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Originally appearing in Volume V27, Page 946 of the 1911 Encyclopedia Britannica.
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FIGS. 22, 23 and 24 from Allchin's Manual of Medicine, by permission of Macmillan & Co. Ltd. A, Primary wave. C, Dicrotic wave. B, Predicrotic wave. D, Post-dicrotic wave. The form of these waves is modified by the pressure of application of the sphygmograph, and by instrumental errors; and we have no scale by which we can measure the blood pressure in sphygmograph tracings. To do this another instrument, the sphygmomanometer, is employed. The pulse may pass through the arterioles and reach the capillaries when the arterioles are dilated or when the capillaries are only filled at each systole, as may be seen in the pink of the nail when the arm is held above the head, and in cases of aortic regurgitation. A venous pulse may be recorded in the jugular vein; it exhibits oscillations synchronous with auricular and ventricular systole, and affords us important information in certain cases of heart disease. The normal average pulse rate is 72 per minute, in woman about 80; but individual variations from 40–100 have been observed consistent with health. In the newborn the pulse beats on the average 130–140 times a minute; in a one-year-old child 120–130; three years too; ten years 90; fifteen years 70-95. Active muscular exercise may increase the pulse rate to 130. Nervous excitement, extreme debility and rise of body temperature also increase it markedly. The pulse is more frequent when one stands than when one sits, or lies down, and this is especially so in states of debility. The taking of food, especially hot food, increases it. By placing tambours on, say, the carotid and radial arteries and recording the two pulses synchronously, it has been found that the pulse occurs later, the further the seat of observation is from the heart. The velocity with which the pulse wave travels down the arteries has been determined thus. It is about 7–8 metres per second. The wave length of the pulse is obtained by multiplying the duration of the inflow of blood into the aorta by the velocity of the pulse wave. It is about 3 metres. As the return of venous blood and pulmonary circulation is favoured during inspiration so that the output of the left ventricle during the first part of inspiration is lessened and subsequently increased, From Young and Robinson, Cunningham's Text-Book of Anatomy. From Young and Robinson, Cunningham's Text-Book of Anatomy. the sphygmograph reveals respiratory oscillations; the whole line of the tracing falls during the first part of inspiration and rises subsequently. The circulation in the capillaries may be studied by placing under the microscope a transparent membrane such as the web of the The frog's foot, tail of tadpole, wing of bat, &c. By a special capillary illumination one may see the shadow of the blood cor- cacula- puscles moving through the retinal vessels of one's own eye, don. and even calculate the velocity of flow. The diameter of the smaller capillaries is such as to permit the passage of the red blood corpuscles in single file only; their length is about nth of an inch. The endothelial cells confine the blood from direct contact with the tissue lymph and so prevent its coagulation, but allow and regulate the exchange of material between the blood and lymph. This exchange is regulated by the vital activity of the cells, and does not follow such laws as pertain to filtration and diffusion through dead membranes. There is evidence to show that the cells of the hepatic capillaries are capable of protoplasmic movement and of phagocytosis. The pressure in the capillaries stands in closer relationship to that in the veins than to that in the arteries; for example, a rise of pressure in the venae cavae, other things remaining the same, raises the pressure in the hepatic capillaries to a like amount, while a rise of pressure in the aorta does not, for most of the arterial pressure is spent in overcoming the peripheral resistance. The filling of the capillaries in the skin varies greatly with temperature, posture, &c. When the hand is cold the arterioles are so constricted that blood only passes through the wider and more direct capillaries. As the skin becomes warm it flushes, the arterioles dilating and all the capillary networks becoming filled with blood. Muscular movements express the blood out of the capillaries, as may be seen by the blanching of the skin which occurs on clenching the hand. Raising the hand blanches, and lowering it congests the capillaries. The pressure and velocity in the capillaries thus constantly vary, owing to alterations in hydrostatic pressure, the pressure of the body against external objects, the contraction of the muscles, and the contraction of the arterioles. It is not possible therefore to set any definite figure to the capillary pressure or velocity. In the frog's web, with the foot confined and at rest, the velocity is about t mm. per second. We continually make slight movements to counteract the hydrostatic effect and prevent the congestion of blood in the capillaries of lower parts of the body. It is this tendency to congestion which makes it so difficult to stand absolutely motion-less for any length of time. The red corpuscles, being the heavier, occupy the axis, and the white corpuscles the peripheral layer of the capillary stream. If an irritant is placed on the membrane it will be observed that the capillaries become wider and crowded with corpuscles, the flow slackening and finally becoming arrested owing to the passing out of the plasma through the damaged capillary wall. The white corpuscles creep out between the endothelial cells into the tissues. Such are the first phenomena of inflammation. After obstruction of an artery collateral pathways are in most parts rapidly formed, for the anastomatic capillaries, stimulated by the increased blood flow, develop into arterioles and arteries. Numerous anastomoses exist between the veins, so that if the flow of blood be obstructed in one direction it readily finds a passage The flow in another. Muscular movement, alterations of posture and la the respiratory movements particularly forward the venous veins. circulation. The barber's pole of the barber surgeon was grasped to increase the flow in the old blood-letting days. The valves in the veins allow the blood to be forced only towards the heart. The pressure in the veins varies according to the hydrostatic pressure of the blood column above the point of measurement. In the horizontal position, when this factor is almost eliminated, the pressure in the large veins is about equal to 5–Jo mm. of mercury, and even may become negative on taking a deep inspiration. There thus arises the danger of air being sucked into a wounded jugular vein. If air does thus gain entry it may fatally obstruct the circulation. The venous circulation is impeded by (i) a lessening of heart power, (2) valvular defects, such as incompetence or narrowing of the orifice which they guard, (3) obstruction to the filling of the heart, as in cases of pericardial effusion, (4) obstruction of the pulmonary circulation as in coughing, by pleuritic effusion, &c. The results of venous congestion are a less efficient arterial circulation, a dusky appearance of the skin, a fall of cutaneous temperature, and an effusion of fluid into the tissue spaces producing oedema and dropsy. This last effect is not due to increased capillary pressure producing increased transudation as has been supposed, for no such increase in venous and capillary pressure persists under the conditions. It is due to the altered nutrition of the capillary endothelium and the tissues, which results front the deficient circulation. If for any reason the left ventricle fail to maintain its full systolic output, it ceases to receive the full auricular input, and in consequence the pulmonary vessels congest. This tells back on the right heart, and the right ventricle is unable to empty itself into the congested pulmonary vessels, and this in its turn leads to venous congestion. The final result of any obstruction thus is a pooling of the blood in the venous cistern. Dyspnoea results from cardiac insufficiency. It is excited by the increased venosity of the blood acting on the respiratory centre. Both excess of carbon dioxide and deficiency of oxygen excite this centre. The increased respiratory movements aid the circulation. The venous side of the vascular system, owing to the great size of the veins, has a large potential capacity, while many of the capillaries in each organ are empty and collapsed, except at those periods of vaso-dilatation and hyperaemia which accompany extreme activity of function. The vascular system cannot be regarded as a closed system, for the blood-plasma, ,whenever the capillary pressure is increased, transudes through the capillary wall into the tissue-spaces and enters the lymphatics. Thus, if fluid be transfused into the circulatory system, it not only collects in the capacious reservoirs of the veins and capillaries—especially in the lungs, liver and abdominal organs–but leaks into the tissue-spaces. Hence the pressure in the vascular system cannot be raised above the normal for any length of time by the injection of even enormous quantities of fluid. The lymphatics of tissue-spaces must be regarded as part of the vascular system. There is a constant give and take between the blood-plasma and the tissue lymph. If the fluid part of the blood be increased, then the capillary transudation becomes greater, and the excess of fluid is excreted from the kidneys and glands of the alimentary canal. If the fluid part of the blood diminish, then fluid passes from the tissue-spaces into the yaemor- blood, and the sensation of thirst arises, and more drink is rh~e and taken. The circulation may be greatly aided by the trans-. fusion of salt solution (0.8 %) or blood after severe hemor- sion. rhage, or in states of surgical shock. Only the blood of man must be used. The direct giving of blood by connecting the radial artery of a relation to the median vein of a patient has been used as a means of effecting restoration. Blood may be withdrawn from the system slowly to the extent of 4 %, rapidly to the extent of 2 % of the bodyweight, without lowering the arterial pressure, owing to the compensatory contraction of the arterioles and the rapid absorption of fluid from the tissues into the blood. The withdrawal of the tissue-lymph excites extreme thirst and the great need for water which occurs after severe hemorrhage. About 75 % by weight of the tissues, excluding fat and bone, consists of water. The quantity of blood in the body is about Q~th of the body weight. That of tissue-lymph is unknown, but it must be considerable, probably greater than that of the blood; The lymphatics drain off the excess of fluid which transudes from the capillaries, and finally return it to the vascular system. The interchange between tissue, blood and lymph depehds on the forces of the living cells, which are as yet far from complete elucidation. We may define the velocity of the blood at any point in a vessel as the length of the column of blood flowing by that point in' second. In the case of a tube, supplied by a constant head of pressure, we can divide the tube and measure velocity the outflow per second; knowing the volume of this, oTf blood and the cross area of the artery, we can determine the length of the column. This kind of experiment flow. cannot be done on the living animal, because the opening of the vessel alters the resistance to flow, and the loss of blood also changes the physiological conditions. To determine the velocity other means must be devised. Ludwig invented an instrument called the stromuhr, consisting of two bulbs mounted on a rotating platform pierced with two holes. One bulb is filled with oil—the other with blood. The bulbs are connected together by a tube at their upper end, and the lower end of the one full of oil is brought over the hole in the platform. The central end of the artery is connected to the same hole and the peripheral end to the other, over which stands the bulb full of blood. The blood being allowed to flow displaces the oil out of the one bulb into the other; directly this happens, the bulbs are rotated and the one full of oil is again brought over the central end of the artery. The number of rotations per minute is counted, and the volume of the bulb being known we obtain the volume of blood that passes through the instrument per a - minute. In another instrument, the haemo- c dromograph of Chauveau, there is inserted FIG. 25.-Ludwig', into the artery al tube in which hangs a small Stromuhr. pendulum; the stem of the pendulum passing through a rubber dam which closes the vertical limb of the tube. The pendulum is deflected by the flow, and the greater the velocity the greater the deflection. The deflection can be recorded by connecting the free end of the pendulum to a tambour arrangement. This instrument allows us to record and measure the variations of velocity during systole and diastole of the heart, but it can only be used in the vessels of large animals. Still other methods have been employed by Cybuleki and Stewart. The general relations of the velocity of the blood in the arteries, capillaries and veins is expressed by the curve shown in fig. 26. The velocity in the large arteries may reach 50o mm. per second in systole and fall to 15o mm. in diastole. The smaller the artery I The introduction of rubber tubing for the connexions made the the less is this difference and the more uniform the rate of flow, method. of inquiry comparatively simple. The tubing connecting the arterial cannula and the manometer was filled with a suitable fluid to prevent coagulation of the blood; also to prevent more than a trace of blood entering the connexions. A saturated solution of sodium sulphate, or a i % solution of sodium citrate, may be employed for this purpose. Ludwig (1847) added a float provided 1; ; 1 with a writing style to the mercurial manometer, and brought the style to write on a drum covered with smoked paper and driven slowly round by clockwork—a kymograph By this means tracings of the arterial blood pressure are obtained, and the influence upon the blood pressure of various agents recorded and studied. For the veins a manometer filled with salt solution is used, as mercury is too heavy a fluid to record the far slighter changes of venous pressure. The manometer may be connected with a recording n Je`~> tambour. The arterial blood-pressure record obtained with the mercurial manometer exhibits cardiac and respiratory oscillations as shown ' lreiha in fig. 18. The method gives us a fairly accu- • rate record of the mean pressure, but the mass of the mercury causes such inertia that the instrument is quite unable to faithfully record the systolic and diastolic variations of pressure. To effect this record, delicate spring manometers of rapid action and small inertia have been in-vented. A mercury manometer provided with maximum and minimum valves has also been employed to indicate the maximal systolic and minimal diastolic pressure. To determine the blood pressure in man, an instrument called the sphygmometer is used. The writer's sphygmometer consists of a rubber bag covered with d silk which is filled with air, and con- nected by a short length of tube to a manometer. This manometer con- sists of a graduated glass tube, open at one end. A small hole is in the side of the tube near this end. A r,.r may meniscus of water is introduced up to the side hole—the zero mark on the scale—by placing the open end of the i tube in water. The bag is now con- nected 1 to the gauge so that the side hole is closed by the rubber tube. Covering the rubber bag with the hand and pressing it on the radial artery until the pulse (felt beyond) is obliter- ated, one reads the height to which i the meniscus rises in the manometer, and this gives us the systolic pressure in the artery. The air above the meniscus acts as a spring, converting the instrument into a spring manometer. It is empirically graduated in mm. Hg. r It is very necessary to remember that the blood pressures, taken in different vessels and postures, vary with the hydrostatic pressure of the column of blood above the point of measure- ment. (t, Thus in the standing posture the arterial pressure in the arteries of the leg is higher than in the arm by the height of the column of blood that separates the two points of measure- ment. In the horizontal posture the pressure is practically the same in all the big arteries. The pressure in the ascending aorta is kept about the same in all postures, while that of the leg arteries varies widely. The effect of gravity is compensated there by active changes in heart force, splanchnic dilatation, &c. (L. Hill). The systolic pressure of young men, taken in the radial artery with the arm at the same level as the heart, may be taken to be about Ito mm. of Hg. In men of 4o-6o years the systolic pressure is often about 140 mm., but in some robust men it is no higher than in youth. The venous pressure in man may be measured by finding the pressure just required to prevent a cutaneous vein refilling after it has been emptied beyond a valve. There is no accurate method The time necessary for a section of the system. Thus the greatest velocity is where the total bed is narrowest, and slowest where the bed widens to the dimensions of a lake. The blood in leaving the heart may take a short circuit through the coronary system of the heart and so back to the right heart, or it may take a long an devious course tothe toes and back, or through the intestinal capillaries, portal system and hepatic capillaries. It is obvious, then, that the time any two particles of blood take to complete the circuit may be widely different. Experiments have been made to determine how rapidly any substance, like a poison, which enters the blood ma be distributed over the body. A salt such as potassium ferrocyanide is injected into the jugular vein, and the blood collected• in successive samples at seconds of time from the opposite jugular vein. These samples are tested for the presence of the salt, or a strong solution of methylene blue is injected into the jugular vein, and the moment determined with a stop-watch when the blue colour appears in the carotid artery. The velocity of flow also can be determined in any organ by injecting salt solution into an artery, and observing, with the aid of a Wheatstone's bridge arrangement, the galvanometric change in electrical resistance which occurs in the corresponding vein when the salt solution reaches it. The moment of injection and that of the alteration in resistance are observed with a stop-watch (Stewart). It has been determined that the blood travelling fastest can complete the circuit in about the time occupied by 25 to 30 heart-beats, say in 20 to 30 seconds; a result which shows how rapidly methods must be taken to prevent the absorption of poisons—for example, snake-poison. The blood travelling fastest in the pulmonary circuit occupies only about one-fifth of the time spent by that in the systemic circuit. That some of the blood takes a very long time to return to the heart is shown by the long time it takes to wash the vascular system free of blood by the injection of salt solution. That the blood is under different pressure in the various parts of the The system has long been known. From a divided artery the pressure blood flows out in forcible spurts, while from a vein it relation flows out continuously and with little force. It takes in the very little pressure of the fingers to blanch the capillaries vascular of the skin, but an appreciable amount to obliterate the system. radial artery. Flo. 28.—Hill's Sphyg- Capillaries .. From Allchin's Manual of Medicine, by permission of Macmillan & Co. Ltd. , complete circula- tion. Arteries the Blood in the Arteries, Capillaries and Veins. The flow in the large veins is approximately equal to that in the large arteries. In the jugular vein of a dog the mean velocity was found to be 225 mm. and in the carotid 260 mm. per second. The velocity in the capillaries has been measured by direct observation with the microscope. It is very small, e.g. o .5-I mm. per second. The variation of velocity in different parts of the vascular system is explained by the difference in width of bed through which the stream flows. The vascular system may be compared to a stream which on entering a field is led into a multitude of irrigation channels, the sum of the cross sections of all the channels being far greater than that of the stream. The channels unite together again and leave the field as one stream. If the flow proceeds uniformly for any given unit of time, the same volume must flow through any cross Stephen Hales (1733) was the first to measure the blood pressure. He inserted a brass tube into the femoral vein of a horse and connected it to a long glass tube held vertically, using the trachea of a goose as a flexible tube, and found the blood rose to the height of 8 ft., oscillated there with each heart-beat, and rose and fell some-what with inspiration and expiration. In the vein he found the pressure to be only about 12 in. Poiseuille (1828) adapted to the same purpose the mercurial manometer, a U-shaped tube containing mercury, which, being 13.5 times heavier than blood, allowed the manometer to be brought to a convenient height. mometer. From Howell's Text-Book of Physiology, by permission of W . B. Saunders Co. and Diastolic Pressure. Systolic or nl xtmuof ro i mm zoo mm Mean `WA~. _- WAIL Diastolic or minimum 8omm Base line -6o mm -4o mm -somm it is difficult to determine whether a rise of pressure in the pulmonary artery is induced really by constriction of the pulmonary system, or by changes in the output of the heart; hence different observers have reached conflicting conclusions. In the case of lungs which have been supplied with an artificial circulation and a constant head of pressure to eliminate the action of the heart, no diminution in outflow has been observed in exciting the branches of the vagus or sympathetic nerves which supply the lungs, or by the injection of adrenalin (Sir Benjamin C. Brodie (1783–1862), and Dixon, Burton-Spitz). The portal circulation is peculiar in that the blood passes through two sets of capillaries. Arterial blood is conveyed to the capillary networks of the stomach, spleen, pancreas and intestines The by branches of the abdominal aorta The portal vein is of measuring the capillary pressure. It and the venous pressure constantly vary from nothing to a positive amount with rest or movement of muscles, change of posture, &c. The arterial pressure is raised during exertion by the more forcible beat of the heart—e.g. pressures of 140–190 mm. Hg have been observed immediately after a 3-mile race. It rapidly sinks to a lower level than usual after the exertion is over, e.g. 90 mm. Hg, owing to the quieter action of the heart and the persistence of the cutaneous dilatation of the blood vessels which is evoked by the rise of body temperature. The writer has observed in athletes rectal temperatures of 102–105° F. after long races. After meals there is an increase in cardiac force to maintain the flow through the dilated splanchnic vessels. Mental excitement raises the pressure—e.g. the writer's pressure may be to mm. before and 125 mm. Hg after giving a lecture. The origin of the blood pressure in the arteries is the energy of the heart. The pressure gradient depends on the peripheral resistance. In the arterials the pressure is spent, and little of it reaches the capillaries. The return of the capillary blood to the veins and the pressure in the veins is due partly to the remainder of the cardiac force, but more largely to the contraction of the skeletal muscles and the viscera, to the action of gravity in changes of posture and to the respiratory pump. The pulmonary artery, carrying venous blood, divides and sub- divides, and the smallest branches end in a plexus of capillaries The pul- on the walls of the air-cells of the lung. From this plexus the blood is drained by the radicles of the four pulmonary monary veins which open into the left auricle. The pressure in c/rcu/a- the pulmonary artery is less than one-third the aortic uO°' pressure, and the blood takes only one-third of the time to complete the pulmonary circuit that it takes to make the systemic. The four chief factors which influence the pulmonary circulation are: (1) the force and output of the right ventricle; (2) the diastolic filling action of the left auricle and ventricle; (3) the diameter of the pulmonary capillaries, which varies with the respiratory expansion of the lungs; (4) the intrathoracic pressure. In inspiration the lungs are distended in consequence of the greater positive pressure on the inner surfaces being greater than the negative pressure on their outer pleural surfaces. The negative pressure in the intrathoracic cavity results from the enlargement of the thorax by the inspiratory muscles. When the elastic lungs are distended by a full inspiration they exert an elastic traction amounting to about 15 mm. Hg. The heart and vessels within the thorax are submitted to this traction—that is, to the pressure of the atmosphere minus 15 mm. Hg—while the vascular system of the rest of the body bears the full atmospheric pressure. The thin-walled auricles and veins yield more to this elastic traction than the thick-walled ventricles and arteries. Thus inspiration exerts a suction action, which furthers the filling of the veins and auricles. This action is assisted by the positive pressure exerted by the descending diaphragm on the contents of the abdomen. Blood is thus both pushed and sucked into the heart in increased amount during inspiration. Experiment has shown that the blood vessels of the lungs when distended are wider than those of collapsed lungs. Suppose an elastic bag having minute tubes in its walls be dilated by blowing into it, the lumina of the tubes will be lessened, and the same occurs in the lungs if they are artificially inflated with air; but if the bag be placed In a glass bottle, and the pressure on its outer surface be diminished by removing air from the space between the bag and the side of the bottle, the bag will distend and the lumina of the tubes be increased. Thus it is evident that inspiration, by increasing the calibre of the pulmonary vessels, draws blood into the lungs, and the movements of the lungs become an effective force in carrying on the pulmonary circulation. It has been estimated that there is about one-twelfth of the whole blood quantum in the lungs during inspiration, and one-fifteenth during expiration. The great degree of distensibility of the pulmonary vessels allows of frequent adjustments being made, so that within wide limits,as much blood in a given time will pass through the pulmonary as through the systemic system. The limits of their adjustment may, however, be exceeded during violent muscular exertion. The compressive action of the skeletal muscles returns the blood to the venous cistern, and if more arrives than can be transmitted through the lungs in a given time, the right heart becomes engorged, breathlessness occurs, and. signs of venous congestion appear in the flushed face and turgid veins. The weaker the musculature of the heart the more likely is this to occur; hence the breathlessness on exertion which characterizes cardiac affections. The training of an athlete consists largely in developing and adjusting his heart to meet this strain. Similarly the weak heart may be trained and improved by carefully adjusted exercise. Rhythmic compression of the thorax is the proper method of resuscitation from suffocation, for this not only aerates the lungs, but produces a circulation of blood. By compressing the abdomen to fill the heart, and then compressing the thorax to empty it, the valves meanwhile directing the flow, a pressure of blood can be maintained in the aorta even when the heart has ceased to beat, and this if patiently continued may lead to renewal of the heart-beat. There is no certain evidence that the pulmonary arteries are controlled by vaso-motor nerves. In the intact animalformed by the confluence of the mesenteric veins with the Portal splenic vein, which together drain these capillaries. The ctionrcala- portal blood breaks up into a second plexus of capillaries . within the substance of the liver. The hepatic veins carry the blood from this plexus into the inferior vena cava. Ligation of the portal vein causes intense congestion of the abdominal vessels, and so distensile are these that they can hold nearly all the blood in the body: thus the arterial pressure quickly falls, and the animal dies just as if it had been bled to death. The portal circulation is largely maintained by the action of the respiratory pump, the peristaltic movements of the intestine and the rhythmic contractions of the spleen; these agencies help to drive the blood through the second set of capillaries in the liver. The systole of the heart may tell back on the liver and cause it to swell, for there are no valves between it and the inferior vena cava. Obstruction in the right heart or pulmonary circulation at once tells back on the liver. The increased respiration which results from muscular exercise greatly furthers the hepatic circulation, while it increases the consumption of food material. Thus exercise relieves the over-fed man. The liver is so vascular and extensile that it may hold one-quarter of the blood in the body. The circulation of the brain is somewhat peculiar, since this organ is enclosed in a rigid bony covering. The limbs, glands and viscera can expand considerably when the blood pressure rises, but the expansion of the brain is confined. By the The expression of venous blood from the veins and sinuses the cerebra! brain can receive a larger supply of arterial blood at c/rcu/a- each pulse. Increase in arterial pressure increases the tlon. velocity of flow through the brain, the whole cerebral vascular system behaving like a system of rigid tubes' when the limits of expansion have been reached. For as the pressure transmitted directly through the arteries to the capillary veins must always be greater than that transmitted through the elastic wall of the arteries to the brain tissue, the expansion of the arteries can-not obliterate the lumina of the veins. The pressure of the brain against, the skull wall is circulatory in origin: in the infant's fontanelle the brain can be felt to pulse with each heart-beat and to expand with expiration. The expiratory impediment to the venous flow produces this expansion. A blood clot on the brain or depressed piece of bone raise the brain pressure by obliterating the capillaries in the compressed area and raising the pressure therein to the arterial pressure. The arterial supply to the brain by the two carotid and two vertebral arteries is so abundant, and so assured by the anastomosis of these vessels in the circle of Willis, that at least two of the arteries in the monkey can be tied without grave effect. Sudden compression of both carotids may render a man unconscious, but will not destroy life, for the centres of respiration, &c., are supplied by the vertebral arteries. The vertebral arteries in their passage to the brain are protected from compression by the cervical vertebrae. Whether the muscular coat of the cerebral arteries is supplied with vaso-motor nerves is uncertain. Hurthle and others observed a rise of pressure in the peripheral end of the carotid artery on stimulating the cervical sympathetic nerve. The writer found this to be so only when the cervical sympathetic nerve was excited on the same side as the carotid pressure was recorded. If the circle of Willis was constricted, excitation of either nerve ought to have the effect; it is possible that the effect was produced by the vasoconstriction of the extra-cranial branches of the carotid. After establishing an artificial circulation of the brain Wiggins found that 'adding adrenalin to the nutritive fluid reduced the outflow, and it is supposed that adrenalin acts by stimulating the ends of the vasomotor nerves, rather than by stimulating the muscular coats of the arteries. The veins of the pia and dura mater have no middle muscular coat and no valves. The venous blood emerges from the skull in man mainly through the opening of the lateral sinuses into the internal jugular vein; there are communications between the cavernous sinuses and the ophthalmic veins of. the facial system, and with the venous plexuses of the spinal cord. The points of emergence of the veins are well protected from closure by compression. The brain can regulate its own blood supply by means of the cardiac and vaso-motor centres. Deficient supply to these centres excites increased frequency of the heart and constriction of the arteries, especially those of the great splanchnic area. Cerebral excitement has the same effect, so that the active brain is assured of a greater blood supply (Bayliss and L. Hill). In each unit of time the same quantity of blood must, on the average, flow through the lesser and greater circuit, for otherwise the The a circulation would not continue. Likewise, the average The Non velocity at any part of the vascular system must be incul during versely proportional to the total cross-section at that part. muscular In other words, where the bed is wider, the stream is slower; actin #y. the total sectional area of the capillaries is roughly estimated to be 700 times greater than that of the aorta or venae cavae. Any general change in velocity at any section of this circuit tells both backwards and forwards on the velocity in all other sections, for the average velocity in the arteries, veins and capillaries, these vessels being taken respectively as a whole, depends always on the relative areas of their total cross-sections. The vascular system is especially constructed so that considerable changes of pressure may be brought about in the arterial section, without any (or scarcely any) alteration of the pressures in the venous or pulmonary sections of' the circulatory system: A' high-pressure main (the arteries) runs to all the organs, and this is supplied with taps; for by means of the vaso-motor nerves which control the diameter of the arterioles, the stream can be turned on here or there, and any part flushed with the blood, while the supply to the remaining parts is kept under control. Normally, the sum of the resistances which at any moment opposes the outflow through the capillaries is maintained at the same value, for the vascular system is so co-ordinated by the nervous system that dilatation of the arterioles in any one organ is compensated for by constriction in another. Thus the arterial pressure remains constant, except at times of great activity. The great splanchnic area of arterioles acts as " the resistance box " of the arterial system. By the constriction of these arterioles during mental or muscular activity the blood current is switched off the abdominal organs on to the brain and muscles, while by dilating during rest and digestion they produce the'contrary effect. The constriction of the splanchnic vessels does not sensibly diminish the capacity of the total vascular system, for the veins possess little elasticity. Thus variations of arterial pressure, brought about by constriction or dilatation of the arterial system, produce little or no effect on the pressure in the great veins or pulmonary circuit. The contraction of the abdominal muscles, on the other hand, greatly influences the diastolic or filling pressure of the heart. It is obviously of the utmost importance that the heart should not be over-dilated by an increased filling pressure during the period of diastole. When a man strains to lift a heavy weight he closes the glottis, and by contracting the muscles which are attached to the thorax raises the intrathoracic pressure. The rise of intrathoracic pressure aids the pericardium in supporting the heart, and prevents over-dilatation by resisting the increase in venous blood pressure. This increase results from the powerful and sustained contraction of the abdominal and other skeletal muscles. In the diagram already given it is clear that the contraction of T will counteract the contraction of A. At the same time the rise of intrathoracic pressure supports the lungs, and prevents the blood, driven out from the veins, from congesting within the pulmonary vessels. Over-dilatation both of the heart and lungs being thus prevented, the blood expressed from the abdomen is driven through the lungs into the left ventricle, and so into the arteries. So long as the general and intense muscular spasms continue, there is increased resistance to the outflow of the blood through the capillaries both of the abdominal viscera and the limbs. The arterial pressure rises, therefore, and the flow of blood to the central nervous system is increased. The rise of the intrathoracic and intra-abdominal pressures, and the sustained contraction of the skeletal muscles, alike hinder the return of venous blood from the capillaries to the heart, and, owing to this, the face and limbs become congested until the veins stand out as knotted cords. It is obvious that at this stage the total capacity of the vascular system is greatly diminished, and the pressure in all parts of the system is raised. It is during such a muscular effort that a degenerated vessel in the brain is prone to rupture and occasion apoplexy. The venous obstruction quickly leads to diminished diastolic filling of the heart, and to such a decreased velocity of blood flow that the effort is terminated by the lack of oxygen in the brain. During any violent exercise, such as running, the skeletal muscles alternately contract and expand, and the full flood of the circulation flows through the locomotor organs. The stroke of the heart is then both more energetic and more frequent, and the blood circulates with in-creased velocity. Under these conditions the filling of the heart is maintained by the pumping action of the skeletal and respiratory muscles. The abdominal wall is tonically contracted, and the reserve of blood is driven from the splanchnic vessels to fill the dilated vessels of the locomotor organs. The thorax is tonically elevated and the thoracic cavity enlarged, so that the pulmonary vessels are dilated. At each respiration the pressure within the thoracic cavity becomes less than that of the atmosphere, and the blood is aspirated from the veins into the right side of the heart and lungs; conversely, at each expiration the thoracic pressure increases, and the blood is expressed from the lungs into the left side of the heart. While the respiratory pump at all times renders important aid to the circulation of the blood, its action becomes of supreme importance during such an exercise as running. The runner pants for breath, and this not only increases the intake of oxygen, butmaintains the diastolic filling of the heart. It is of the utmost importance that man should grasp the fact that the circulation of the blood depends not only on the heart, but on the vigour of the respiration and the activity of the skeletal muscles. Muscular exercise is for this reason a sine quit non for the maintenance of vigorous mental and bodily health. Under the influence of the muscular system comes not only the blood but the lymph. The lymphatics form a subsidiary system of small valved vessels, and drain the tissues of the excess of lymph, which transudes from the capillaries of the organs during functional activity, or in con-sequence of venous obstruction. The larger lymphatics open into the veins at the root of the neck. It is chiefly by the compressive action of the skeletal and visceral muscles, and the aspirating action of the respiratory pump, that the lymph is propelled onwards. It must be borne in mind that the descent of the diaphragm during inspiration compresses the abdominal organs, and thus aids the aspirating action of the thorax in furthering the return to the heart both of venous blood and of lymph. The circulation remains efficient not only in the horizontal but also in the erect position, and just as much so when a man, like a gymnast, is ceaselessly shifting the position of his body. Influence Yet in a man standing six feet the hydrostatic pressure of of poa a column of blood reaching from the vertex to the soles of tore on the feet is equal to 14 cm. of mercury. The blood, owing the d, to its weight, continually presses downwards, and under the culation. influence of gravity would sink if the veins and capillaries of the lower parts were sufficiently extensile to contain it. Such is actually the case in the snake or eel, for the heart empties so soon as one of these animals is immobilized in the vertical posture. This does not occur in an eel or snake immersed in water, for the hydrostatic pressure of the column of water outside balances that of the blood within, During the evolution of man there have been developed special mechanisms by which the determination of the blood to the lower parts is prevented, and the assumption of the erect posture rendered possible. The pericardium is suspended above by the deep cervical fascia, while below it is attached to the central tendon of the diaphragm. Almost all displacement of the heart is thus prevented. The pericardium supports the right heart when the weight of a long column of venous blood suddenly bears upon it, as, for example, when a man stands on his head. The abdominal viscera are slung upwards to the spine, while below they are sup-ported by the pelvic basin and the wall of the abdomen, the muscles of which are arranged so as to act as a natural waist-band. In tame hutch rabbits, with large patulous abdomens, death may result in from 15 to 30 minutes if the animals are suspended and immobilized in the erect posture, for the circulation through the brain ceases and the heart soon becomes emptied of blood. If, however, the capacious veins of the abdomen be confined by an abdominal bandage, no such result occurs. Man is naturally provided with an efficient abdominal belt, although this in many is rendered toneless by neglect of exercise and gross or indolent living. The splanchnic arterioles are maintained in tonic con-traction by the vaso-motor centre, and thus the flow of blood to the abdominal viscera is confined within due limits. The veins of the limbs are broken into short segments by valves, and these support the weight of the blood in the erect posture. The brain is confined within the rigid wall of the skull, and by this wall are the cerebral vessels supported and confined when the pressure is increased by the head-down posture. Every contraction of the skeletal muscles compresses the veins of the body and limbs, for these are confined beneath the taut and elastic skin. The pressure of the body against external objects has a like result. Guided by the valves of the veins, the blood is by such means continually driven upwards into the venae cavae. If the reader hangs one arm motionless, until the veins at the back of the hand become con• Bested, and then either elevates the limb or forcibly clenches the fist, he will recognize the enormous influence which muscular exercise, and continual change of posture, has on the return of blood to the heart. It becomes wearisome and soon impossible for a man to stand motionless. When a man is crucified—that is to say, immobilized in the erect posture—the blood slowly sinks to the most dependent parts, oedema and thirst result, and finally death from cerebral anaemia ensues. In man, standing erect, the heart is situated above its chief reservoir—the abdominal veins. The blood is raised by the action of the respiratory movements, which act both as a suction and as a force pump, for the blood is not only aspirated into the right ventricle by the expansion of the thoracic cavity, but is expressed from the abdomen by the descent of the diaphragm. When a man faints from fear, his muscular system is relaxed and respiration inhibited. The blood in consequence sinks into the abdomen, the face blanches and the heart fails to fill. He is resuscitated either by compression of the abdomen, or by being placed in the head-down posture. To prevent faintness and drive the blood-stream to his brain and muscles, a soldier tightens his belt before entering into action., Similarly, men and women with lax abdominal wall and toneless muscles take refuge in the wearing of abdominal belts, and find comfort in prolonged immersion in baths. It would be more rational if they practised rope-hauling, and, like fishermen, hardened their abdominal muscles. In the mature foetus the fluid brought from the placenta by the umbilical vein is partly conveyed at once to the vena cava ascendens Foetal by means of the ductus venosus and partly flows through two trunks that unite with the portal vein, returning the blood from the intestines into the substance of the liver, thence to be carried back to the vena cava by the hepatic vein. Having thus been transmitted through the placenta and the liver, the blood that enters the vena cava is purely arterial in character; but, being mixed in the vessels with the venous blood returned from the trunk and lower extremities, it loses this character in some degree by the time that it reaches the heart. In the right auricle, which it then enters, it would also be mixed with the venous blood brought down from the head and upper extremities by the descending vena cava were it not that a provision exists to impede (if it does not entirely prevent) any further admixture. This consists in the arrangement of the Eustachian valve, which directs the arterial current (that flows upwards through the ascending vena cava) into the left side of the heart, through the foramen ovale—an opening in the septum between the auricles—whilst it directs the venous current (that is being returned by the superior vena cava) into the right ventricle. When the ventricles contract, the arterial blood contained in the left is propelled into the ascending aorta, and supplies the branches that proceed to the head and upper extremities before it undergoes any further admixture, whilst the venous blood contained in the right ventricle is forced into the pulmonary artery, and thence through the ductus arteriosus—branching off from the pulmonary artery before it passes to the two lungs—into the descending aorta, mingling with the arterial currents which that vessel previously conveyed, and thus supplying the trunk and lower extremities with a mixed fluid. A portion of this is conveyed by the umbilical arteries to the placenta, in which it undergoes the renovating influence of the maternal blood, and from which it is returned in a state of purity. In consequence of this arrangement the head and upper extremities are supplied with pure blood returning from the placenta, whilst the rest of the body receives blood which is partly venous. This is probably the explanation of the fact that the head and upper extremities are most developed, and from their weight occupy the inferior position in the uterus. At birth the course of the circulation undergoes changes. As soon as the lungs are distended by the first inspiration, a portion of the blood of the pulmonary artery is diverted into them and undergoes aeration; and, as this portion increases with the full activity of the lungs, the ductus arteriosus gradually shrinks, and its cavity finally becomes obliterated.' At the same time the foramen ovale is closed by a valvular fold, and thus the direct communication between the two auricles is cut off. When these changes have been accomplished, the circulation, which was before carried on upon the plan of that of the higher reptiles, becomes that of the complete warm-blooded animal, all the blood which has been returned in a venous state to the right side of the heart being transmitted through the lungs before it can reach the left side or be propelled from its arterial trunks". After birth the umbilical arteries shrink and close up and become the lateral ligaments of the bladder, while their upper parts remain as the superior vesical arteries. The umbilical vein becomes the ligamentum teres. The ductus venosus also shrinks and finally is closed. The foramen ovale is also closed, and the ductus arteriosus shrivels and becomes the ligamentum arteriosum. The blood vessels are supplied with constrictor and dilator nerve fibres which regulate the size of the vascular bed and the distribution The vaso- of the blood to the various organs. The arteries may be motor compared to a high pressure main supplying a town. By m means of the vaso-motor nerves the arterioles (the house nerves. taps) can be opened or closed and the current switched on to or off any organ according to its functional needs. If all the arterioles be dilated at one and the same time, the aortic pressure falls, and the blood taking the pathways of least resistance, gravitates to the most dependent parts of the vascular system, just as if all the taps in a town were opened at once the pressure in the main would fail, and only the taps in the lower parts of the town would receive a supply. The discovery of the vaso-motor nerves is due to Claude Bernard (1850. He discovered that by section of the cervical sympathetic nerve he could make the ear of a rabbit flush, while by stimulation of this nerve he could make it blanch. Claude Bernard had the good fortune to make the further discovery that stimulation of certain nerves, such as the chorda tympani supplying the salivary gland, produces an active dilatation of the blood vessels. The vaso-constrictor fibres issue in the anterior spinal roots, from the second thoracic to the second lumbar root, and pass to the sympathetic chain of ganglia. The fibres are of small diameter, and probably arise from cells situated in the lateral, horn of the grey matter of the spinal cord. They each have a cell station in one other ganglion and proceed as post-ganglionic fibres to the cervical sympathetic, to the mesenteric nerves and to the nerves of the limbs. Nicotine paralyses ganglion cells, and by applying this test to the various ganglia the cell stations of the vaso-constrictor fibres sup-plying each organ have been mapped out. The vaso-dilator fibres have not so restricted an origin, for they issue in the efferent roots in all parts of the neural axis. The two kinds of net'ves, although antagonistic in action, end in the same terminal plexus which'surrounds. the vessels. The presence of vaso-dilator fibres in the common nerve trunks is masked, on excitation, by the overpowering action of the vaso-constrictor nerves. The latter are, however, more rapidly fatigued than the former, and by this and other means the presence of vaso-dilator fibres can be demonstrated in almost all parts of the body. The nervi-erigentes to the penis and the chorda tympani supplying the salivary glands are the most striking examples of vaso-dilator nerves. The vaso-dilator nerves for the limbs issue in the posterior spinal roots (Bayliss). The posterior roots contain the afferent nerves (touch, pain, &c.). Excitation of these fibres causes reflexly a rise of blood pressure directly, a vaso-dilatation of the part the nerves supply. Thus it is assured that the irritated or injured• part receives immediately a greater supply of blood. The vaso-motor ,centre exerts. a tonic influence over the calibre of the arterial and portal systems. Much labour has been done. since to determine the origin and exact distribution of the vaso-motor nerves to the various organs, and the reflex conditions under which they come normally into action, and, as the fruit, our knowledge of these inquiries has come to a condition of considerable exactness. This knowledge is of great practical importance to the physician, and it is worth noting that it has been obtained entirely by experiment on living but anaesthetized animals. No dissections of the dead animal could have informed us of the vaso-motor nerves. Vaso-motor effects can be studied by (I) inspection of the flushing or blanching of an organ; (2) measuring the venous outflow; (3) recording the pressure in the artery going to and the vein leaving the organ; (4) observations on the volume of an organ. To make these observations, the organ is enclosed in a suitable air-tight box or plethysmograph, an opening being contrived for the vessels of the organ to pass through so that the circulation may continue. The box is filled with air or water and is connected with a recording tambour (see fig. i8). The chief effects of vaso-constriction are an increased resistance and lessened flow through the organ, diminished volume and tension of the organ, the venous blood issues from it darker in colour. and the pressure rises in the artery and falls in the vein of the organ, and its temperature sinks. Lastly, if a large area be constricted the general arterial pressure rises. The centre is situated in the spinal bulb beneath the middle of the floor of the fourth ventricle. The tone of the vascular system is not disturbed when the great brain and mid brain is destroyed as far as the region of the pons Varolii, but as soon as the spinal `bulb is injured or destroyed the arterial pressure falls very greatly, and the animal passes into the condition of surgical shock if kept alive by artificial respiration. Painting the floor of the fourth ventricle with a local anaesthetic, e.g. cocaine, has the same lowering effect on the blood pressure. Division of the cervical spinal cord or of the splanchric nerves lowers the blood pressure greatly. The one lesion cuts off the whole body, the other the abdominal organs from the tonic influence of the centre. The fall of pressure is due almost entirely to the pooling of the blood in the portal veins and vena cava inferior. On the other hand, electrical excitation of the lower end of the divided cord or splanchnic nerves raises the pressure by restoring the vascular tone. If an animal be kept alive after division of the spinal cord in the lower cervical region, as it may be, for the phrenics, the chief motor nerves of respiration, 'come off above this region, it is found that the vascular tone after a time becomes restored and the condition of shock passes away. By no second section of the spinal cord can the general condition of shock be reproduced, but a total obstruction of the cord once more causes a general loss of the vascular tone. From the experimental result, so obtained, it is argued that subsidiary vaso-motor centres exist in the spinal cord, and there is evidence to show that these centres may be excited reflexly. After the lumbar cord has been destroyed the tone of the vessels of the lower limbs is recovered in the course of a few days. In this case the recovery is attributed to the ganglionic and nervous structures which are intercalated between the spinal cord and the muscular walls of the blood vessels. There are thus three mechanisms of control, the bulbar centre influenced particularly by the visual, auditory and vestibular nerves, the spinal centres and the peripheral ganglionic structures. The vaso-motor centre is reflexly excited by the afferent nerves, and its ever-varying tonic action is made up of the balance of the " pressor " and `° depressor influences which thus reach it, and from the quality of the blood which circulates through it. Pressor effects, i.e. those causing increased constriction and rise of arterial pressure, may be produced by stimulating the central end of almost any afferent nerve, and especially that of a cutaneous nerve. Depressor effects are always obtained by stimulating the depressor nerve, and may be obtained by stimulating the afferent nerves under special conditions. That these reflex vaso-motor effects frequently occur is shown by the blush of shame, the blanching of the face by fear,, the blanching of the skin by exposure to cold and the flushing which is produced by heat. The rabbit's ear blanches if its feet are put into cold water. The vaso-motor mechanism is one of the most important of those mechanisms which control the body heat. , Stimulation of the nasal mucous membrane causes flushing of the vessels of the head, constriction elsewhere and a rise of arterial pressure. Food' in the mouth,. or even the sight or 944 smell of food, cause dilatation of the vessels of the salivary gland. The mucous membrane of the air passages flush and secrete more actively when a draught of cold air strikes the skin. Ice placed on the abdomen constricts not only the vessels in the skin but those in the kidney. Many other examples might be given of the control which the vaso-motor system exerts, but the above are sufficient to suggest the influence which the physician can bring to bear on the blood supply of the various organs. Discussion has taken place as to whether depressor reflexes are brought about by lessening of the vaso-constrictor tone or by ex-citation of vaso-dilator nerves. Proof of an undoubtable character seems to have been produced that after division of the vaso-constrictor nerves dilatation of a limb can be brought about reflexly by stimulating the depressor nerve, and in this case the effect must be produced by active excitation of the vaso-dilator nerves. Under certain unusual conditions, e.g. deficient supply of oxygen, the vaso-motor centre exhibits rhythmical variations in tonicity which make themselves visible as rhythmical rises and falls of arterial pressure of slow tempo. A waxing and waning of respiration (Cheyne-Stokes breathing) frequently accompanies these waves. Such are observed in sleep, especially in children and in hibernating animals. IV. PATHOLOGY OF THE VASCULAR SYSTEM On account of its intimate relations with every part of the body, the circulation is prone to disturbances arising from a great series of causes. Some of these produce effects which may be regarded as functional—mere changes in metabolism, whose disturbances react upon the rest of the body; others give rise to definite structural alterations. In considering the pathology of the circulation, it is useful to divide it into that of the heart, that of the blood vessels and that of the blood. The heart is liable to changes in the pericardium, malformations, changes in the myocardium, changes in the The heart. endocardium, valvular lesions and functional disorders. he (1) The pericardium may become the seat of morbid changes in various cardiac enlargements, it may become stretched or distended; but the most common and important of the changes is an inflammatory one, i.e. pericarditis. This may arise by way of the blood stream, as in rheumatism, scarlatina and other infective diseases, or by way of the lymph stream. The micro-organisms chiefly responsible for the production of pericarditis are the pneumococcus, the different varieties of streptococci and staphylococci, the bacillus tuberculosis, the bacillus coli, and sometimes the gonococcus. In the acute form of the disease the shining serous membrane becomes first dull and lustreless, the blood vessels engorged and an exudation of serum takes place; then fibrin is deposited both on the visceral and parietal layers. When the fluid is insufficient to keep the surfaces apart, the separation at each diastole gives rise to the well-known " friction rub." Sometimes the amount of exudation pent up in the pericardial sac is so great as to necessitate its being drawn off. The fluid may be serous or sero-fibrinous, or may be haemorrhagic, or have undergone a putrefactive change. An effusion of serous fluid into the pericardial sac causes considerable embarrassment to the course of the blood, by rendering the negative pressure, normally present in the sac, positive. The reason for the interference with the circulation brought about by this alteration of pressure is that the auricles are by compression rendered incapable of accommodating the blood-return from the veins. Analogous effects are produced by pressure upon the heart from without, whether by aneurysm or tumour, and pleural effusion or pneumothorax, affecting the viscera from without. In pericarditis it has further to be remembered that the effect of the process itself upon the muscle fibres lying beneath the membrane is to cause a softening of texture and weakening of function, whereby the driving power of the heart is diminished. In obliteration of the pericardium, again, the presence of the adhesions between these two layers leads to interference with the contraction of the myocardium, whereby its functions are interfered with. Acute ventricular dilatation may be associated with pericarditis particularly when the latter is of rheumatic origin and is the result of the myocardial softeningreferred to. Pericardial effusions usually undergo absorption, but various adhesions, and thickenings known as " white spots," may remain. Effusions other than inflammatory are found in the pericardium, i.e. hydropericardium, a dropsical accumulation, may be mistaken for an inflammatory one. It occurs in scarlatina, Bright's disease, as part of a general dropsy, or occasionally from some mechanical difficulty interfering with the local circulation. When the fluid is abundant, it may produce the effects noticed under the inflammatory effusion, and the pericardium may become soddened and its endothelium degenerated. Haemopericardium, or blood in the pericardium, may occur apart from the amount that may be mixed with inflammatory effusions. It is associated with foreign bodies penetrating from the oesophagus, rupture of an aneurysm, or occasionally associated with scurvy and purpura. Gas and air may sometimes distend the pericardium. It is also liable to new growths, which are usually secondary in character, and tuberculosis and hydatids are sometimes found. (2) Malformations.—We are ignorant of the causes which lead to imperfect development of the heart. Many of its malformations are of purely pathological interest, but others, such as deficiencies of the intraventricular septum, non-closure of the foramen ovale, patency of the ductus arteriosus, or malformations of the valves, pro-duce a series of secondary effects resultant on the deficient aeration of the blood and sluggishness of the circulation and of venous congestion. The train of symptoms is similar to those mentioned below under acquired valvular lesions, but dropsy is very rare. (3) The Myocardium.—The coverings of the heart muscle can-not long be diseased without affecting the contractile substance itself. Any morbid changes in the lung tissues which impede the circulation through them, and more particularly emphysema, lead to change in the substance of the right ventricle, while morbid changes in the systemic arteries lead to changes in the left ventricle. In hypertrophy we have an increase of substance. Tangl found by direct measurement that the muscle cells are increased in diameter. The hypertrophy may be due to increased work thrown upon the muscle, as in athletics (idiopathic hypertrophy), or may be compensatory, when the muscle is trying to overcome a circulatory defect, as in valvular stenosis or regurgitation. Hyper-trophy, when within physiological limits, is to be considered as a means of adaptation. When occurring in pathological circumstances, it must be regarded as a method. of compensation. Every structure and every function in a healthy body has greater or lesser reserve of energy. In healthy conditions the ordinary demands made upon various organs are far below their possible responses, and if these be excessive in extent or duration, the organs adapt themselves to the conditions imposed on them. In abnormal circumstances the process of hypertrophy is brought about by the power which the structures have of responding to the demands made upon them; and so long as the process is adequate, all disturbances may be averted. As an example of such readjustment may be cited the fact that in chronic renal cirrhosis, with increased thickness of the middle tunic of the arteries, there is hypertrophy of the left ventricle. Dilatation of the heart is due to the inability of the heart muscle to expel the contents of its cavities. It may occur from temporary overstress or in the failing 'compensation of valvular disease, or may accompany pathological changes in the muscle such as myocarditis or one of the degenerations. From the presence of toxic substances in the blood (whether introduced from without or arising within the body) the cells of the cardiac muscle fibres are apt to undergo what is termed cloudy swelling—the simplest form of degenerative process. The cells become larger and duller, with a granular appearance, and the nuclei are less distinct. As a result of interference with nutrition, whether by simple diminution or perverted processes, fatty de-generation ensues. It may be associated, but is not necessarily connected, with adipose accumulation and encroachment commonly termed infiltration. In true fatty degeneration the muscle cells have part of their protoplasm converted into adipose tissue. The fibres become granular, and the cells lose their definition, while the nuclei are obscure. The myocardium undergoes both acute and chronic reaction changes. In the former there is enlargement of the nuclei, with proliferation but without karyokinesis. The muscle cells become swollen and lose their striation, while they are softer in texture and altered in outline. The intermuscular tissues are swollen, and may be invaded by leucocytes; this may end in abscess formation or in the production of newly formed fibrous tissue. Chronic processes affecting the myocardium give rise to a large amount of fibrosis, and the newly formed fibrous tissue separates and compresses the areas of muscle fibres, giving rise to what is commonly known as chronic interstitial myocarditis. Restitution or recovery may occur to a varying extent in almost all of the disease-processes which have been considered, but it has to be kept in view that in certain of the degenerative affections there is little if any possibility of getting rid of the results of the process, which in the reactive changes terminating in the formation of much fibrous tissue, or its conversion into adipose or calcareous material, the same holds true. Many of the changes, which are no doubt in their essence conservative, lead to far-reaching con-sequences, by their interference with nutritive possibilities. Diseased conditions of the myocardium are frequently associated with atheromatous degenerations of the coronary arteries, and angina pectoris is said to depend upon such state of malnutrition. The causes which operate by means of the myocardium are almost invariably of a secondary character. The various degenerations already detailed, and the different forms of myocarditis, as well as simple debility of the muscle, are all examples of changes due to general or local disturbance. All • processes which directly or indirectly interfere with the energy of the walls of the heart produce twofold effects, by diminishing the aspiratory or suction-pump action daring diastole, and by lessening its expulsive or force-pump action during systole. The immediate result upon the heart itself of such disturbances is dilatation of that cavity immediately affected. This may occur under perfectly healthy conditions. In these, however, the dilatation is evanescent, while in the circumstances now under consideration it is permanent, and, although compensated, it leads to persistent dilatation. Upon the blood vessels the result, whether on account of diminished aspiratory or propulsive energy, is that the amount of blood in the arterial system is decreased, while it is increased in the venous. It is not a necessary consequence that because there is less blood in the arteries the arterial pressure will be diminished, or the venous pressure increased because the veins contain more than their normal amount of blood, seeing that the blood pressure depends upon many different factors. It is a fact, nevertheless, that in consequence of the alteration in the relative amount of blood in the arteries and veins there is a considerable disturbance of blood pressure. Gravitation may overcome the contractile and elastic factors, and several consequences arise from the resulting venous engorgement. From transudation, oedema of the de-pendent parts of the body and the serous membranes occurs. From the sluggish nature of the current, the blood absorbs too much carbonic acid and loses too much oxygen, hence cyanosis is the result. On account, also, of the slowness of the circulation, there is a longer period for radiation of heat, and the superficial parts of the body accordingly become cold. The engorgement of internal organs leads to distinct changes in them. The solid viscera, such as the liver, the spleen, the kidney and the lung, become enlarged and hyperaemic, and if the disturbance be continued, cyanotic atrophy ensues. Change in structure, with loss of function, takes place from blocking of the vessels by blood-clot, whether due to coagulation on the spot, or by the conveyance thither of clots formed elsewhere; a cirrhotic termination also is not infrequent, although there is salienttie:doubt whether in this latter condition other concomitant causes have not at the same time been operative. The brain, although suffering less from hyperaemia, is subject to disturbance of the circulation through it, while it is a common seat of embolic and thrombotic processes. The heart itself, lastly, suffers in consequence of the disturbed circulation through it, and by undergoing venous stasis, with weakening of its walls and increase of its fibrous tissue, it completes the final link in a vicious circle. Effusion into the serous sacs, such as the pleura, the pericardium and the peritoneuin, leads to great disturbance of the viscera with which they are connected. The mucous membranes, both respiratory and digestive, become the seat of catarrhal changes in consequence of the back-ward pressure and impure blood. (4) Changes in the Endocardium.—In endocarditts, or inflamma- tion of the lining membrane of the heart, that portion of the membrane which covers the valves is invariably affected first. Two varieties of endocarditis are described, simple and infective or ulcerative, but it is difficult to separate them pathologically. Both result from poisoning of the membrane by micro-organisms and their toxins; the main difference seems to lie in the variety of micro-organism present. Simple endocarditis may be associated with a variety of diseases, acute rheumatism and scarlet fever being the most frequent. In many fatal cases of chorea associated with endocarditis the micrococcus rheumaticus has been found in the endocardium, while the streptococci present in tonsilitis have produced endocarditis in animals. The membrane covering the valves loses its smoothness, granulations or elevations forming on the free edges; then the endothelium proliferates and is destroyed and fibrin becomes deposited, producing what is termed a " vegetation." In the lower layers of this vegetation micro-organisms can be demonstrated. Finally, portions of the vegetations may be broken off and carried as emboli in the blood stream, or two valves may become glued together, narrowing the opening and producing stenosis, or the deformed valves may be unable to close properly and regurgitation takes place. Thus the lesions of valvular disease are produced. In infective or ulcerative endocarditis, occurring in conjunction with such diseases as pyaemia, septicaemia, smallpox and pneumonia, pyogenic micrococci are carried into the blood stream, and purulent deposits take place around the valves. In this case, however, the emboli are septic, and when carried to distant tissues produce there ulceration and pus-formation. Numerous abscesses may occur in the well of the heart muscle itself. (5) Valvular Lesions.—All the valves of the heart are not equally liable to disease; those most frequently affected are the aortic and mitral valves. We have seen how the lesions of the valves are brought about. A valvular lesion may act in two. ways: it may impede the onward flow of the blood by narrowing the orifice, or the mat-closure of the valves may allow a reflex of blood, Either of these processes may occur at any of. the valvular orifices of the heart. Obstruction is usually complicated by some regurgitation as well, though the converse does not hold good. An increase of the quantity of blood in the auricles, particularly the left, has a less marked effect on the heart itself than an increase in the con-tents of the ventricles,, owing to the left auricle being in. continuity with the pulmonary system; whereas if the amount of blood in the left ventricle be doubled the ventricle must. dilate in order to accommodate it. The reserve power of the heart is. called upon to meet the dilatation, the muscular tissues becoming hypertrophied, and a more powerful systole is produced. As the left is the chief ventricle to undergo this change, the apex of the heart becomes displaced downwards. Similar changes take place it the right ventricle in pulmonary stenosis or tricuspid incompetency. Changes in the right ventricle other than primary valvular disease of the right side of the heart are frequently, preceded by mitral incompetence, and are due to extra pressure being thrown upon the pulmonary semilunar valves by the pressure in the overfull pulmonary system. In mitral regurgitation the accumulation of blood in the right. auricular cavity leads to its dilatation and an engorgement of the pulmonary vessels, pulmonary oedema and induration of the lung, which in turn affects the right heart. Should compensatory hypertrophy of the right ventricle fail to be established, we get the general venous congestion, dropsy and sequence before alluded to. (6) Functional Cardiac Disorders. Cardiac rhythm may be modified in several ways; there may be variation in either the length or the strength of the beat, or the beats may not be asynchronous. In palpitation or tachycardia its frequency is increased. This increase depends upon the inhibition of the action of the cardio-inhibitory centre, impulses passing to it from the stomach (as in dyspepsia) or from other organs. Tachycardia is also produced by toxic action, as in diphtheria and Graves's disease. Irt bradycardia the frequency is diminished. It may be due to toxins or to degenerative changes. Intermittence may simulate brady cardia, though the actual rate of the beat is not lessened; but the weak beats fail to reach the periphery. Various irregularities may take place, dependent upon perverted nerve action. It is considered that the intrinsic nerve elements play a large part in these; and In some forms of disease the irregularity is of myocardial origin. The blood vessels possess the properties of contractility and elasticity in different degrees. Their 'contractility is char- acterized by great tonicity, considerable rh'ythn4ic The bid action` and little or no rapidity of contraction. Their vessels. elasticity stores up energy in a potential condition, and this may be liberated in kinetic form as required. The vessels are supported in various degrees by the different tissues in which they are found. In the more solid viscera they are strongly supported, as in the liver and kidney, while in those which are less dense,. as in the case of the brain and the ' lungs, they are not so well sustained.. In many conditions the contractility and elasticity of the blood vessels become diminished according as they may be involved in various pathological processes—purulent, tuberculous or syphilitic. Chronic toxic conditions lead to numerous degenerations, such as fatty degeneration or hyaline degeneration of muscle fibre, apparently as the effect of coagulative processes. The tissues assume a somewhat glassy appearance, with a distinct tendency towards segmentation. Calcareous infiltration•is brought about by the deposition of lime salts in tissues which have previously,. under-gone fatty or fibroid changes; it particularly affects the arteries in senile affections. In consequence of many toxic agencies as part . of a senile change, and as the effect of long-continued 'stress, the blood vessels undergo a loss of their normal properties. This is compensated by the growth of an excessive amount of fibrous tissue, leading to various forms of arterial sclerosis, of which the best known are endarteritis obliterates, which affects the smaller arteries and is due to a toxic irritant and may occur at any age, and endarteritis deformans (atheroma), which affects the larger arteries during middle age, and is usually due to mechanical irritation, As the result of these fibrous changes there is interference with the blood current, since the vessels become unyielding yet frangible, instead of distensile and elastic, tubes. The sclerotic changes lead, moreover, to dilatation of blood vessels, as well as to the formation of definite aneurysms. They also pave the wan for coagulation of blood within them, i.e. thrombosis, while in certain situations, more particularly in the brain and in the kidney, rupture is apt to take place. Upon the heart also these changes bring about far-reaching effects. Dilatation, accompanied by hyper-trophy, is a certain result of generalized arterial degeneration, while changes in the coronary arteries lead to some of the definite results in the walls of the heart which have already been considered. Veins are subject also to mechanical and toxic effects. The pressure of abdominal tumours, the effects of the weight of a column of blood on a long vein, constipation or obstruction to the venous return may cause dilatations or varicosity. The dilatation thins the walls of the veins and the valves become incompetent; the di4ated vessel then becomes twisted and the surrounding tissues thickened by the growth of fibrous tissue. The thinned walls may rupture, and, owing to the loss of the valves, extensive haemorrhages may take place. Thrombosis may follow the slowing of the blood current, and phleboliths are produced by the deposit of lime salts in it. Phlebitis is an acute inflammation of a vein.' Apart from injury it usually follows invasion by a septic thrombus, as in the ' well-known phlegmasia alba dolens, when an infective clot from the uterine sinuses reaches the iliac veins. The pathology of the blood itself is treated under Betio!).
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