; how they are poured out, in extravasations, &c.; these are different effects that arise from the different organization of the parts; but the principle is always the same, it is always the same disease. If we could analyze thoroughly the state of all the systems in inflammation, we should see perhaps, that there was a difference in the inflammation of each. Besides, the diversity of the symptoms that it exhibits, a diversity of which I have already spoken, proves that the state of the solids and the fluids are not the same.

How is it that the blood can pass through the lungs of phthisical patients, in whom this organ is reduced nearly one half? I would observe upon this subject, that the blood in the great vessels is diminished in proportion to the ulceration of the lungs. The diminution of this fluid is remarkable in many organic affections, but especially in these, as Portal has observed. If a phthisical patient in the last stage had as much blood, as before the disease, the circulation certainly could not go on, or at least there would be a constant reflux towards the right auricle. Who is ignorant of the small pulse, feeble though frequent, particularly towards night, in phthisis? Compare it with the pulse of an inflammatory fever, in which there is evidently plethora; you will see that they are really the two extremes.

I will make a general observation upon this subject, it is this, that when the forces are weakened in our organs, or life languishes in them, the blood is diminished almost continually in proportion; so that this fluid being considered in the capillary system, as the resistance opposed to the power of the small vessels, the proportion remains always the same between this power and this resistance. It is necessary that the whole should be in relation. If blood was transfused into a phthisical patient, he would die, because the forces of the solids would not correspond with the increase of action to which they would be forced.

The circulation of the pulmonary capillaries, is, like that of the others, under the influence of the tonic forces of the part, and not under that of the impulse of the heart. This impulse terminates at the extremity of the branches of the pulmonary artery. In inflammation then of the lungs, the blood is not mechanically arrested in this organ; then, when you bleed, it is not to diminish the vis à tergo. You might draw ten basins from the patient, but the lungs most commonly would not empty themselves; they would be less fatigued by the entrance of the blood; but that which was stagnant in the capillary system would still remain there. So long as there is a point of irritation, it will be, if we may so say, a magnet which will attract the blood, and completely change its direction; which was before from the artery to the veins, it will now be only towards the irritated point. Bleeding acts then, 1st, by diminishing the blood that enters the lungs, and consequently by lessening the fatigue of this diseased organ; 2d, by diminishing the irritation of the solid, which attracts the blood, and retains it around the irritated place.

The constant excitement that the air gives to the pulmonary capillary system is favourable to its circulation; but the blood can traverse this system without this excitement, as is proved by my experiments mentioned elsewhere.

III. Alteration of the Blood in the Pulmonary Capillaries.

There takes place here the reverse of what happens in the general capillaries; the fluid changes from black to red. We have already some data upon the causes of this phenomenon; but I think new experiments should be made before a thorough explanation can be given. This is so much the more necessary, because if we knew how the black blood becomes red, it would seem that we might know how the red becomes black.

I have stated the phenomena of this change of colour in my work upon Life and Death; it would be superfluous to repeat them. There will be found there also many details upon the circulation of the two capillary systems, which I shall not mention here.

IV. Remarks upon the state of the Lungs in Dead Bodies.

I will only corroborate here a remark already made in the same work, upon the extreme frequency of pulmonary congestions in the last moments of life. As the lungs alone receive the whole blood of the body, when their forces are weakened, the blood stagnates and accumulates in them; so that according to the state of their forces in the last moments, and the disease, these organs will be more or less heavy, and more or less full of blood. We hardly find them twice in the same state. All subjects that die in pain have these congestions. Thus compare the lungs of dead bodies in our dissecting rooms, with those of animals killed in slaughter-houses; they are entirely different. The organization is almost always concealed in the first by the fluids that crowd them. We cannot study this organization well except in subjects that have died of hemorrhage or syncope. In most others, it is impossible to distinguish any thing. Hence no doubt the reason that we know as yet so little of the intimate structure of this important viscus, as the description I shall give of it will, I hope, prove. I have shown elsewhere how we can at will accumulate a greater or less quantity of blood in the lungs of an animal, by the way in which we kill him.

No other organ in the economy exhibits these extreme varieties of congestion at the moment of death, in so evident a manner at least, because no one is a centre of circulation, like the lungs; the liver even is not an exception, as I have observed. In this respect, those who open dead bodies, and examine the state of the lungs, should carefully distinguish the congestion that arises from the disease, from that which may be perhaps the effect of the interruption of the circulation in the last moments. I suppose two affections of the chest exactly similar in their nature, duration and the two subjects they attack; that syncope terminates the life of one of them; that that of the other is closed after long distress, in which there is what is called the rattles; the lungs of the second will certainly weigh much more than those of the first.

It is very probable that during life, the lungs are in very different degrees of congestion. We know that most chronic diseases of this organ occasion, when the patients take rather violent exercise, a sense of suffocation, oppression, &c. which appear to be owing only to the superabundance of blood, which, not being able to pass through this viscus as fast as it is sent there, is stopt, and checks the entrance and exit of the air.

It is only the diseases of the lungs and heart that are accompanied constantly with these oppressions, and sense of suffocation. This is seen in this last organ in aneurisms, sometimes in ossifications, &c.

EXHALANT SYSTEM.

Exhalation and secretion are two functions, analogous in this, that both of them separate from the blood fluids differing from it, and pour them upon surfaces where they serve different uses. But the following are their differences.

1st. In exhalation, there is no intermediate organ between the arteries and the exhalants; a capillary net-work alone separates them; whilst on the contrary there is always an intermediate organ between the excretories and the arteries; it is in this organ that the capillaries are found, in which the second begin and the first terminate. 2d. The organized machines which elaborate the secreted fluids are then much more complicated than those which separate the exhaled fluids. Thus the bile, the urine, the saliva, &c. differ on the one hand essentially from the blood, and are on the other much compounded; whilst the serum, &c. closely resembles some parts of the blood, and is but slightly compounded, containing but few elements. This double distinctive character of the two kinds of fluids appears to me to be very striking. 3d. The exhaled fluids are poured out by an infinity of small tubes separate from each other; the secreted fluids, on the contrary, are collected in one or more principal tubes that pour them on the surface where they terminate. 4th. The exhaled fluids re-enter in great part into the circulation, after having been thrown out; the secreted fluids, on the contrary, appear to be especially destined to be rejected. 5th. Many parts receive the first fluids; they are deposited upon the serous, mucous, synovial and cutaneous surfaces, in the cellular texture and even in all the organs of nutrition. The mucous and cutaneous surfaces, the first especially, are the only ones upon which the others are poured out.

It follows from all these considerations, that the exhaled fluids, as the fat, the serum, the synovia, the marrow, &c. differ essentially from the secreted fluids, as the bile, the urine, the saliva, the mucous, prostate, spermatic, pancreatic fluids, &c. This difference appears to have struck a great number of authors; yet most of them have made use of the term secretion to express the separation of the exhaled fluids from the mass of blood. I think that there is much analogy between exhalation and secretion. In both, there is the capillary system, as I have said, between the vessel that brings and that which carries away; but the capillary system is certainly arranged very differently in a gland, from what it is in a serous surface; for example, wherever there is exhalation, there is certainly nothing but the capillary system; but where there is secretion, the secretory organ is too considerable not to admit of something more. Besides, by trusting to inspection, and without wishing to examine the intimate nature of the organs, it is evident that where there is secretion, there is a gland, and that this gland is wanting where there is exhalation.

ARTICLE FIRST.

GENERAL ARRANGEMENT OF THE EXHALANTS.

I. Origin, course, and termination.

Authors have formed very different ideas concerning the exhalants. We know the decreasing vessels of Boerhaave, and the error loci for which his imagination created these vessels. Lately all the white vessels continuous with the arteries have been rejected, and in order to explain exhalation, recourse has been had only to inorganic pores in the arterial parietes, through which the fluids transude upon the organs. Frequent observation of similar transudations upon the dead body, as those of the bile through the gall-bladder, of the marrow through the osseous texture which it discolours, &c. is one of the great supports of this method of explaining the exhalant system. But we have already many times observed, that these phenomena never take place during life, when the organic sensibility of the parts refuses to produce them. Besides, exhalation is evidently subjected to the influence of the vital forces, since it varies continually in a part, according as the vital forces of the part themselves vary. Moreover, if the exhaled fluids escaped through inorganic pores, it would be necessary that not only the vascular parietes, but also those of the serous surfaces which receive these fluids, should be perforated with small holes; why then would not these fluids, of which these surfaces are the reservoirs, transude into the neighbouring cellular texture? Let us reject then every opinion that disregards anatomical observation, and let us endeavour by this observation to ascertain what the exhalants are.

It is undoubtedly difficult to form a precise idea of these vessels, their extreme tenuity constantly conceals them from us in a natural state. Yet by the aid of experiments and accurate reasoning, it appears to me that we may come at some degree of accuracy.

We have seen that the existence of a capillary system terminating the arteries, is in the parts where exhalation takes place as in the others, a thing incontestably proved by experiment with injections, by inflammations which arise spontaneously, and by those that are produced at will; so that a serous, cutaneous surface, &c. on which nothing appears, is covered with an infinity of little vessels suddenly in the first case, and at the end of a longer or shorter time in the second.