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Title: On the origin of inflammation of the veins
and of the causes, consequences, and treatment of purulent deposits
Author: Henry Lee
Release Date: October 29, 2014 [EBook #47234]
Language: English
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ON PHLEBITIS.
----"Whose effect Holds such an enmity with blood of man,
That, with a sudden vigour, it doth posset
And curd, like eager droppings into milk,
The thin and wholesome blood."
HAMLET.
PLATE SHEWING THE FIRST MORBID APPEARANCE PRODUCED BY THE STAGNATION
OF VITIATED BLOOD IN THE CAPILLARIES OF THE LUNGS.
[Illustration: Surface of Lung with Pleura Removed.
Section of Lung.]
ON THE ORIGIN
OF
INFLAMMATION OF THE VEINS,
AND
ON THE CAUSES, CONSEQUENCES, AND
TREATMENT OF PURULENT
DEPOSITS.
BY
HENRY LEE, F.R.C.S.
ASSISTANT SURGEON TO KING'S COLLEGE HOSPITAL, ETC.
"There is more to be learnt of the use of the blood in the animal
economy from its coagulation than from its fluidity."--HUNTER.
[Illustration: Coat of arms]
LONDON:
HENRY RENSHAW, 356, STRAND.
1850.
LONDON.
RICHARDS, PRINTER, 100, ST. MARTIN'S LANE.
PREFACE.
Since the period when Humoral Pathology fell into merited disrepute,
comparatively few attempts have been made, to define with any degree
of accuracy, the conditions under which morbid secretions may find
their way into the circulation. The diseases produced by the presence
of vitiated fluids in the general system, and in parts of the body at
a distance from their original source, have received more attention;
but they are still far from occupying that position in our systems of
medicine and surgery which their importance deserves.
The difficulty of tracing diseased secretions after they have become
mingled with the blood, or of recognising their presence in the
vessels, has rendered the investigation of their actions often tedious
and inconclusive; while, on the other hand, the changes of structure
in solid parts, readily appreciated by the senses, have been more
calculated to arrest the attention, and to afford that ready solution
of the origin of the symptoms which, whether imaginary or real, has a
tendency to relieve the mind from farther doubt and suspense. Hence it
has happened, that the pathology of the solid parts of the body has
received a very disproportionate share of attention.
Most of the observations which have tended to advance our knowledge of
the effects of the introduction of diseased fluids into the blood, have
been recorded under the name of Phlebitis or Inflammation of the Veins;
and I have retained this title, although it is obviously inadequate to
express those constitutional affections which form the most important
and characteristic features of these complaints.
The introduction of pus into the system has justly been regarded as
the most important of this class of diseases. But the theory of the
circulation of pus globules with the blood, supported as it has been
by much ingenious reasoning, and most conveniently adapted to explain
the formation of purulent deposits, has yet never obtained general
belief. The stoppage of the pus globules in the capillary tubes, has
appeared to many accustomed to the practical observation of diseases,
too mechanical a solution of the origin of these abscesses; and it has
become necessary to determine, with more precision than has hitherto
been done, the actual conditions under which pus in substance can be
received into the circulation.
The simple experiment of mixing some pus with healthy, recently drawn
blood, will at once shew that such a combination cannot circulate in
the living body. It will be found that the blood coagulates round the
globules of pus, and forms a solid mass which will adhere to the first
surface with which it comes in contact; and it will be evident, that it
is not till the coagulum thus formed is broken up or dissolved, that
its elements can circulate with the blood.
It appears not a little surprising that this, perhaps the simplest and
the most instructive experiment that can be performed in reference to
the subject of the formation of purulent deposits, should not have been
resorted to in preference to others which have been difficult in their
execution, and inconclusive in their results.
It has been remarked by Sir Charles Bell, that we can seldom rely
upon the answers that are extorted from living animals by experiments
which go counter to the natural feeling of mankind; and that it is our
duty, if experiments are performed, at all events to prepare for them
by the closest previous application of our reason, and so to narrow
the question as to be certain that advantage may be gained by our
proceedings. Had the simple experiment mentioned above, illustrating
the action of pus upon blood out of the body, been duly considered, it
might have saved some of the vague and useless experiments which have
been performed upon living animals in the investigation of the present
subject.
_Sept. 1850._
_13, Dover Street, Piccadilly._
PART I.
ON INFLAMMATION OF THE VEINS:
WITH EXPERIMENTS ILLUSTRATING THE EFFECTS OF A VITIATED CONDITION OF
THE BLOOD.
I. John Hunter expressed his belief that the blood has "the power of
action within itself",[1] and that when it coagulates, it does so in
consequence of an "impression" which it receives. Such an impression
may be communicated by separation from the living vessels, or from
"cessation of natural action"[2] in them. In certain circumstances
also the living vessels themselves may be the means of exciting
coagulation.[3] In others, the admixture of extraneous substances may
either retard or hasten this operation.[4] The experiments made to
determine the last point, Mr. Hunter informs us, "were rather imagined
than fully carried out; and the subject rather broached and touched
upon, than prosecuted".[5] In these experiments, different articles
used in medicine were mixed with portions of blood taken from the body;
and it was found that, in some cases, they altered both "the time," and
"the firmness of the coagulation".[6] The circumstance of medicines
being used in such experiments, conveys the idea, that, in instituting
these researches, Hunter conceived that substances which would tend
to produce such actions out of the body, might likewise produce some
effect upon the blood in living animals. In endeavouring to prosecute
the idea thus thrown out, I have been led to try the effect of
different substances upon the blood, and to consider the changes which
may be produced in that fluid, by the admixture of animal secretions.
The experiments which will be hereafter detailed, not only confirm Mr.
Hunter's notion, that foreign substances may induce actions in the
blood when withdrawn from the body, but also show that some of these
effects may be produced still more rapidly in the living vessels.
[1] HUNTER on the Blood. Ed. 1794, p. 21.
[2] P. 25. [3] P. 24. [4] P. 97. [5] P. 94. [6] P. 98.
In these experiments, pus was used in preference to any other fluid;
first, because the power of coagulating the blood which it was found
to possess, enables its influence to be traced within the body; and
secondly, because, being an animal secretion, the results obtained are
likely to be analogous to those produced by the admixture of other
secretions with the blood.
When pus is mixed with blood, fresh-drawn from a healthy animal, it
is found in a marked manner to favour coagulation. This effect does
not take place immediately, as in the case of the mixture of an acid
with the blood; and I have reason to believe, that where the blood has
lost its natural power of coagulation, no visible change is produced
in it by the addition of pus. It appears, therefore, that this effect
depends rather upon a vital than a chemical influence. In some cases,
the coagulation takes place in less than two minutes; in others, after
a longer period; but in all the experiments made, the influence of pus,
when added to blood, in promoting its coagulation, was sufficiently
evident. Putrid pus was found to act more rapidly than healthy pus
(Exp. 1, _b_), but the admixture of water was found to retard the
operation; the result, in this respect, differing in some degree from
the conclusion drawn from a similar experiment performed by Hunter.[7]
The causes which usually favour coagulation out of the body, are rest,
and separation of the blood into small quantities. These conditions
are, in some degree, brought into play during the circulation of the
blood through the capillaries; and when the influence of the admixture
of pus with the blood is not sufficient to produce coagulation at once,
we should naturally expect the effect to be more readily induced,
where these two additional causes concur in favouring such an action.
When the pus introduced is in any large quantity, the coagulation of
the blood is at once determined, and the entrance of pus into the
circulation thereby prevented. The experiments VI, VII, and VIII,
appear to furnish evidence of the correctness of this opinion, and to
show that the result may be produced more quickly in the vessels than
elsewhere. In these cases, so sudden was the effect, that the mixture
of blood and pus coagulated before it could traverse the jugular vein,
as indicated by the induration and cord-like feeling of the vessel.
[7] Op. cit. p. 98.
In Experiment VIII, the obstruction formed was sufficient to resist
even firm pressure, and in a great measure, if not altogether, to
prevent the pus injected from finding its way along the vein. The
coagulum was felt in the vessel during the operation, and was there
found after death. One effect of the coagulation of the blood thus
immediately produced, is necessarily to retain the vitiated blood
in the part, and to prevent its being carried in the course of the
circulation. This intention may be interfered with, either by accident
or design. The coagulum, as in Experiment VI, may be broken up during
the process of its formation, or after it has formed, and the parts
of which it was composed carried forward with the circulating blood.
In such a case, the vein in which the coagulum first formed, is found
in its natural condition (except at the part where it may have been
mechanically injured), and dark patches of congestion may be found in
distant systems of capillaries. If the coagulum be allowed to remain,
the vein in which it is formed soon becomes thickened; but, as the
experiments cited prove, _this thickening is the effect and not the
cause of the stagnation of the vitiated blood in the vessel_.
II. When blood coagulates in a serous cavity, a thin pellicle forms
upon its surface, and, becoming thickened by deposition from the
fibrin of the blood, forms a cyst, which completely circumscribes the
effusion. This point has not probably received the attention which it
deserves; and as it is believed to be of primary importance in the
investigation of the present subject, a short space will be devoted
to the purpose of fully establishing it, and tracing its connexion
with other and subsequent changes. Every layer of lymph observed upon
dissection, has perhaps too generally been considered as the result
of inflammation; and hence there has arisen a confusion in the terms
employed. That lymph may be derived from the blood directly, and
deposited in the form of a membrane, without being secreted by any
vessel, has been fully shown by a paper in the _Medico-Chirurgical
Transactions_.[8] Such layers of lymph assume so much the appearance
of others, derived by secretion from inflamed capillaries, that they
have been described as identical. But the mode of their formation in
the two instances is altogether different. In the one case, the process
is a local one, confined to the blood itself, and subsequently to the
membrane with which it happens to be in contact. In the other case,
it is an effort of the constitution, accompanied by constitutional
symptoms. The former of these processes was clearly described by
Hunter. In describing the process of union by the first intention,
"Coagulation", he says, "I imagine to proceed upon exactly the same
principle as the union by the first intention. It is particle uniting
with particle by the attraction of cohesion, which, in the blood, forms
a solid; and it is this coagulum uniting to the surrounding parts
which forms the union by the first intention: for union by the first
intention is no more than the living parts when separated, whether
naturally, or by art, forming a reciprocal attraction of cohesion
with the intermediate coagulum, which immediately admits of mutual
intercourse, and, as it were, one interest."[9] "When the blood has
coagulated, so as to adhere to both surfaces and to keep them together,
it may be said that union has begun."[10] "The uniting medium becomes
immediately a part of ourselves, and the parts not being offended at
it, no irritation is produced." "If the quantity of blood extravasated
be large, the whole will not become vascular, but the surface only,
which is in contact with the surrounding parts."[11] The process thus
described in general terms may take place in serous cavities. In the
third plate at the end of Mr. Hunter's work, is represented a coagulum
of blood adhering to the _tunica vaginalis_. "The adhesion was firm,
though it admitted of a separation at one end; when separated, fibres
were seen running between it and the testis."
[8] Vol. x, p. 45-82. [9] Op. cit. p. 26. [10] P. 200.
[11] P. 205.
It might seem unnecessary to dwell upon this process further, had
not some of the highest authorities in surgery, both here and on the
continent, described it as identical with adhesive inflammation. Thus
Bichat[12] says, "The cicatrization of wounds in veins after bleeding
is a result of inflammation." Now, it is submitted, that when the blood
coagulates, either in serous cavities or in veins, the process of union
is not usually one of inflammation, or one in which the powers of the
constitution are called into increased activity. It is true, that in
both cases, inflammation may take place, and lymph, as the result of
such inflammation, may be secreted; but this is only when, to use Mr.
Hunter's language, the "primary intention" has not been fulfilled.[13]
[12] Anatomie Générale, vol. ii, p. 423.
[13] In speaking of the two principles, I shall use the term by "first
intention", to designate that the fibrin is derived from coagulated
blood; and restrict the term "adhesive inflammation" to indicate the
effusion of lymph from inflamed vessels.
When a membranous layer of lymph is deposited from effused blood, it
adheres with some firmness to the surface with which it is in contact;
but, as there is at first no vascular connexion established between
them, it may be separated, leaving the part to which it adhered in its
natural condition. Lymph derived from adhesive inflammation, on the
other hand, when separated, leaves the surface upon which it was formed
rough and uneven. Coagulated fibrin, when recently deposited, may thus
be distinguished from effused lymph.
The changes which blood undergoes when effused in serous cavities, may
likewise take place when it is detained in injured or exposed veins.
The coagulation of the blood in such cases (Exp. VII and VIII) serves
as a bond of union between the sides of the veins (which may be either
temporary or permanent), so as to prevent the entrance of any foreign
matter into the circulation. When the blood thus coagulates in veins,
changes may be produced analogous to those mentioned as occurring in
serous cavities. If the quantity of blood be large, a thin pellicle is
at first formed upon its surface (see Preparations 1523-25 and 1525-64,
in the Museum of Guy's Hospital). This membrane becomes thickened
and adheres to the internal surface of the vein (see plate No. 13,
Cooper and Travers' _Surgical Essays_, Part I, and Prep. No. 1736, in
the Pathological Museum of the College of Surgeons). It then becomes
vascular, and finally so firmly united to a part of the circumference
of the vessel as to be inseparable from it, without lacerating its
lining membrane.
If the wounded vessel be small, or if the animal be strong and robust,
the whole of the blood in the vein may at once coagulate and become
united to its sides. The usual economy of nature, however, is here
exercised, with a precision proportionate to the strength of the
patient. A simple wound in a vein, in healing by the first intention,
will not obstruct the circulation through the vessel under ordinary
circumstances. A coagulum will form, sufficient to unite together the
divided edges, and the circulation of blood through the vessel will be
uninterrupted; but if the wound does not readily heal, coagula may
form, which encroach more or less upon the cavity of the vein. There
are then three ways in which a coagulum may obstruct the circulation
through a vein. 1. By the outer layer of the coagulum forming a
membrane, which contains the more fluid parts of the blood. 2. By the
whole of the blood contained in the vessel forming a solid coagulum. 3.
By a coagulum adhering to the injured side only of the vessel.
In whichever of these ways the process of repair is commenced, it
may be interfered with, and the union dissolved. This is practically
known to farriers; who, when they want to bleed a second time from
the same orifice, break down the "union by the first intention" by a
blow upon the vein. During the time that the parts are united only by
the fibrin from the blood, any violence must tend to produce the same
effect. If the constitution is good, and the coagulating power of the
blood unimpaired, the union may be frequently interrupted, and yet
be as frequently re-established in the same way. When from any local
cause, or from any constitutional peculiarity, the union by the first
intention fails at the seat of the injury, it may yet be attempted at
some distance up the vein; and then we have coagula formed at different
distances along the vessel. If these coagula fill the vein, are firm,
and remain undisturbed by violence, the union may be complete, and
the vessel sealed at those parts, even although the original wound
should suppurate. But it sometimes happens, that the same peculiarity
of constitution, or the same local cause, which prevented the union at
the original wound, may prevent complete union by the first intention
at any other point of the vein; and then its canal is open to any
secretion that may be introduced into it. Foreign matter may thus
find its way along a vein; but still there is a provision against
its being carried the round of the circulation. It has been already
shown that the blood, when in a natural condition, has a tendency to
coagulate around pus, and, probably, many other fluids, even out of
the body (Experiments I, V), and that this property is exercised in
a still more remarkable manner in the living vessels (see Experiments
VII, VIII). Foreign matter, even after it has got into the veins, may
then, by the same means, be prevented from proceeding farther towards
the centre of circulation. The process that takes place under such
circumstances, is strictly analogous to union by the first intention.
The blood may coagulate and adhere to the sides of any part of the
vascular system. The union thus formed may be permanent, or the
coagulum may be again broken up and carried with the blood in the
course of the circulation, as shown in Experiment vi. When this occurs,
as is shown in the same experiment, other changes supervene in remote
parts of the body. This tendency to coagulate around the foreign matter
once impressed upon the blood, cannot be destroyed by the coagulum
being mechanically broken up, as indeed is proved by the fact already
mentioned, that after one attempt at union in a vein (in consequence
of the introduction of foreign matter) has failed, another attempt is
made immediately farther up the vessel. Under these last circumstances,
we may find a vein partially obliterated at different points, leaving
intervals where lymph or pus are secreted. If the purulent matter
introduced is allowed to remain a short time only in the vein, no
inflammation is produced (Experiment VI). But when any irritating fluid
is detained there in consequence of the blood coagulating around it,
adhesive, ulcerative, or suppurative inflammation, will be excited
(Experiments VII and VIII).
The slowness with which veins inflame when cut, tied, or bruised, has
been made a subject of comment by different authors; and Mr. Travers,
in particular, has endeavoured to reconcile "the infrequency of its
occurrence" with the rapid and violent character of the inflammation in
certain cases. Although, under ordinary circumstances, a wounded vein
does not inflame, yet the annexed experiments show, that pus introduced
into its cavity will produce inflammation, in which the system will
sympathize. Other fluids besides pus will no doubt produce similar
effects; but those of pus are here particularly noticed, as affording a
good illustration of the series of changes produced by the introduction
of foreign matter into the blood.
What the symptoms are which characterize the presence of pus, as
distinguished from other secretions in the blood, it would probably
be difficult to determine in cases as they occur in practice.
The examination of the blood in these instances affords no very
satisfactory information; for the characters of pus, when the blood has
once coagulated round it, are so altered, that I know of no means by
which a small quantity can be recognized, when it has once entered the
circulation. The conclusions drawn from the different facts now stated
are,--first, that inflammation of a vein, or phlebitis, is no essential
part of the primary affection which precedes constitutional symptoms,
even when morbid matter has found its way into the circulation through
a vein. Secondly, that when inflammation of a vein does occur, in some
instances at least, it is not the cause, but the consequence of the
introduction of diseased or foreign matter into the blood. Thirdly,
that although veins are with difficulty inflamed by any mechanical
injury, they are susceptible of rapid inflammation, accompanied with
constitutional disorder, whenever any irritating fluids are introduced
into their cavities.
III. When the principal veins in a part become obstructed, it is
natural to suppose that changes should be produced in the smaller veins
which supply them. These changes may be expected in a more marked
degree, when the obstruction depends upon coagulation of the blood,
than when it arises from other causes, inasmuch as the coagulum usually
extends to several veins at the same time.
In the experiments that have been made upon animals, it has been a
matter of surprise that, while extreme pain was evinced upon the
injection of irritating fluids into the veins, comparatively little
or no suffering was produced, when similar experiments were performed
upon the arteries. The foreign matter introduced in these cases would
probably have the effect of coagulating the blood, as in the instances
already mentioned. If this occurred in an artery, the supply of blood
below the obstruction would be diminished; but if in a vein, the return
of blood would be prevented: in the latter case, the continued influx
of blood to the part would necessarily distend the capillaries.
In M. Cruveilhier's[14] experiment, of injecting ink into the veins of
dogs, he found, that in thirty-six hours the legs swelled, and a number
of bloody patches (_foyers apoplectiques_) were found in the substance
of the muscles and the cellular tissues of the limb. The large veins
were distended with adherent coagula of blood, and the smaller veins
around the livid patches were also filled with coagulated blood. If
the animal were allowed to live, the congested spots suppurated. The
appearances thus produced in the muscles and cellular tissue of the
limb were evidently not those of inflammatory action propagated along
the coats of the veins, for the affection in the capillaries was
circumscribed, and terminated in many places abruptly, leaving the
veins in the immediate neighbourhood perfectly healthy; still less
could the appearance produced depend upon the injected fluid finding
its way through the veins (contrary to the course of the circulation)
to the capillary system; nor, lastly, could it depend upon the ink
finding its way into the general circulation, and producing its effects
in its course a second time through the limb; for, not to mention that
the capillaries of the lungs and other parts would be equally liable to
be affected, one essential condition of the success of the experiment
is mentioned to have been, that the fluid injected should _not_ find
its way along the vein in the usual course of the blood. We therefore
conclude, that it was the coagulation of the blood in the large veins
which caused the congestion of the capillaries, those veins remaining
unaffected which could discharge their contents by some collateral
channel.
[14] CRUVEILHIER'S Path. Liv. XI.
In cases of phlegmasia dolens after child-birth, the same principle
can sometimes be traced; thus, in a dissection performed by Mr.
Lawrence,[15] the external and common iliac veins were filled with
a substance like the laminated coagulum of an aneurism. "The tube
was completely obstructed by this matter, adhering as firmly as the
coagulum does in any part of an old aneurismal sac. In its centre was a
cavity containing about a teaspoonful of thick fluid of the consistence
of pus, of a light brownish red tint, and pultaceous appearance." The
femoral vein was in this case also filled with a coagulum; but, as is
observed in the account of the dissection, the red colour of that vein
might have been caused by the clot everywhere in contact with it, and
therefore cannot be deemed a proof of inflammation.
[15] Medico-Chirurgical Transactions, vol. xii.
Mr. Guthrie[16] has published a case of inflammation of the veins
after amputation, resembling phlegmasia dolens, in which the veins
of the opposite limb, even down to the foot, had become affected. In
this case, on the fourteenth and fifteenth days after amputation of
the right thigh, the left leg began to swell, and became intolerably
painful. "The swelling was elastic, yielding to the pressure of the
finger, but not in any manner like an oedematous limb. _Upon a
careful examination, no pain was felt in the course of the iliac
vessels upon that side_; the stump looked well, save at one small
point, corresponding to the termination of the femoral vein." On
examination after death, the termination of the vein on the surface of
the stump _was open_, and in a sloughy condition. At the left groin,
the iliac vein was greatly distended with pus. Sir Henry Halford[17]
has also mentioned three cases of what he has termed phlegmasia dolens,
occurring in the male, in one of which the iliac vein was found
obliterated after death. In this case, the patient had suffered, for
several years before his death, from swelling of the left leg and
thigh. In the interior of the obliterated vessel there is a coagulum,
which has lost its colour, and become firm and completely adherent to
the inner surface of the vein. (See Prep. No. 1732, Path. Mus. Coll.
of Surgeons.) The rapid swelling and general pain of the limb in such
cases, indicate a sudden obstruction to the circulation, while the
absence of tenderness in the course of the vessels during the first
stages of the disease, tends to show that the contents of the vessels,
and not the vessels themselves, are primarily interested in its
production.
[16] Medical and Physical Journal, vol. lvi.
[17] London Medical Gazette.
The foregoing remarks have appeared necessary, in order to explain a
circumstance mentioned by Hunter, upon which considerable stress has
been laid by subsequent writers. Mr. Hunter observed that the whole
side of the head in horses that had been bled would frequently become
swollen and inflamed. The explanation of this fact appears very simple,
when viewed in relation to the general principle illustrated by the
above cases. The horse has only one jugular vein upon each side;
and, although in the usual operation of bleeding, its channel is not
obstructed, yet if the wound do not readily heal, its contents will
coagulate. The circulation will then be obstructed in all the distant
branches, and the blood, if long retained, will coagulate in them also.
It will then part with its serum, and give rise to all the symptoms
of inflammation in the distant vessels; a pulpy elastic swelling,
accompanied with great pain, will then be the principal symptom, while
the turgescence on the surface will be less than where the superficial
veins have been mechanically compressed. It will, however, very
frequently happen, that a vein in a part may be felt distended without
any symptom of inflammation being present; and, in other cases, the
pain and swelling will appear and disappear too rapidly to allow the
idea that they depend upon inflammation of the coats of the vein.
It has occurred to the author, to feel a vein in the arm and hand
distended during life, and after death, to find it empty, and its coats
of their natural colour and thickness; in such a case, the coagulum
gives way, becomes broken up, and mixed with the circulating blood.
IV. When pus, or other diseased fluid, is confined to the cavity of
a vein, the constitutional symptoms produced are comparatively mild,
as long as it remains limited and circumscribed by adherent coagula;
that is to say, so as to be excluded from the rest of the circulating
system. (Compare the frequency of the respiration in Experiments VI and
VII.) But the tendency of a clot of blood is to contract; and a time
comes when the coagulum is either broken up, or shrinks, so that if no
further changes are produced, the current of blood through the vein is
re-established.[18] Meanwhile, however, the coats of the veins have
undergone changes corresponding to the degree of irritation produced
by the contained fluids, and the intention or result to which the
inflammation tends. If the coagula have long remained, the coats of
the veins are always found thickened, sometimes to three or four times
their natural thickness, and sometimes so as to completely obliterate
the vessels. The contents of the veins are occasionally found to
consist, as far as can be seen, simply of coagulated blood; at other
times, they are found filled with soft yellowish coagula, deprived,
more or less perfectly, of their colouring matter; more rarely, the
cavity of a vein will be found filled with dark-coloured membranous
layers, leaving still a channel through the vessel; and occasionally it
will be found completely obstructed by "dense, dark-coloured, bluish
membranes."
[18] This remark I have had opportunities of verifying in cases,
where needles have been introduced under varicose veins in the lower
extremities, and allowed to remain, with a ligature around them, for
ten days or a fortnight. The circulation through the vein will in such
cases be obstructed; but, in a year or two, will be found to have
become completely re-established.
As the coagulum contracts in a vein, if the intention is to obliterate
the vessel, its sides are gradually approximated. In the smaller
veins, and in the divided extremities of large veins, the sides are
soon completely drawn together. But the latter, if not wounded, may
for a long time (see Prep. 1732, Path. Mus., Coll. of Surg.) retain
coagulated blood in their contracted, but not completely closed,
cavities. In both cases, the coagula which close the veins are liable
to be displaced by accident, or to have their adhesions loosened by the
changes which they undergo. The position of a vein, and the structure
of the organ through which it passes, may be unfavourable to its
healthy reparation. The process of repair goes on frequently during
a continued flow of blood over the part, and sometimes during the
constant action of the muscles in the neighbourhood: at other times, an
injured vein will be situated immediately in the bend of a joint, and
will be subject to be continually bent and extended with the motions of
the limb. In the structure of the bones, the veins lie in unyielding
channels, and are consequently deprived of the assistance derived from
the approximation of their sides, as in soft parts, during the process
of reparation. As the coagula contract in such a case, there is danger
lest the union by the first intention should be disturbed, and that the
cavities of the injured veins should be left exposed.
Again, in the uncontracted uterus after child-birth, the veins which
open upon the placental surface, pass through the firm texture of
the organ, and are incapable of contraction independently of the
muscular structure which surrounds them. The coagula which close their
extremities secure them against the entrance of any foreign matter;
but should these coagula be removed before the vessels are otherwise
protected, their open mouths are exposed to any secretions that the
uterus may happen to contain. In these cases, if a coagulum is not
firmly formed, or if it is displaced by violence, it may be broken
up, and portions of it mixed with the fluid blood. Subsequent coagula
may form in the veins and offer fresh obstructions to the admission
of any foreign matter, but these may, as in the first instance, be
disturbed, and carried, together with any admixture of the secretions
of the part, in the course of the circulation. The period at which
the union of a coagulum in a vein is dissolved, is sometimes marked
with great precision. In a case recorded by Dr. Davis,[19] a patient
was convalescent from an attack of phlegmasia dolens, when death took
place instantaneously, while the patient was in the act of changing
the sitting for the recumbent posture; the left external iliac vein
was thickened, and its internal tunic was studded in several places
with deposits of adherent lymph. The portion most remarkable for this
incrustation, as well as for other disease, was immediately beneath
Poupart's ligament; the vein, although contracted, was _manifestly
pervious_.
[19] Medico-Chirurgical Transactions, vol. xii.
V. It has been shown in the previous sections, that secretions mixed
with the blood will alter its properties, and influence the period
of its coagulation: that when the blood is thus altered, it may pass
through a vessel without leaving any trace of its passage; but that
if it coagulates and remains in a vein, the coats of the vessel will
then take on increased action. The exciting cause of the inflammation
in such cases appears to be conveyed by means of the contents of the
vessels to the vessels themselves. But, as in post-mortem examinations,
the changes produced in the vessels are much more easily recognized
than the alterations in their contents, the former have of late years
almost exclusively occupied the attention of pathologists. The cases in
which constitutional symptoms follow inflammation of the veins, will
be found to divide themselves principally into three large classes. 1.
Those in which one of the larger veins has been opened. 2. Those in
which some portion of bone has been involved in the original lesion. 3.
Those that occur after child-birth.
In each of these three classes of cases, a free communication will be
found to exist between the injured part and the general circulation.
The natural mode of sealing this communication, when it is no longer
proper, is the coagulation of the blood in the veins of the injured
part. When, from some constitutional affection, or from some local
peculiarity of structure, this intention is not fulfilled, a ready
passage remains open, through which the blood may become infected.
When pus has been injected into the veins, it has frequently happened,
that no great constitutional disturbance, and no signs of secondary
inflammation, have been produced; but this is believed to have depended
upon the coagula in the veins having prevented (as probably occurred
in Experiments VII and VIII) the foreign matter from finding its way
along the vessels. But if this obstruction be not offered, or be
overcome, then the appearance of secondary inflammation, accompanied by
corresponding constitutional symptoms, will be produced.
If water be injected into the cancellous structure of bone, it will
find its way out in drops through the apertures of the nutritious
vessels. The ready communication which is thus shown to exist
between the interior of bones and the veins, has been but too often
exemplified by M. Cruveilhier's experiments of introducing mercury
into their cancellous structure, and finding it subsequently in the
vascular system. This fact assumes peculiar significance, when taken
in conjunction with the very large proportion of cases, in which some
portions of bone will be found to have been involved in the primary
lesion, in those who have died of secondary inflammations. Of fifty-two
consecutive cases, occurring in surgical hospital practice, of which I
have preserved notes, in no less than forty-one was some portion of the
osseous system implicated.
Again, in the third class of cases above-mentioned, if the vena cava be
injected after parturition, the injection will very speedily find its
way into the uterus.[20] The ready communication which is thus shown to
exist between the vascular system and the local affection, in each of
the three large classes of cases which usually give rise to subsequent
disease, would of itself afford at least a very remarkable coincidence.
But more direct evidence presents itself of the way in which the system
becomes contaminated in these affections: thus, after an operation
for hæmorrhoidal tumours, an effusion of lymph and pus has been found
in the hæmorrhoidal veins,[21] from thence the same appearances have
been traced to the inferior mesenteric vein, and the severity of the
secondary affection, indicated both by the symptoms and the post-mortem
appearances, has fallen upon the liver. These circumstances all tend to
point to the venous system as the means by which morbid matter in such
instances is introduced: and the still more conclusive facts afforded
in the production of secondary disease, by injecting fluids into the
veins,[22] allow scarcely a doubt to remain upon the mind, that the
unprotected veins are the channels, in a very large proportion of
cases, through which the blood becomes infected.
[20] DANCE. Archives Générales de Méd. vol. xviii, p. 480, Dec. 1828.
[21] In cases where pus has been found in veins surrounded by coagula,
its presence and detention there have been differently accounted for.
M. Cruveilhier appears to have imagined that the loose coagula act as
filters, through which the blood passes, while the pus is retained.
(_Dict. de Méd. et de Chir._ t. xii, p. 641.) The true explanation of
the way in which coagula form round pus in the veins has already been
given.
[22] See M. Gaspard's experiments.
VI. The cancellous structure of bone may be compared to the cellular
tissue in soft parts. When inflamed, its intervals become filled up
by effusion from the vessels, and an abscess may be as accurately
circumscribed in the hard as in the soft structures of the body. In
a healthy constitution, the adhesive inflammation will, in this way,
always precede the suppurative; but where the inflammation is not
circumscribed by adhesion, the secretions may permeate from cell to
cell in unadhering parts. In soft structures, a remedy is at hand for
allowing the escape of the matter, by a free division of the parts; but
in bone, where the same thing takes place, the hard unyielding sides
offer an effectual obstruction to the escape of any effused fluid. The
cells of the bone then may become infiltrated, and, unless the veins
of the part have been closed, there is nothing to prevent the diseased
secretions from finding their way into the circulation.
M. Cruveilhier assures us, that a single drop of mercury introduced
into the cancellous structure of living bone, may subsequently be
detected in the capillaries of the lung, where it becomes the centre
of one or more patches of livid congestion. This experiment appears to
afford a perfect illustration of the way in which diseased secretion
may be conveyed into the circulation, when the natural processes of
repair in bone are abortive. These processes are the same in bone as in
the other structures of the body; viz., union by the first intention,
and adhesive inflammation. In soft parts, as the fibrin, which forms
the bond of union in the first of these, is absorbed, the divided veins
collapse, and thus continue closed; but in bony structures, where the
injured vessels are held open, as the fibrin which at first closed
their extremities becomes removed, their channels may be left as much
open to the diseased secretions of the part, as to the globule of
mercury in M. Cruveilhier's experiment.
The low degree of organization in bone, and the comparative slowness
with which actions are there carried on, render it, in a peculiar
degree, liable to interruptions in the process of repair; especially
when, as not unfrequently happens, there is reason to believe that the
vitality of some portion of the bone has been threatened. The offensive
smell of the bone, as well as the appearance of its cancellous
structure infiltrated with puriform matter, will frequently show in
such cases, that the processes above-named have not followed their
natural course.
VII. As a necessary deduction from the accompanying experiments, and
those of M. Cruveilhier, alluded to in the previous section, we arrive
at the conclusion, that a vitiated condition of the blood may give
rise to inflammation of the veins in different parts of the body. The
circumstances which occasionally attend reparation of the uterine
veins after child-birth, will be found to lead to the same inference;
and the same general proposition will derive fresh support from the
consideration of this class of cases.
The veins which terminate upon the placental surface of the uterus
are necessarily open when this organ is distended, and become more or
less perfectly closed when it contracts. In cases when the contraction
is incomplete, innumerable open-mouthed orifices are left bathed in
secretions, which are often offensive and undergoing decomposition;
the natural protection to the vessels then, is the coagulation of the
blood in them. If examined, the uterine veins will be found filled with
coagula for some distance. But in cases where this power is impaired,
all the uterine veins and arteries recently separated from the placenta
may be found bathed in the secretions of the part, under circumstances
most favourable for their absorption. The passage of diseased
secretions through the vessels cannot always be traced in this, any
more than in the other forms of the disease. Many of the substances
introduced artificially into the circulation by M. Gaspard, produced no
action upon the coats of the veins through which they passed, and yet
the general symptoms were precisely similar to those originating from
genuine phlebitis. In accordance with this, it may be observed that the
uterine veins are often found perfectly healthy when the spermatic,
or renal, or still more distant veins are thoroughly disorganized.
In either case, the healthy condition of the veins near the original
lesion forbids the idea of inflammation having been propagated along
the coats of the vessels, while all analogy appears in favour of the
disease being transmitted through their contents.
In a certain number of cases no lesion will be found in any of the
veins of the body, but the uterine veins will be found to contain some
unnatural fluid; at other times coagula of blood, which have lost
their elasticity, gritty to the feel, and greyish or light brown in
appearance, will be found filling the veins or leaving intervals in
them, where lymph or pus may be recognized. It matters little whether
the unnatural fluids, thus found in the uterine vessels, have been
absorbed from the cavity of the uterus, or are the product of venous
inflammation. The effect upon the blood in either case would be the
same.
When obstructions form in the spermatic veins, they are not indicated
by any external symptoms; but when the veins opening into the internal
iliac are similarly affected, the coagula are liable to extend into its
cavity, and even beyond it to the external and common iliac vessels.
The free return of the blood from the inferior extremity, will then be
prevented. The effects of this have already been described (sec. III.)
The connection of this form of disease with affections in distant parts
of the body, has been noticed by several eminent writers. Legallois
has expressed his conviction, that phlegmasia dolens, puerperal fever,
and many other puerperal ailments, are solely dependent upon the
absorption of pus from the uterine surface. This opinion appears to
have been formed upon too hasty a generalization, inasmuch as other
fluids besides pus, as evinced by some of the annexed experiments, may
produce similar effects upon the blood. But that pus, when absorbed,
will determine the coagulation of the blood in the iliac as well as
in other veins, must be allowed; and that the symptoms of obstructed
venous circulation arising from this cause, will exactly resemble those
of phlegmasia dolens, will scarcely be denied.
"Besides depositions of pus in certain portions of the frame," observes
Dr. Ferguson, "I have seen two other states of the limb, which are
connected with and traceable to the cause originating puerperal fever.
In one of these the malady looks like erysipelas...; in the other, the
leg is attacked with a disease so exactly resembling phlegmasia dolens,
as to leave no doubt in my mind that they are one and the same malady.
In this, as in other forms of the disease, there may be a tendency to
gangrene of the skin."
The period of the occurrence of what has been described under the name
of uterine phlebitis is marked with much precision, and the affection
of the system is often general and sudden. It may be stated as the
result of all the observations hitherto made, that it occurs most
frequently from the 10th to the 20th day after parturition.[23] If
the inflammation in such cases were propagated along the vessel only,
it would be difficult to account for such an apparently capricious
selection of time for its development. This difficulty, however,
disappears when the period is observed to be so strictly in accordance
with the time at which the same symptoms occur after other local
complaints, and to be, moreover, the time at which the coagula formed
in the veins, may naturally be expected to shrink.
[23] DR. LEE. Medico-Chirurgical Transactions.
It has been observed, that inflammation after child-birth usually
attacks the spermatic veins alone, and for the most part the one only
on that side of the uterus to which the placenta has been attached. The
hypogastric veins are comparatively rarely affected. The appearances
observed upon dissection in the spermatic vein, usually terminate
abruptly at its opening into the vena cava on the right side, or into
the renal on the left. This fact is in perfect accordance with that
observed by Mr. Arnott, that the coagulum in veins extends usually
only to the nearest collateral branch; the explanation appears to
be the same in both cases, as illustrated by Experiment VI. If the
coagulating blood be left undisturbed, it will form adhesions to the
sides of the vessel and produce increased action in its coats; but
if mechanically disturbed, it will be carried forward before the
process of coagulation is completed, and leave the vein in its natural
condition. When any portion of a vein is obstructed, the blood is
kept at rest between the obstruction and the next collateral branch;
and, if disposed to coagulate, there is nothing to interfere with
such an action. But the case is different, as soon as one vein opens
into another. A fresh current of blood is then continually sweeping
the orifice of the obstructed vessel; and, even although the blood
at this point should have a tendency to coagulate, it is carried on
in the course of the circulation, before it can adhere to the sides
of the unobstructed vein. The sudden termination of the diseased
appearances in these cases, affords an additional proof that the blood
is the medium by means of which this affection is transmitted. It is
true, in such instances the diseased fluid cannot be always, or even
generally, traced in the veins, and very many cases occur where a
retained and putrid placenta, or decomposing coagula, remain in contact
with the mouths of the uterine veins, without any of the symptoms of
local phlebitis being produced; but this is only in accordance with
what is observed in cases where purulent or other fluids have been
directly injected into the blood. The examination of the blood, or of
the vessels, in such cases, will by no means invariably indicate the
presence of foreign matter after it has once become thoroughly mixed
with the blood, nor will inflammation of the vein through which the
fluid passes, be by any means invariably produced.
When a foreign substance is introduced into an artery, any immediate
effects upon the blood may naturally be looked for in the system
of capillaries which it supplies. If the blood then coagulates,
local symptoms alone, will, in the first instance, be produced, and
the constitution will remain unaffected. M. Magendie,[24] indeed,
asserts that fluids injected into the arteries of animals, return
quickly through the corresponding veins, and that this takes place
even more rapidly in the living than in the dead body. If this were
universally true, it would matter little whether foreign matter were
introduced into the arterial or venous system. The effect upon the
constitution would be the same in either case. But if, as is now
maintained, extraneous matter introduced into the blood may, under
certain circumstances, produce its coagulation, then the effects
will be confined, more or less completely, to the first system of
capillaries which the blood meets with in the natural course of its
circulation, and the constitution will be affected only in consequence
of the changes which then take place. M. Gaspard has shown that greasy
fluids, and such as contain sediments, do not find their way readily
from the small arteries into the veins. They become entangled in the
intermediate capillaries, and there produce, first patches of local
congestion, and subsequently serous effusion and abscesses. Some clear
fluids, on the other hand, such as solutions of tartar emetic, of
opium, and of nux vomica, when introduced into an artery, pass readily
in the course of the circulation, and produce their full effect upon
the constitution; and in such cases no irritation is manifested in
the capillaries through which they pass. The first of these poisons
produces vomiting and purging, the second stupor, and the third tetanic
rigidity, exactly in the same manner as if they had been introduced
into the stomach, or injected into a vein.
[24] Précis Elémentaire de Physiologie, t. ii, p. 389.
There are yet another class of substances differing in their effects
from both of the former; and under this head are classed infusion of
tobacco, solution of acetate of lead, putrid fluids, etc. These are
distinguished from the first class above mentioned, as not offering in
themselves any mechanical impediment to the circulation of the blood,
and from the second, as not producing the same constitutional symptoms
when injected into an artery as when thrown into a vein. M. Gaspard
found that, when introduced into an artery, the infusion of tobacco
neither produced vomiting nor stupor, the solution of acetate of lead
did not act upon the intestines, and the putrid fluids did not produce
the evacuations usually observed after their introduction into the
system by other means. All these substances, however, were found to
produce violent local irritation in the parts to which the branches of
the injected artery were distributed, and the constitutional symptoms
were those produced in consequence of the local irritation, and not
those which would arise directly from the action of those poisons upon
the system.
In Experiment XX, seven or eight cubic inches of common air were
gradually injected into the carotid artery of a dog, and half an hour
afterwards an ounce of water, to which seventy drops of medicinal
prussic acid had been added, was thrown into the same vessel; none of
the peculiar effects of the poison followed this operation. At the
expiration of another quarter of an hour, an ounce of a saturated
solution of nux vomica was likewise injected, still without producing
any constitutional symptoms. It is very remarkable in this experiment,
that M. Gaspard[25] should have considered that the elasticity of the
air contained in the vessels was sufficient to counteract the impetus
of the blood, and thus to prevent the progress of the poison along the
vessels, especially when we find him stating that, on a post-mortem
examination, the smaller vessels appeared to have been _obstructed by
very hard clots of blood_.
[25] Journal de Physiologie, t. v, p. 328 and 336.
EXPERIMENT I.
(_a_). On the 25th of September, 1848, having procured four small
vessels of equal sizes, I placed in the first some dilute sulphuric
acid, in the second some offensive pus, and in the third some water.
The fourth vessel was left empty. They were then all equally warmed,
and some blood from the jugular vein of a healthy horse was received
into each of them so as to fill them to the same level. They were now
stirred with separate pieces of wood. At the expiration of two minutes
(noted by a watch), the contents of the second vessel had become
coagulated into one uniform mass. The contents of the first vessel
(containing the acid) were thickened and of a dark brown colour; in
the third and fourth cups the blood was of its natural fluidity, but
darker coloured in the cup containing water than in the other. At the
expiration of ten minutes, the blood contained in the fourth cup had
begun to coagulate; the blood and water still remained fluid. At the
expiration of a quarter of an hour, the blood had completely coagulated
in the fourth cup, containing blood alone; and had very partially
coagulated in the third cup containing the blood and water.
(_b_). Four vessels were taken, each capable of holding three fluid
ounces. In the first was placed half an ounce of cold water, in the
second half an ounce of dilute sulphuric acid, and in the third half a
drachm of pus, which was quite fresh and sweet. All the vessels were
then quickly filled with blood, from the jugular vein of a horse. The
contents of each vessel were stirred. The blood and dilute sulphuric
acid became thick, and changed in colour almost immediately, as in the
first experiment, but did not coagulate. The pus and blood coagulated
in six minutes, and the mass was firm in seven. The pure blood
coagulated in twelve minutes and was firm in sixteen. The blood and
water coagulated in about the same time, but took nineteen minutes to
become firm.
The above and the following experiments were made at the suggestion of
the author, in conjunction with Mr. T. W. Mayer,[26] veterinary surgeon.
[26] The present mayor of Newcastle-under-Lyme.
EXPERIMENT II.
An abscess was opened in the groin and a quantity of pus received into
a gallipot; some blood from the divided vessels was also received into
the same vessel; they were then stirred together, and in two minutes
the mass coagulated. Some blood taken from the same patient in the
same manner, but not mixed with pus, coagulated in eleven and a half
minutes.
EXPERIMENT III.
On the 20th of January, 1849, an inflamed and suppurating abscess was
opened, and the blood and pus which flowed from it were mixed together.
They coagulated in two minutes and twenty seconds. This experiment was
repeated several times, with nearly similar results.
EXPERIMENT IV.
In June 1849, a tense inflamed swelling was opened in the perinæum of a
patient, who had for years laboured under a very obstinate stricture.
A quantity of matter first escaped, and subsequently serum, mixed with
shreds of lymph and small quantities of pus and blood, continued to
flow for some time. Portions of this mixed fluid were received into
separate vessels; they coagulated on an average in about two minutes.
EXPERIMENT V.
Two ounces and six drachms of blood were taken from a healthy horse,
and two drachms of pus were mixed with it. The mass coagulated in three
minutes and three-quarters.
EXPERIMENT VI.
A healthy male ass, three years old, was procured, and, with the
assistance of Mr. Mayer, was made the subject of the following
experiment, on the 23rd of September, 1848. Three drachms of pus were
collected from an issue in the chest of a horse, which laboured under
inflammation of the lungs. The pus thus obtained was quite pure and
sweet, and having been warmed, was injected, by means of a syringe,
into the left brachial vein of the ass. The animal lay quiet, till
nearly the whole of the pus was injected; it then struggled, and a
small quantity of the pus may have been lost. When the operation was
completed, the sides of the vein were brought together with a pin, and
the animal was allowed to get up. The vein above the opening could
now be felt as a hard, unyielding cord, as high as it could be traced
with the hand; but upon gentle pressure being made, so as to propel
the blood in the course of the circulation, the hardness completely
disappeared. The vein which, immediately after the operation, was hard
and prominent, no longer presented anything remarkable to the touch.
The animal now moved from side to side, as if inclined to lie down.
Two hours and a half after the operation, the pulse, which naturally
was 36, had risen to 60; and the respiration from 12 per minute had
increased to 26.
_September 24th._ Pulse 52; respiration 20; mouth hot; ears cold. In
the evening the pulse became 48 and the respiration 16; he coughed
occasionally.
_25th._ Pulse 48; respiration 12; some dullness of countenance, but he
is lively and occasionally playful. The left fore-leg is swollen; the
ears are very cold. In the afternoon he was killed, and the blood was
allowed to flow from the body.
_Post-mortem appearances._ The wound in the left leg opened directly
into the brachial vein, which was filled with lymph and a thin pus
for a very short distance, both above and below the external opening;
immediately above this, the vein was healthy, nor was there any
appearance of disease in any of the other veins of the limb, nor in
the veins leading to the heart. The glands in the axilla were swollen.
The lungs were found studded irregularly in different parts, with
circumscribed spots of livid congestion: these existed both upon the
surface and in the substance of the lungs; they were generally about
the size of a filbert, but in some places they occupied a single
lobule, and were accurately circumscribed by its outline.
EXPERIMENT VII.
On the 23rd of November, 1848, about an ounce of perfectly pure pus
(previously warmed) was injected into the right jugular vein of an aged
ass; the vein immediately became "corded", and the blood appeared to
have coagulated in the vessel. The operation did not much excite the
breathing; but the pulse, which naturally was 35 in the minute, rose to
60, and subsequently fell to 55.
_24th._ The animal dejected; appetite indifferent. The vein can be
traced as a thickened cord as far as the sternum. Respiration 12 (the
natural standard); pulse 50.
_25th._ The parts around the vein much infiltrated with serum: pulse
55; respiration 12.
_26th._ The wound in the neck began to suppurate, and an abscess
subsequently formed in the course of the vein, about midway between
the opening and the sternum. The general symptoms continued, with
very slight variation, until the 4th of December, when the animal was
destroyed.
_Post-mortem appearances._ The jugular vein was found to have become
inflamed only in the course of the circulation, and to be obliterated a
short distance below the external opening. The surrounding parts were
greatly infiltrated with serum and lymph, and several abscesses had
formed in the immediate neighbourhood. The lungs did not present any
well-defined patches of congestion, as in the last mentioned experiment.
EXPERIMENT VIII.
A healthy ass, six years old, was operated on upon the 16th of
November, 1848. The respiration was naturally 14 in the minute, and the
pulse 38. About two ounces of highly offensive pus, obtained from the
frontal sinus of a horse, were injected into the left jugular vein; the
pus had unintentionally been mixed with water previous to its being
injected. The vein became full during the operation, as though the
blood in it were in a semi-coagulated state. The pulse now became 60,
and the respiration 20 in a minute; slight rigors occurred in two hours.
_November 17th._ The animal is tranquil; appetite good; pulse 48, small
and wiry; respiration 16. In the evening he was rather more excited;
the vein was becoming inflamed downwards towards the heart; pulse 60;
respiration 20.
_November 18th._ The vein was more inflamed, and slight suppuration was
visible at the orifice of the wound. Respiration 16; pulse 55. From
this period to the 23rd, the pulse continued from 55 to 60, and the
respiration varied from 12 to 18.
_November 26th._ The swelling in the situation of the vein is rapidly
subsiding; pulse 55; respiration 12.
The animal gradually recovered, and on the 26th of February, 1849, was
made the subject of another experiment. The right jugular vein having
been opened, two fluid ounces of pure healthy pus were injected, and
propelled in the course of the circulation, by pressure upon the vein
externally. The vein became tense during the operation, and sensibly
resisted the attempts that were made to propel its contents towards
the heart. _Even forcible pressure was not sufficient to overcome the
resistance offered to the return of blood._ Soon after the operation,
the animal had a rigor; the breathing became laborious, but not
accelerated; pulse 57.
After the lapse of seven hours, the animal appeared dejected; he
refused to eat or drink; the extremities were cold; breathing 16 in the
minute; pulse 60, small and irregular.
_February 27th._ The vein can be felt thickened as far as the sternum.
The general symptoms are the same as on the previous evening.
_28th._ There appears less constitutional irritation; pulse 60;
respiration 14.
_March 2nd._ Appetite still indifferent; pulse 60; respiration 16.
From this date to the 7th, when the animal was destroyed, the general
symptoms continued much the same, but the induration and swelling
around the jugular vein, from the opening to the sternum, became
greater.
_Post-mortem appearances._ The left jugular vein was found completely
obliterated. The remains of a firm coagulum obstructed its canal for
some distance below the opening which had been made into it, and
terminated, below, in an elongated conical portion, which adhered to
one side only of the vessel. On the right side, an abscess had formed
in the course of the vein; and for two inches, the whole of the parts
were imbedded in a confused mass of pus and lymph, in which it was
impossible to distinguish the structure of the vein. Both above and
below this, for several inches, the vein was filled with coagula,
which effectually obliterated it. These coagula extended for several
inches in the course of the circulation; but beyond them, in both
directions, the vessel was pervious. The lungs presented some slight
spots of congestion, but not of the same characteristic kind observed
in Experiment VI. The other organs were healthy.
EXPERIMENT IX.[27]
[27] This, and the following experiments, are among those recorded by
M. Gaspard, referred to in the foregoing dissertation.
Two drachms of pus, somewhat fetid, derived from a large common ulcer,
and diluted with a little water, were injected into the jugular vein of
a middling-sized dog. The animal immediately made several convulsive
efforts to swallow, and soon became faint. It showed indications of
pain, and vomited more than six times in the course of the day. At the
expiration of an hour, it appeared slightly relieved by an evacuation,
and by passing turbid urine. In the evening, it was very ill; it lay
upon its side with its legs extended; had a very feeble pulse and
scarcely perceptible respiration. Ten hours after the experiment, it
passed black, liquid, and extremely offensive motions; these were
accompanied by immediate relief. The animal regained its appetite, eat
and drank freely, and went to sleep. The day following, it appeared
nearly well. On the third day, three drachms of the same pus were
injected into the opposite vein; after the lapse of a certain time,
there occurred, as in the first instance, faintness, vomiting, and
frequent desire to pass urine; twelve hours after the injection,
frequent liquid, white, and very fetid motions were passed, and the
animal died at the expiration of twenty-four hours. On opening the
body, no alteration was found either in the intestines or other organs.
EXPERIMENT X.
The last experiment was repeated on a greyhound with the same results:
faintness, fever, vomiting, and repeated evacuations succeeded each
other, with recovery after the first experiment, but not after the
second. On opening the body, no lesion was observed, except that the
inferior lobes of the lungs were gorged and almost hepatized.
EXPERIMENT XI.
Three drachms of recent pus, derived from the same patient as in the
last experiments, were injected into the jugular vein of a small
emaciated unhealthy dog. After the expiration of three minutes, there
was an abundant evacuation of urine, followed by continued vomiting,
and repeated ineffectual efforts to pass fæces. For nearly a quarter
of an hour, there was a kind of emprosthotonos, rigidity of the limbs,
and a death-like condition. Subsequently, fresh vomiting ensued, with
very fetid liquid evacuations, which were followed by apparent relief;
soon after, however, long continued tenesmus made its appearance, and
terminated in death, five hours after the injection of the pus. On
opening the body, the mucous membrane of the intestines was found red,
swollen, and inflamed, especially in the colon and rectum.
EXPERIMENT XII.
Half an ounce of pus, similar to that used in the preceding instances,
but more putrid, in consequence of having been longer kept, was
introduced into the veins of a middling sized dog. The animal, as in
the other cases, was seized with vomiting, accompanied by violent
straining. Subsequently, strongly marked nervous symptoms made their
appearance. The eyes wandered; there was extreme sensibility, and
involuntary convulsive twitching over the whole body, accompanied by
faintness, hiccough, and short piteous cries. The walk was unsteady,
staggering, and without apparent object. There was furious delirium,
ardent thirst, dyspnoea, palpitation of the heart, etc. This
state lasted for nearly two hours, and the animal died in frightful
convulsions, without having experienced any critical evacuations, as in
the former cases.
_Post-mortem appearances._ On opening the body, while still warm, the
venous blood was found very firmly coagulated, not parting with any of
its serum when left at rest; the left ventricle of the heart showed, on
its external surface, some stains of the colour of lees of wine, formed
by a kind of concrete pellicle, which disappeared only after long
rubbing and maceration. The other organs appeared healthy.
EXPERIMENT XIII.
Some beef was allowed to decompose in some dog's blood; half an ounce
of the fluid resulting from the decomposition, was injected into the
jugular vein of a little bitch. Immediately, the animal made several
convulsive efforts to swallow, and soon became oppressed, uneasy, and
faint. At the expiration of an hour, there was great prostration,
accompanied by repeated gelatinous and bloody evacuations, and vomiting
of bilious matter. The strength became gradually less, and the animal
died three hours after the injection.
_Post-mortem appearances._ The lungs were found inflamed in a very
peculiar manner. They were gorged with blood, of a violet or black
colour, and presented many petechial spots, like small ecchymoses.
These spots existed also on the left ventricle of the heart, in the
spleen, in the mesenteric glands, in the gall-bladder, and even in the
subcutaneous cellular tissue. The peritoneum contained some spoonsful
of a reddish serum; but the mucous membrane of the digestive organs was
found to have been principally affected. In the stomach it was slightly
inflamed. In the intestines, but especially in the duodenum and rectum,
it was of a livid colour, presenting many black spots, and covered by a
gelatinous and bloody secretion, resembling lees of wine. The tissues
in these parts were slightly thickened.
EXPERIMENT XIV.
The preceding experiment was repeated, by injecting into the jugular
vein of a moderately large dog, an ounce of fluid, derived from the
maceration of putrid beef in water. The animal very soon passed
extremely offensive, liquid evacuations, with much urine. The breathing
became quick and deep, the pulse small and quick. Repeated efforts
were made to empty the bowels. There was great depression and want
of strength. At the expiration of an hour, a kind of diarrhoea or
dysentery made its appearance. Liquid, bloody, and fetid evacuations,
continued for an hour and a half, when the animal died.
_Post-mortem appearances._ Livid, brown, and black patches were found
scattered over the lungs. The intestinal canal was filled with a bloody
mucous secretion, resembling the matter that had been voided; its
mucous membrane was of a livid colour, as in the preceding case.
EXPERIMENT XV.
Two ounces and a half of thick fetid fluid, derived from the maceration
of cabbage leaves in an equal quantity of water, for two days, at a
temperature of 77 Fah., were injected into the right jugular vein of
a moderate sized dog. During the operation, the animal made several
efforts to swallow, and soon became faint, and vomited several times.
Some hours afterwards, there was great uneasiness and oppression,
with recurrence of the vomiting, and continued faintness during the
day. After nine hours, a most copious and very fetid evacuation took
place. The discharge was as black as soot, and composed of mucus, with
a little fæcal matter, and a large quantity of what appeared to be
corrupted blood. Some time afterwards, there was a second evacuation of
bloody mucus, exactly resembling the first. On the following day, there
was much loss of strength: the animal lay upon its side, or staggered
as it walked. There was great and insatiable thirst, with a small
feverish pulse. But the most remarkable symptom was the occurrence, at
intervals, of palpitation of the heart, accompanied by extraordinary
force and sound, resembling that produced by long continued hypertrophy
of that organ, in consequence of aneurism[28] of one of the large
arteries. On the third and fourth days, the animal was better, but
there were still great thirst, fever, and occasional rejection of
fluids from the stomach. On the fifth day, the symptoms became
aggravated; there was extreme weakness, a tottering gait, excessive
thirst, the eyes red and filled with gum; the nostrils were stuffed,
swollen, and obstructed with mucus; and the lining membrane of the
mouth was tumid, and of a violet red colour. In the middle of the day,
there was a liquid greyish white evacuation, resembling pus in its
odour, consistence, and appearance, mixed with some clots of putrified
blood. Death occurred during the following night.
[28] I once observed a similar condition in a young woman in St.
George's Hospital. Each pulsation of the heart could be heard with
great distinctness at a distance of two or three yards from the
patient; during the paroxysms, there was the greatest difficulty of
breathing; the countenance became anxious and livid, and a distinct
thrill was communicated to all the arteries. After death, the
countenance and upper part of the body were found livid from venous
congestion. The lungs did not readily collapse when the chest was
opened. The auricles of the heart were greatly distended with black
blood; the inner surface of the left ventricle presented a white patch,
of about two square inches in extent; the lining membrane of the aorta,
for several inches, was of a bright red colour; this extended round
one-third only of the circumference of the vessel. No other structural
change could be found in the heart or vessels, which would account for
the symptoms observed during life.
_Post-mortem appearances._ The mucous membrane of the eyes, nose, and
mouth, was red or violet, and covered by a very abundant thick mucus.
The lungs were of a dark colour, with some black patches, but still
crepitant. The left ventricle of the heart presented several brown
stains, resembling ecchymoses, which penetrated into its tissue. Its
internal surface was of the colour of lees of wine, offering a singular
contrast to that of the right side, which, however, contained a hard
fibrinous concretion, two drachms and a half in weight, of a light
yellow colour, and resembling grease in appearance. This was of the
same consistence throughout, everywhere free, with the exception of a
portion of the size of a finger nail, which adhered to an irregular
and apparently inflamed spot on the inner surface of the ventricle; no
appearance of the injected fluid could be recognized in this clot. It
was continued of the same colour and consistence into the pulmonary
artery, and into the vena cava, the vena azygos, the axillary, and even
the right jugular vein.
The intestinal mucous membrane, especially in the rectum, the duodenum,
and a small portion of the small intestines, was of a violet red
colour. It was inflamed in longitudinal stripes and in patches, which
gave a mottled appearance, even to the outer surface of the intestines,
before they were opened. This discolouration was not accompanied by any
thickening of the tissues, nor by ulceration, and appeared rather the
result of ecchymosis or hæmorrhage. The lining membrane of the rectum
was principally affected, and its mucous glands were swollen and very
prominent. This intestine contained puriform fluid, resembling the
matter evacuated before death. The other intestines contained a very
thick greyish white mucus. The mesenteric glands were inflamed, and
appeared as if infiltrated with blood. The gall bladder was mottled on
its surface by brown and violet patches, and contained black, thick,
ropy bile, resembling melted tar.
EXPERIMENTS XVI AND XVII.
_Shewing the effects of the introduction of Mercury into an artery._
An ounce and a half of mercury, mixed with water, was injected into the
left carotid artery of a sheep. The animal immediately evinced pain,
and stood immoveable upon its feet. The head was held down, there was
stupor and heaviness, and the eyes were protruded and widely open. The
fore legs subsequently became bent, and the head inclined over the
right shoulder with a kind of convulsive rigidity, which continued
till death. Two hours afterwards, the animal became comatose, with
some convulsive motions of the limbs, and the left eye became red and
inflamed. Death took place fifty hours after the operation.
_Post-mortem appearances._ The left eye was found in a state of
suppuration, and contained mercury. Many of the branches of the left
carotid artery also contained some mercury, which had not penetrated
to the capillary system. All the organs supplied with these vessels
were red, swollen, and inflamed, in consequence of the presence of the
foreign matter. The thyroid gland, the tongue, the cheeks, and the
lips, were, however, only affected as far as the median line, leaving
the opposite halves pale and in their natural condition.
A drachm and a half of mercury, mixed with some warm water, was
injected into the crural artery of a large dog. The animal evinced no
pain, and walked resting slightly on the affected limb, which became
sensibly colder. After the expiration of an hour, the animal refused
its food, became restless, and indicated severe pain in the limb,
which was now very hot. On the following day, the leg was swollen and
oedematous. On the third day, there was extreme thirst, increased
oedema, and great suffering. The animal was killed sixty hours after
the operation.
_Post-mortem appearances._ No disease was found in any organ,
excepting the affected limb. This was swollen and oedematous in
every part; abscesses of different sizes had formed, which contained
sanious fluid, mercury, and pus; some parts were in an incipient state
of mortification, and gave out a considerable quantity of air. Globules
of mercury were found in different parts, occupying usually the centre
of the abscesses, and ran out upon the scalpel when incisions were made
into the limb.
EXPERIMENT XVIII.
_Shewing the effect of the injection of Oil into an artery._
Three drachms of olive oil were thrown into the crural artery of a
large dog. Slight pain was experienced, and the limb became evidently
cold, and the pulse under the tendo-Achillis could no longer be felt.
Two hours afterwards, a like quantity of oil was again injected.
The leg now began to inflame, and became tender. The following day,
the whole limb was oedematous, much swollen, and very painful.
Twenty-nine hours after the first experiment, the muscles of the
thigh and leg, as well as the cellular tissue, were found in some
places gorged with blood, and inflamed in livid patches; in others,
infiltrated with yellow serum and gelatinous exudations. No oil could
be detected in the affected parts.
EXPERIMENT XIX.
An ounce of putrid water, in which some beef had been macerated, was
injected into the crural artery of a middling-sized dog. The artery
having been tied, the pulse ceased below the tendo-Achillis; the limb,
however, preserved its usual degree of heat, offering a contrast in
this respect to the last experiment. A considerable degree of fever
and restlessness followed the operation; this continued the whole day
and the following night, without any vomiting or evacuations, which so
constantly followed similar operations upon the veins. The next day
the limb was very painful, but not swollen; there was thirst, with the
ordinary secretion of fæces and urine. On the third day, the animal
was evidently better; the appetite had become almost natural, and he
could walk more easily, although the limb was still very painful. In
the night, there were some soft, almost liquid, evacuations. The fourth
day, the animal was evidently recovering, when an ounce and a half of
very fetid and very concentrated fluid (derived from the maceration
of beef), was injected into the crural artery of the opposite limb.
The animal immediately evinced pain, accompanied by very violent and
remarkable palpitation of the heart. It walked lame, keeping the leg
raised, and soon became feverish and uneasy. The symptoms were exactly
the same as after the first experiment. The leg became gradually more
and more painful, extremely sensitive, but not infiltrated with serum.
During the night, there was much expression of pain, and the animal was
in continual motion. Death occurred nineteen hours after the second
injection. The limb had become swollen only within five or six hours
previous to death.
_Post-mortem appearances._ The limb presented a very large quantity of
bloody fluid infiltrated in all the tissues. The superficial muscles
were black, and presented more or less the appearances of gangrene. The
deep muscles existed as such no longer, but were entirely disorganized,
and converted into a putrid pulp, resembling masses of the red lees
of wine, extremely fetid, and disengaging a quantity of gas. The limb
first injected was still swollen, and presented, in the interior of
the adductor muscles, two or three cavities filled with a putrid
bloody serum. In the chest, the lungs were healthy, as were also the
right cavities of the heart; but the left cavities presented several
reddish-black spots, scattered over their external surface. In the left
auricle was a firm yellowish-white coagulum, adhering to an inflamed
spot on its inner surface. The intestinal canal was filled with a
brownish red fluid, resembling altered blood, which, in the stomach
and duodenum, was of the colour of soot. The mucous membrane of these
organs, as well as of the jejunum and rectum, were gorged with blood,
of the colour of the lees of red wine, but without any inflammatory
thickening of their coats.
EXPERIMENT XX.
_Shewing the effect of the introduction of Air into an artery._
Seven or eight cubic inches of common air were injected gradually
into the crural artery of a large dog. A peculiar rustling noise,
depending upon the admixture of the air with the blood, accompanied
the operation. No particular symptoms followed; but after some minutes
the corresponding vein became distended with frothy blood, which moved
with difficulty, and became stagnant in the vessel. The whole limb
crepitated upon pressure, but no untoward symptom presented itself for
more than half an hour. An ounce of water, to which seventy drops of
medicinal prussic acid had been added, was now injected into the same
artery. This produced no apparent effect upon the constitution.
A quarter of an hour after, an ounce of saturated solution of nux
vomica was injected into the same vessel. This also was followed by no
particular symptoms. An hour after the first injection, half an ounce
of a weak infusion of tobacco was introduced into the same artery.
Excessive pain immediately followed, accompanied by great rapidity
of breathing. The animal now appeared as if he were going to die;
however, he slowly recovered, appeared giddy and inclined to vomit, and
kept himself in a continual state of restlessness. This condition was
succeeded by fever, accompanied by extreme sensibility of the limb, and
irregularity of the pulse. At the expiration of some hours, he appeared
better; the pulse became more regular and less feverish, but the leg
continued swollen, and extremely painful upon pressure. During the
night, the pain returned, indicated by howling and restlessness. There
were several evacuations of fæces and urine. The following morning,
there was great prostration with much fever, and apparent suffering.
The limb was slightly emphysematous, swollen, inflamed, and infiltrated
with serum.
On the following day, two ounces and a half of water, in which some nux
vomica had been boiled, were injected into the crural artery of the
opposite limb. The dog expressed no pain; but, at the expiration of
ten or twelve minutes, slight convulsive motions became evident, which
were gradually converted into violent tetanic spasms. The animal threw
himself backwards with his limbs extended, and died, after repeated
convulsive attacks, an hour and a half after the last injection.
_Post-mortem appearances._ On opening the body, _no unusual appearances
were observed in the limb_ upon which the last experiment had been
tried, but the opposite one was tumid and emphysematous, infiltrated
with a greyish red frothy serum of a fetid odour. _The small vessels
were obstructed by firm clots of blood._ The gall-bladder was greatly
distended; and the intestinal canal contained a quantity of yellowish
mucus.
PART II.
ON THE INTRODUCTION OF VITIATED FLUIDS INTO THE BLOOD; ITS
CONSEQUENCES, AND TREATMENT, WITH CASES.
VIII. The experiments cited in the first part of this essay, illustrate
the power possessed by the blood of preventing certain foreign
substances from circulating with it. They shew that pus, in particular,
has a tendency to coagulate the blood; and that by this means, when
introduced into the vessels, its progress is arrested in some part of
the circulating system. This fact, which, taken by itself, might appear
of little consequence, assumes considerable importance when considered
as one of the inherent properties of the blood, at all times ready,
under favourable circumstances, to be called into action in the living
body. The conditions under which pus will determine the coagulation
of the blood, and those under which it will circulate in the living
vessels, require to be accurately ascertained, before we can rightly
interpret the discordant evidence which we at present have upon this
point.
Dr. Sédillot,[29] in a work recently published, mentions, that a great
number of cases are met with, in which pus is poured into the general
circulation without meeting with any obstruction, and states that, in
such instances, he can detect the globules of pus in different parts
of the circulating system. He even affirms that he can recognise
a disease caused by purulent infection, by examining, under a
microscope, a portion of the blood abstracted from the body.
[29] De l'Infection Purulente, p. 399.
M. Dance, and, since his time, equally accurate observers, have, on the
other hand, failed to detect the characters of pus in the blood, even
when that fluid had been injected into the veins of living animals.
The results of these different observations may perhaps be reconciled,
by considering the influence exercised upon the globules of pus by the
blood, before its coagulating power has been impaired. This subject
appears not to have hitherto occupied the attention of pathologists.
In all the cases quoted by Dr. Sédillot, in which he detected the
globules of pus in the blood, the patients died of the disease; but
in the researches instituted by M. Dance and others, the experiments
were made upon animals in perfect health. In the latter, the pus cannot
enter the circulation, as has already been shewn, or can only do so
after the blood has partially or entirely coagulated round it, and the
coagulum has subsequently become broken up.
In the act of coagulation under these circumstances, the appearances
of the globules of pus are changed,--these being perhaps mechanically
compressed by the contraction of the fibrine,--so that the most
experienced eye can no longer recognise them.
Pus, mixed with healthy recently drawn blood, out of the body, will
entirely lose its characters in this way; and as the coagulation, is
by no means retarded in the living vessels, we may, without fear of
contradiction, affirm, that globules of pus cannot be detected when
introduced into the vessels in small quantities, and mixed with healthy
blood.
In cases where, from long-continued disease and the repeated
introduction of vitiated fluids into the circulation, the blood has
lost its power, there appears no reason to doubt the correctness of Dr.
Sédillot's observations; and it is probable that pus-globules may then
circulate with those of the blood.
In experiments upon animals, it has always been found that the power
of the constitution, in resisting the effects of the injection of pus
into the veins, was much greater at the first than at any subsequent
operation. This circumstance would appear to associate itself directly
with the observations now made, and to afford another illustration of
the power of healthy blood in resisting the entrance of some foreign
matters into the system.
From the consideration of these facts, and of the experiments
previously recorded, it becomes evident, that the introduction of pus
into the system through an injured or inflamed vein, can rarely be the
first step towards purulent infection of the system. Some change must
previously have passed in the blood, by which its coagulating power is
impaired, or some unusual mechanical means must have been employed,
before the pus can find its way in the course of the circulation.
The contradictory statements which have been made by those who have
injected pus into the veins, may thus be reconciled, by taking into
account the power exercised by the blood in the experiments which have
been made. There can be little doubt that, while, in some instances,
a portion of the pus has been forced into the general circulation, in
the great majority of cases it has been detained in the vein into which
it was first introduced, and has never become part of the circulating
fluid. We accordingly find some experimenters recording the secondary
diseases which they observed, while in other hands these appearances
were not produced.
Dr. Sédillot[30] has attempted to prove that the globules, or solid
parts of pus, must be introduced into the system, in order to produce
well-marked indications of purulent infection. But this hypothesis
would not only appear to be at variance with the oft-repeated
experiments of MM. Gaspard and Cruveilhier, in which similar effects
were produced by the injection of mercury and of putrid fluids,
but would also leave unexplained the mode of the introduction of
these globules, where there is evidence that the disease has been
communicated through the lymphatic system. The changes which all
substances undergo in their passage through the absorbent glands, would
at once forbid the idea that globules of pus could be thus introduced
unchanged into the circulation; and yet we have direct evidence (Case
XXIX) that irritating fluids are conveyed in this way into the system,
and lead to the formation of secondary abscesses.
[30] In deducing general conclusions from experiments upon animals, it
must be borne in mind, that in them suppuration is induced with great
difficulty. Many of the appearances produced by the injection of putrid
fluids (as in Experiment XIV) would, in man, probably have terminated
in suppuration. Dr. Sédillot has nevertheless established the fact,
that, generally speaking, a different class of post-mortem appearances
may be expected from the introduction of decomposed serum, to those
produced from fluids containing solid particles.
Another class of cases, in which there would be difficulty in
admitting the doctrine of the introduction of pus in substance into
the circulation, presents itself, where, in the primary affections (as
in Case VI), no evidence can be obtained of the original lesion having
suppurated. The fluids effused in such cases may be serum, lymph, or
blood, mixed in different proportions; and yet the constitutional
symptoms will be exactly similar to those which follow the formation
of pus in other instances. There may exist, both in the primary and
in the secondary affection, every intermediate gradation between the
healthy secretion of a part, and the formation of pure pus, or pus
mixed with blood or lymph, without any of the essential characters of
the disease being absent. An inflamed bursa, or a punctured wound,
without the formation of pus, (Cases IV and V), may give rise to
symptoms as severe, and consequences as fatal, as any that arise
from the direct introduction of pus into the system. The secondary
affections, in such cases, may run their course and prove as speedily
fatal, as where well-formed purulent deposits have taken place. The
most severe constitutional symptoms will sometimes be followed by the
effusion of bloody fluid only, in one of the serous cavities (Case
XXX). It would be unphilosophical, even were it practicable, to refer
such cases to a different disease, merely because the accidental
circumstance of the formation of pus is wanting. The origin of the
affection in such instances may be as well-marked, the poison can often
be traced as distinctly into the system, and the secondary disease may
be as clearly connected with the primary, as in any case where pus
has been originally formed. In some cases again, the constitutional
symptoms which accompany, or are followed by, effusions into distant
parts of the body, begin before sufficient time has elapsed to allow
the supposition that pus can have been fully formed at the original
seat of injury. Such instances occasionally, although rarely, present
themselves in extensive burns and scalds, occurring in enfeebled
habits, and after amputation of the limbs in scrofulous children.
In nearly all cases, when the origin of the constitutional disease
cannot be traced to the introduction of diseased fluid into the system
through an open vein, it will be found that the part primarily injured
has wanted the degree of vigour, requisite to establish and maintain
healthy adhesive inflammation.
Upon another occasion,[31] I have endeavoured to show that, where lymph
is effused around a poisoned wound, the virus will find its way less
easily along the absorbent vessels, than when no such effusion has
taken place; and that when, in such a wound, the effusion of lymph is
checked or prevented, as by the administration of mercury, a larger
proportion of cases will indicate an affection of the lymphatic system,
than when the natural process has not been interfered with. There can
be little doubt, that the same principle may be observed with regard to
ordinary wounds. The number of cases in which the absorbents inflame,
will be in inverse proportion to the number of those in which the
original wounds are circumscribed by healthy adhesive inflammation. In
Case XXVII, it is mentioned, that the surface of a muscle, implicated
in the original lesion, was as cleanly dissected as if done with a
scalpel, thus showing the total absence of any surrounding effusion
of lymph. The absence of, or defect in, the process of adhesion may
thus be associated with inflammation of the absorbents, as the want
of "union by first intention" has been shown to be connected with
inflammation of the veins (Section ii.)
[31] LONDON JOURNAL OF MEDICINE, vol. i, p. 799.
The minuteness of the absorbent vessels, and the changes which their
contents undergo in their glands, prevent any unhealthy fluids from
being as readily recognised in them as in the veins. But when the
progress of inflammation can be traced along these vessels from a
wound, towards the centre of the circulation, marked, as it often is,
at intervals, by the formation of abscesses, we cannot doubt that an
irritating fluid has found its way along their canals: and when the
constitutional symptoms, which arise at the same time, terminate in
the formation of purulent deposits (as in Case XXIX), we cannot but
admit that the absorbent vessels are the direct means by which, in
such cases, diseased secretions are poured into the blood, and the
system becomes infected. It would, therefore, appear that there are two
principal conditions, under which local disease may produce a general
infection of the system by the direct introduction of vitiated fluids
into the blood. The first of these is connected with defective union in
injured veins; the second is associated with want of healthy adhesion
in inflamed lymphatics.
The period of invasion of the attack differs in some degree in the
different classes of cases, but it is generally marked with great
precision: even when apparent recovery has been followed by a second
attack, the occurrence has in each instance been accurately noted by
the sudden appearance of constitutional symptoms (see Case XXXVII).
When one of the large veins has been originally affected, the period
which elapses before symptoms of infection of the system manifest
themselves, is comparatively short (Case I). In cases occurring after
child-birth, it is usually longer, extending to the end of the second
week. After surgical operations or accidents involving some portion
of bone, the access of the disease will be marked by a rigor during
the third or fourth week; and finally, when the absorbent system is
primarily affected, the period of the occurrence of the constitutional
symptoms may be much farther removed from that of the original injury
(if any such existed), and is by no means so accurately defined.
At the time of the occurrence of the general disturbance of the
system, the local injury or wound will generally put on an unhealthy
appearance. The skin in the immediate neighbourhood will sometimes
assume a dull brownish-red appearance, which will gradually fade
into the colour of the surrounding parts. This symptom will usually
commence near the termination of the vessels, which are derived from
the same trunk as those which supply the injured part. When the
original injury is complicated with a wound upon the surface of the
body, it will usually become dry and glazed, and the blush upon the
skin will commence in its neighbourhood, or a short distance from it,
and will usually extend towards the centre of the circulation, without
presenting any very defined margin: occasionally it will extend, in the
form of erratic erysipelas, over a large part of the body.[32]
[32] In a case of fracture of the femur into the knee-joint, I have
observed a dark ill-defined erysipelatous blush extend from the
affected limb to the body, and thence to the head. Purulent deposits
formed in various parts of the body, of which the patient died.
IX. The commencement of constitutional disease, after direct infection
of the blood, is marked by a sudden change in the manner and appearance
of the patient; a severe rigor is usually the most prominent symptom,
and is followed by much febrile excitement, or by extreme depression;
a very peculiar heat of skin (Case XXII) will sometimes be present,
while, at other times, the surface will be covered by a profuse clammy
perspiration. The rigor may be repeated at irregular intervals, but
occasionally it will recur about the same hour for three or four days
in succession (Case XXXVII); and in a few instances it will not be
observed at all.
Great depression frequently accompanies even the first stages of this
disease, indicated by a want of tone in the pulse, by an extremely
listless manner, and sometimes by a tendency to syncope (Case I). The
countenance becomes anxious, the tongue dry and brown in the centre,
and red at the edges, or, in other instances, it presents a coating of
a pasty yellowish-white colour; a dusky yellow hue frequently pervades
the skin, and sometimes the conjunctivæ of the eyes. This may or may
not depend upon an accompanying affection of the liver. The pulse
varies much in frequency in different cases, and at different times in
the same case: generally it is very rapid, especially when accompanied
with much heat of skin.
The pain is sometimes severe, and may be referred exactly to the spot
which subsequent examination shows to have been the seat of secondary
inflammation; at other times it is not confined to any particular
situation, but consists of general ill-defined feelings of short
duration, and recurring at irregular intervals. The peculiarity of
such sensations is best expressed by the terms applied to them by
the patients themselves. "Catching pains all over", "soreness of the
stomach", and "thrilling in the blood", not unfrequently accompany this
disease.
Vomiting may occur, either as a symptom of constitutional disturbance,
or as indicative of inflammation of an abdominal organ (Case XXVI).
In the latter case, it is extremely obstinate, and the fluid ejected
is generally of a green colour. Diarrhoea is a symptom of frequent
occurrence, and appears to exercise a considerable influence on
the course of the disease. Its appearance will not unfrequently be
accompanied by relief of the other symptoms (Case III); when it occurs,
it is generally profuse, and little under the control of medicine,
but, if checked, may be followed by a sudden change for the worse in
the condition of the patient.
The intellect is seldom affected during the first stages of the
complaint; but subsequently, in severe cases, restlessness, delirium,
and coma, seldom fail to succeed each other. These symptoms are all
peculiar, both in regard to the rapidity with which they make their
appearance, and also the sudden manner in which they occasionally
disappear. The disease may seem, within a few hours, to leave a part
which it has first attacked, and to fall upon a different organ in some
remote part of the body.
X. The post-mortem appearances observed in those who die in consequence
of the introduction of vitiated fluids into the blood, cannot, for
the most part, be distinguished from similar changes produced by
other causes; yet there are some effects which are peculiar, and may
be directly associated with the reception of foreign matter into the
circulation. The most characteristic circumstance, attending the
extension of disease to different organs of the body through the medium
of the blood, is that several parts of these organs, or even different
organs, will be simultaneously attacked. The disease will appear at
once in various spots, which will become rapidly disorganized, while
the surrounding textures will remain unaltered, either in structure or
colour. The appearances observed upon dissection will vary according to
the part attacked, and the stage of development in which the disease is
found.
The lungs are the organs in which the successive changes may best be
observed. When puriform fluid has entered the circulation, the first
appearance produced in the structure of the lungs, is that of one or
more congested or dilated veins[33] of very small diameter. This will
be followed by a well defined spot, of much darker colour than the
surrounding texture. Several of these spots will probably appear at the
same time, and each one of them will soon become surrounded by a hard
spherical patch of purple congestion. Effusion of lymph will now take
place, commencing in the centre of each affected portion, and gradually
extending towards its circumference. If the disease continue, each spot
will suppurate, and the different parts will become softened and broken
down, in the same order in which they were previously solidified.
[33] For the knowledge of this fact, I am indebted to Mr. Cæsar
Hawkins, of St. George's Hospital.
The liver frequently becomes the seat of secondary inflammation. In
the early stage, brownish-red spots may be observed scattered through
its substance. These, as they extend, assume a bluish or slate-colour;
and the structure of the liver thus affected is found to have lost
its consistence, and to be very easily broken down by pressure. Every
part affected here, as in the lungs, proceeds rapidly to suppuration;
and the usual appearance presented after death, is that of several
small circumscribed abscesses, around which the structure of the liver
has been condensed only to a very small extent. It sometimes happens,
that the larger veins in the liver become inflamed. These vessels,
being held open by the firm structure of the part, are not so readily
obliterated as in other situations; and it consequently happens, that
the lymph and pus poured into them become irregularly mixed with the
blood, more or less perfectly coagulated, which they contain: a very
peculiar mottled appearance, resembling granite, is thus occasionally
produced.
Affections of the spleen, produced by the introduction of foreign
matter into the blood, are probably not so readily recognised as
similar affections in the lungs and liver. For, although the spleen
is often found to be diseased in those who die from infection of the
blood, yet it is comparatively seldom that secondary abscesses have
been found in it. In the accompanying table, containing twenty-three
cases, some morbid appearance, not recognised as peculiarly the result
of secondary inflammation, was observed in the spleen in no less than
eight instances. So large a proportion of cases renders it probable,
that the alterations observed have more than an accidental connexion
with the disease of which the patient died, although they presented
no characters which could be said to be peculiar to that disease. In
well-marked cases of secondary affections of the spleen, one or more
well defined, but frequently irregular indurations, of a chocolate
colour, may be recognised; such patches are usually seen soon after the
commencement of the complaint, and in a very short time become softened
or broken down. The rapidity with which they lose their original
character, may probably account for their being comparatively seldom
observed in post-mortem examinations.
Deposits of lymph are sometimes met with in the kidneys; but these are
of small extent, of a light colour, and resemble lymph deposited in
consequence of ordinary inflammation. The patches of congestion, so
characteristic of this disease in other organs, are not here observed.
This may depend upon the peculiar disposition of the capillary system
of the kidney. The blood has to pass through the Malpigian tufts, and
may be purified, or altered in character, before it reaches the proper
venous system of the organ.
In cases where purulent infection of the blood has been purposely
produced, portions of the kidney will not unfrequently be found
inflamed and firmer than natural; but, if the origin of the disease
were not known these appearances could not be distinguished from those
produced by inflammation of the kidney from other causes.
The skin is liable to be affected in three different forms. (See Cases
I, II, III, IX, X, and XXXIV). The first of these occurs very rarely,
and consists of small deposits of matter in the structure, or upon
the surface of the skin, resembling in many respects the pustules of
small-pox. The second form is also of rare occurrence, and consists of
small congested spots on the surface of the skin. These are generally
of a dark purple hue, but I have seen one case in which they were of a
bright red colour. In this instance, a secondary abscess had formed
in the knee-joint, and some pustules appeared upon the skin in the
neighbourhood. A fortnight before the death of the patient, a number
of small bright red spots made their appearance in different parts of
the thigh and upper part of the leg; some of these were three or four
lines in diameter while others were so small as not to be seen without
attention; they appeared in accurately defined spots, of a brighter
colour than the mucous membrane of the lips, and continued unchanged
in appearance till death. The third form presents itself much more
frequently than either of the others, although it has not hitherto much
attracted the attention of pathologists, in connexion with purulent
or other infection of the blood. It commences very suddenly, and
frequently without any particular attention being directed to the part.
A large circular patch of congestion, livid or purple in the centre,
but becoming of a lighter colour towards the circumference, will form,
usually upon some part of the lower extremities. The skin of the calf
of the leg is perhaps more frequently attacked than that of any other
part. In the centre of the congested portion, mortification very
rapidly takes place, and is indicated by the part assuming a black or
dull leaden colour. In some cases, it would be difficult to say where
the mortification ceases, and the congestion begins; but in other
instances, there is a distinct line of demarcation formed: a zone of
bright red congestion will then occasionally surround the mortified
part.
Some modifications of this third form of affection of the skin may be
met with occasionally in the course of the disease. Blotches assuming a
livid or dusky red appearance (which gradually fades into the colour of
the surrounding skin), will present themselves in different parts (Case
XXXVI), and terminate in thick exfoliation of the cuticle, or in small
sloughs of the skin. In some instances, the superficial portions only
of the skin are destroyed, and the parts beneath appear comparatively
unaffected; small circumscribed portions of the outer layer of
the skin will exfoliate, and the subjacent parts will heal without
suppuration, by a process similar to that of scabbing (Case III).
It is remarkable in this disease, that the most vascular parts are
those which soonest lose their vitality. Thus, in the case last
referred to, portions of the surface of the skin perished, while the
deeper layers recovered; again, it is not unusual to observe the whole
thickness of the skin destroyed, without any corresponding affection
of the cellular membrane beneath. The quantity of blood sent to a part
would thus appear to favour mortification in this disease. The reason
of this peculiarity will be considered in the next section.
In two of the instances recorded in the Appendix (Cases XXII and XXVI),
the lining membrane of the rectum was found of a very dark colour, and
in one it had assumed a greenish appearance. This discoloration was at
first looked upon as some accidental complication, or as depending upon
previous disease. But M. Gaspard has noticed a similar condition, after
the artificial introduction of putrid fluid into the blood.[34] In one
of the experiments referred to, the mucous membrane of the intestines
was everywhere healthy, except in the _rectum_ and _duodenum_. In the
former situation, the rugæ were prominent, and of a violet colour;
in the latter, the membrane was of the colour of pale lees of wine.
From the coincidence thus observed, we are led to believe that the
same condition which produces congestion in the skin, may produce an
analogous affection of the mucous membrane. Nor must we omit to note,
in connexion with this subject, the fact of the mucous membrane of the
vagina being occasionally found of a dark purple colour in those who
die of puerperal affections.
[34] Journal de Physiologie, t. iv, p. 45.
In the cellular membrane, serum, lymph, and pus, may be deposited,
mixed with each other in various proportions. The surrounding
vascularity, in these cases, is unusually small, and the lymph effused
not properly organized; there is, consequently, no natural boundary to
the disorganizing process, and the fluid secreted becomes infiltrated
in the surrounding parts.
When the muscular structure is affected, suppuration takes place with
great rapidity; portions of muscles may be found quite soft, and
sometimes pultaceous, in circumscribed patches, around which the fibre
is perfectly healthy. Pus is occasionally deposited on the exterior
of muscles; and it will be then smeared over the surface, and rather
infiltrated in the cellular tissue, than contained in a cyst. In the
interior of muscles, there is the same absence of the natural limit to
the inflammation; but, owing to the more compact structure of the part,
the deposits of matter generally remain circumscribed.
The brain and its membranes frequently present diseased appearances
in those who die from secondary inflammation; these, for the most
part, may be altogether independent of any peculiar effects of the
disease; but, in some cases, it appears probable that they are not
altogether unconnected with it. In one of the accompanying cases, the
_pons Varolii_ and _medulla oblongata_ were found of a pink colour, in
consequence of congestion, where the system had become contaminated
by the absorption of diseased secretion; and, in another, a layer
of purulent lymph was found within the cavity of the arachnoid,
accompanied by marks of inflammatory action in the fourth, and in one
of the lateral ventricles.
The serous membranes are peculiarly liable to be attacked by secondary
inflammation; and, when affected, suppurate with the greatest
readiness. They generally exhibit but a slight degree of vascularity,
and sometimes scarcely appear more injected than in their natural
condition. In the peritoneal cavity, large quantities of unorganised
lymph are frequently poured out, mixed with turbid serum or pus. The
synovial membranes of joints, when affected, appear to run directly
into suppuration, and will become distended with pus in a very short
space of time. The pleura, on the other hand, will seldom suppurate
at first; but lymph will be deposited upon its surface, and its cavity
will contain turbid serum, occasionally mixed with blood.
XI. In the first sections, the changes produced in the blood, both
in and out of the body, by the admixture of purulent or diseased
secretions, were considered; and, in the last section, the post-mortem
appearances observed in the different organs of those who have died in
consequence of secondary inflammations, have been described. It now
remains to connect these two series of observations, and to trace the
relation that they bear to each other.
The most direct way in which diseased blood produces disease in the
parts to which it is conveyed, is by communicating to them its own
condition. Even foreign substances, which have no natural connexion
with the body, may, in this way, be conveyed in the blood, and
deposited in the organs of the body. Hunter relates a case,[35] in
which a house-painter, who had been paralytic in his hands and legs
for a considerable time, had his thigh broken, and died, about three
weeks after, of the accident: "On examining the body, after death, the
muscles, particularly those of the arms, had lost their natural colour;
but, instead of being ligamentous and semitransparent, as happens in
common paralysis, they were opaque, resembling exactly in appearance
parts steeped in a solution of Goulard's extract. From this case it
appears, that the lead had been evidently carried along with the blood
into the muscles themselves. The blood can thus receive and retain
extraneous matter capable of destroying the solids."
[35] Op. cit. p. 99.
If foreign matter may, in this way, be conveyed to different parts of
the frame, and there produce its chemical effects, it will readily
be admitted, that a mechanical or vital action commenced in the
blood,[36] may be continued in it when moved to a different part of
the body.
[36] It may appear unusual to speak of action going on in the blood;
but, in so doing, we only illustrate the principle with which we
commenced, viz., that "the blood has the power of action within itself."
In those who die of secondary inflammations, the result of such actions
may frequently be traced from the seat of the primary injury even to
the heart itself; and, as it has already been shown that contaminated
blood will communicate morbid action to the vessels in which it is
contained (section III), there no longer remains any difficulty in
accounting for the sudden way in which this disease may fall upon a
particular organ, or the unexpected manner in which the symptoms may
shift from one part of the body to another. The conditions of the
blood, which may be observed upon dissection, in this disease, so
far as they tend to illustrate the present subject, may be included
in two general expressions: 1st, those in which the blood has had a
preternatural tendency to coagulate impressed upon it; and, 2nd, those
in which its coagulating power has, to a greater or less extent, been
impaired. In one case, the blood is generally found of a dark colour,
with firm, and sometimes adherent coagula in the vessels; in the other,
it is thin and fluid.
When a preternatural tendency to coagulate has been impressed upon
the blood, it will lodge in different parts of the vascular system,
in situations which are most favourable to such an action; when, on
the contrary, it has lost its coagulating power, extensive effusions
may be expected, or the symptoms included under the term "gangrenous
diathesis" may manifest themselves.
As the aggregate diameter of the vessels in the body decreases, the
blood in them flows with greater rapidity and force; and when near
the heart, it is placed in circumstances unfavourable to coagulation,
in consequence of the rapid motion there communicated to it; and we
accordingly find that, although adherent coagula may be formed in the
veins leading from the seat of injury, and may be traced thence through
other larger vessels, they will usually terminate abruptly, when these
open into the vena cava. But when the blood arrives in the cavities
of the heart, the tendency to coagulate may again manifest itself.
Diseased coagula, presenting a "mottled appearance, partly brown,
and partly of a dirty yellow colour", or "dark coloured, and partly
composed of a yellowish grey opaque substance", or "with portions
inelastic, and of an opaque yellow colour", will be found entangled
among the projecting fibres of the auricles and ventricles. In the
arteries, the blood is in the most unfavourable circumstances for
coagulation during life, in consequence of the comparative smallness of
their diameters, and the succession of impulses communicated to their
contents; but even here, diseased and adherent coagula may be found in
cases of secondary inflammations.
M. Cruveilhier[37] relates an instance in which, after child-birth, the
pulmonary artery was found filled with coagula following its divisions.
The principal clot had lost its colour, and was _adherent_ to the sides
of the vessel, and contained in its centre puriform fluid.
[37] Op. cit. p. 669.
In another case, following the operation for necrosis, the following
post-mortem appearances were observed. The left lung presented, in
several places, patches of red hepatization, perfectly defined, and
resembling so many spots of lobular inflammation. When cut into, these
patches presented several puncta of puriform fluid. The _veins_ of the
lung contained fibrinous-looking coagula blocking up their cavities;
and in the centre of these coagula was a whitish purulent looking fluid.
The diseased condition of the blood may thus be traced visibly from the
original wound, through the larger vessels, to the heart, and again
from the heart to the capillary system. The disposition to coagulate,
once impressed upon the blood, is not destroyed by that fluid being
conveyed to a different part of the body: the action may be retarded by
motion in, as well as out of the body, but will nevertheless occur when
it is placed under more favourable circumstances.
These circumstances, in the living vessels, are when the blood
becomes separated into small quantities, and when it moves slowly
along the capillaries. The blood will then coagulate in circumscribed
patches,[38] as illustrated in the first characteristic marks of
secondary disease which have already been mentioned as occurring in the
lungs, the liver, the spleen, and the skin. The accompanying plate is
taken from the lung of a donkey in which purulent fluid had been made
to circulate with the blood. The stagnation of the blood, when the pus
was first introduced, was mechanically prevented, and the livid spots
produced by its subsequent coagulation in the capillaries of the lungs
has been very faithfully represented. (See Experiment No. VI.)
[38] The term ecchymosis does not appear appropriate to the discoloured
condition of parts observed in the commencement of this disease; the
blood is not at first extravasated from the vessels, but coagulated in
them.
"Besides the disposition for coagulation," observes Mr. Hunter,
"the blood has, under certain circumstances, a disposition for the
separation of the red globules, and probably of all its parts; for I
have reason to believe, that a disposition for a separation of the
red part and coagulation, are not the same thing, but arise from two
different principles. This is always observable in bleeding; for if
we tie up an arm and do not bleed immediately, the first blood that
flows from the orifice, or that which has stagnated for some time in
the veins, will soonest separate into its three constituent parts: this
circumstance exposes more of the coagulating lymph at the top, which is
supposed by the ignorant to indicate more inflammation, while the next
quantity taken suspends its red parts in the lymph, and gives the idea
that the first small quantity had been of such service at the time of
its flowing, as to have altered for the better the whole mass of blood.
Best, therefore, maybe regarded as one of the immediate causes of the
separation." _Hunter_, p. 29.
This disposition of the blood to separate into its constituent parts is
evinced in a very marked degree in one class of secondary affections.
Extensive effusions of serum, lymph, and pus, mixed in different
proportions, will take place in the serous cavities of the body, and
become infiltrated in the cellular membrane, accompanied with very
slight indications of inflammatory action. The colouring matter of the
blood will also sometimes become effused with its other parts; but when
this is the case, the blood will be found to have lost its coagulating
power: in this respect presenting a direct contrast to the effusion
from a healthy wounded vessel. The lymph deposited will be found lying
in unorganized flakes, wanting its usual adhesive properties, and
very slightly attached to parts, presenting little or no increased
vascularity. The rapid manner in which these depositions take place,
shows that they are separated from the blood without undergoing any
very elaborate process. In this condition of the system, any organ
upon which the disease falls, may rapidly become disorganized, or may
readily mortify; and, after death, a tendency to rapid decomposition
will be manifested. The veins on the surface of the body may frequently
be traced as dark blue lines, as though the skin covering them were
stained by the colouring matter of the blood. The lungs and other
organs may, under these circumstances, be found in every grade of
disorganization, till they present all the characteristics of gangrene:
even the peculiar fetor which accompanies mortification of the lung,
will, in some instances, be present. A tendency to the formation of
petechial spots may also be observed in different parts; and even
the organs which do not appear to have been the peculiar seat of the
disease, will be found to have lost their consistency, and to break
down upon comparatively slight pressure.
Mr. Hunter found, that in proportion as the blood retained the power
of coagulation, it had the power of resisting putrefaction; and
conversely, we observe that, in this class of cases, the deficiency
of the former is accompanied in a marked manner by the absence of the
latter.
The two conditions of the blood which have now been mentioned,
appear to bear a direct relation to the two classes of post-mortem
appearances, observed in cases of secondary inflammations: the first
being generally connected with congestion of different organs during
the first stages of the disease, the second with extensive effusions,
accompanied with comparatively little vascularity.
XII. The treatment of secondary inflammations naturally divides itself
into local and constitutional, both as regards the primary lesion
and the subsequent affections. The circumstances which interfere
with union by the first intention in veins, have been shown to be
the same as those which precede the formation of purulent deposits,
in a large class of cases. Whatever then tends to favour the healthy
reparation of a wounded vein, may be regarded as affording security
against any subsequent disease; and the chief point in the local
treatment is, perhaps, to prevent any accidental circumstances from
interfering with the natural process of repair. When the powers of the
constitution are enfeebled, even the natural motions of a part may
interfere with recovery, and rest sometimes becomes an important object
in the treatment. How necessary this is after child-birth, when the
divided veins are being closed, every one who has attended such cases
practically knows.
Again, after bleeding, the arm will inflame in a much greater
proportion of cases, when the patient is obliged to follow his usual
occupation, or when, from accidental circumstances (as from the pain
experienced in Case I), the arms are kept in motion. It has occurred
to me, to see the symptoms of purulent deposits set in, on the day
following prolonged attempts to bring fractured portions of bone into
position. In all such cases, any external violence (as in Experiment
No. VI), or even the motion of the body, as in Dr. Davis's case
(section IV) may loosen the coagula formed, either between the wounded
edges, or in the cavities of veins.
In the treatment of the local injury, a valuable hint has been left
us by Mr. Hunter, connected directly with the consideration of the
pathology of the disease. "The way in which sore arms after bleeding
come on, shows plainly that they arise from the wound not healing by
the first intention"; and he recommends that the two sides of the vein
should be approximated by a compress, until union of the divided edges
has taken place.
It has been shown upon very high authority, that the sides of a vein
do not unite after venesection (as has sometimes been presumed to be
Mr. Hunter's opinion); but that the divided edges only of the vessel
are agglutinated by the coagulum, which "serves as a bed to the new
membrane." But the case is different, should this first attempt at
union fail; the sides of the vessel may then become united, and its
cavity for a time obstructed (section IV). The approximation of the
sides of the veins would materially facilitate this action, which is
the natural security, under the circumstances, against the admission of
foreign matter. When an abscess is suspected to have formed in a vein,
a similar mode of treatment is recommended by Hunter; the compress, in
this case, being placed between the inflamed part and the centre of the
circulation. In the pathological museum of the College of Surgeons, one
of Mr. Hunter's preparations (No. 1728) exhibits such a case, where,
from the imperfect union of a vein, the contents of the abscess had
become mixed with the blood.
As the process of reparation has been variously described by authors,
so the different theories propounded have led to different kinds of
treatment. At the Veterinary College, even within the last few years,
it was publicly taught, that a coagulum in a vein was a foreign
substance, and ought to be removed; and the jugular vein in horses
which had been bled, was sometimes slit up for several inches, in order
to remove the coagula which formed in successive portions of its course.
That a coagulum in a vein may be an irritating substance has been
fully proved (sections I and II); but the irritation depends upon
the accidental admixture of foreign matter: and the inflammation of
the veins, produced by the contact of impure blood, requires to be
carefully distinguished from the natural mode of union by the first
intention.
To remove coagula which have formed round purulent secretion (if such
could be recognised), might be to remove a cause of irritation; but to
remove them in ordinary cases, is to remove the very means prepared
by nature for the restoration and safety of the part. In operations
involving large vessels, the local conditions which may influence the
actions in the veins, appear not to have been fully determined; for
while some surgeons regard the tying or cutting of a vein as a serious
operation, others are in the habit of doing it without any unusual
precaution. In operations upon hæmorrhoidal tumours, the veins involved
are of some size, and in two of the instances recorded in the Appendix,
a ligature applied to them was followed by purulent deposits. In the
usual mode of passing a needle armed with a double ligature through the
base of such a tumour, the hæmorrhoidal veins are necessarily sometimes
wounded, and there is danger that, in tying the ligatures, the sides
of a wounded vein may be drawn asunder. The vessel may thus be held
open, and be in a similar condition to the vessels contained in bony
structures.
A safe way of performing this operation, when admissible, is to destroy
a portion of the mucous membrane with strong nitric acid. The blood
in the vessels then becomes charred, and their cavities obstructed,
till they are permanently closed by adhesive inflammation. Every
means of treating a local injury which tends to produce healthy
union or adhesion, may be considered in some sort as a preventive
mode of treatment. Position, topical applications, bandages, and
temperature, may all have their influence in producing these healthy
actions; but, as the wounds which precede purulent deposits are
generally characterized by feeble powers, those conditions which tend
to invigorate the parts are principally indicated. "When action is
greater than strength, whatever has the tendency to raise the power
above irritability should be used: the object of this practice consists
in bringing the strength of the constitution and parts as near upon a
par with the action as possible, by which means, a kindly resolution,
or suppuration may take place, according as the parts are capable
of acting." The irritability of a wound frequently appears nothing
else than a series of attempts to bring about an action, which it has
not the power to accomplish: as soon as that is fulfilled, which the
necessity of the parts demands for their healthy condition, irritation
will cease. In such cases, everything that will confer strength to
carry out the intended action, will prevent inflammation. But no local
applications will be sufficient to produce this effect, unless the
powers of the constitution are supported at the same time.
A heavy man received a wound in the back of his head from an iron
spike; he was kept very low, complaining occasionally of want of food.
Repeated hæmorrhage took place at intervals of a day or two, which no
local applications could suppress, and he ultimately died from loss of
blood. The wound was found to extend through the bone into the lateral
sinus, which contained only some fluid blood. No inflammatory action
had taken place within the skull, nor had any attempt apparently been
made to close the wounded vessel. Any vitiated secretion in contact
with the lacerated edges of the vessel would, in such a case, have free
access to the circulation.
The constitutional treatment of cases, liable to be succeeded by
purulent deposits, is most important; for during the healing of the
primary wound, the system may be influenced by remedies, which may be
subsequently quite useless. It is evident, observes M. Cruveilhier,[39]
that the treatment of phlebitis ought to be concentrated on the first
period of the disease, viz., that of the coagulation of the blood; for
as soon as pus has become mixed with the circulating blood, medicine
is generally of no avail. When there are indications of the extension
of inflammation along a vein, the mode of treatment usually adopted
in this country has been the administration of calomel and opium;
and, in France, general bleeding, but especially the application
of large numbers of leeches. "We may subdue inflammation of veins,
whatever their situation, by general blood-letting, and especially
by local bleeding, repeated sufficiently often and in sufficient
quantities!"[40] It is true that patients recover after such treatment;
but the published records of cases not unfrequently terminate with such
a description as the following: "The patient was repeatedly bled, and
with apparent relief every time, the blood being extremely sizy. _Two
days, however, previous to death, the vital principle was so exhausted
as to need the use of cordials!!_"
[39] Op. cit. p. 662.
[40] Op. cit. p. 662.
If the explanation of the mode of adhesion in veins already given be
correct, neither the propriety of bleeding, nor of the administration
of mercury, as a rule, derives much support from a consideration of
the pathology of the disease. Careful comparative experience is still
wanting, before we can form a satisfactory judgment of the value
of these remedies. The theoretical views upon which they have been
adopted, are confirmed neither by the statistical records of cases, nor
by the principles of sound physiology. The numerical evidence which
we have in some instances, even tends to indicate an opposite plan of
treatment.
At a period when puerperal fever was rife, forty cases, attacked
with some form of the disease, "were treated without any bleeding
or leeching, or without any attempt to induce the constitutional
effects of mercury; and of these, only two died."[41] "In irritable
habits, when the inflammation becomes more diffused," says Mr. Hunter,
"bleeding should be performed with great caution: even a quick, hard
pulse, and sizy blood, are not always to be depended upon as sure
indications of bleeding being the proper method of the resolution of
the inflammation; more must be taken into the account. The kind of
blood is of great consequence to be known; for although it should prove
sizy, yet if it lies squat in the basin, and is not firm in texture,
and if the symptoms at the same time are very violent, bleeding must
be performed very sparingly, if at all; for I suspect, that under such
a state of blood, if the symptoms continue, bleeding is not the proper
mode of treatment. If we had medicines which, when given internally,
could be taken into the constitution, and were endowed with a power
of making the vessels contract, such, I apprehend, would be proper
medicines. Bark has certainly this property, and is of singular
service, I believe, in every inflammation attended with weakness; and
therefore, I conceive, should be oftener given than is commonly done."
[41] FERGUSON (Dr.) On the Diseases of Women. These cases formed
one-fifth of the whole number treated.
In bleeding women suffering from puerperal fever during an epidemic,
in which the disease frequently terminated in purulent deposits, I
have occasionally seen an irregular transparent bluish layer form upon
the surface of the blood, almost immediately after the operation;
in consequence of this, a repetition of the bleeding was sometimes
had recourse to, when the subsequent stages of the disease appeared
to indicate that it had not been required. The transparent layer of
lymph on the surface of the blood, may, in such instances, be only
an indication of its tendency to separate into its different parts,
as previously described. Large bleedings, under such circumstances,
inasmuch as they tend to diminish the already enfeebled power of
coagulation in the blood, may predispose to the infection of the
system, and to the formation of purulent deposits. The influence of
mercury upon the system, as illustrated in Case XXVI, may have the same
tendency.
The action of mercury, so far as it can be traced upon the surface
of the body, is certainly unfavourable both to union by the first
intention, and to adhesive inflammation; and, inasmuch as the safety of
the patient, after an injury or wound, depends upon the due performance
of these processes, its effect upon the system must be regarded as of,
at least, doubtful advantage.
When salivation has been induced, serum is poured out, and the texture
of the gums is loosened and rendered spongy. When lymph is effused upon
the iris, the action of mercury loosens its adhesions, and dissolves
its connexions; it cannot, therefore, be supposed that its effect upon
the system should render the union of divided vessels stronger, or the
newly-formed adhesions in wounds, firmer.
The cases in which purulent deposits usually form, indicate a
debilitated state of constitution. They are of much more frequent
occurrence in large towns than in the country, and in hospital than
in private practice. The depressing influences which give rise to
erysipelas, or puerperal fever, will also predispose to the formation
of these abscesses; and as scanty diet, loss of blood, debilitating
surgical operations, and over-crowded rooms, have been found among
the causes of the former, so may they be looked upon as favouring the
production of the latter.
The Treatment of Inflammation of the Veins, in which purulent deposits
frequently originate, is thus spoken of, after matured observation:
"All the experience that I have had on the subject, would lead me to
believe that, like erysipelas, it has its origin in a low asthenic
state of the system, and that those persons are especially liable
to it, who have been much lowered by hæmorrhage at the time of an
operation, or by too scanty a diet afterwards. An operation is a shock
upon the system, making a great demand upon the vital powers. The
effects of this shock are often much aggravated by loss of blood, and a
very scanty diet actually makes the patient more liable to some kinds
of inflammation. Our mode of practice ought to be rather to sustain
his powers by allowing him wholesome nourishment, and not to add to
the influence of the other depressing causes, the still worse one of
starvation."[42]
[42] BRODIE (Sir B. C.) Medical Gazette, vol. xxxvii, p. 642.
The lowering influence of mercury may be considered in a similar way.
There can be little doubt that while, on the one hand, it favours the
absorption of vitiated fluids, it may, on the other, render the system
less able to resist the injurious consequences which they produce.
As many circumstances, besides mere debility, tend to depress the vital
powers, so tonic medicines, and a generous diet, must not be looked
upon as the only preventive modes of treatment. Each case that occurs
in practice may present some peculiarity; in one case, the patient
will be found to have previously suffered from diabetes; in another,
from disease of the spleen; and in a third, from organic disease of
the kidney; and, in each of these, a peculiar mode of treatment may be
required.
The general management of this disease, after the formation of purulent
deposits has commenced, is probably as little satisfactory as any
that come under the notice of the surgeon. The whole character of the
affection is characterized by what has been aptly designated as action
without power. The excitement of the system will imitate all the acts
of genuine inflammation, without any of its healthy results; and loss
of energy will appear immediately after, or even arise in conjunction
with, the first symptoms of increased action.
In the treatment of such cases, it must be borne in mind, that the
secondary inflammations are not the disease, but the effect of a
concealed cause, which may develope itself in any part of the system;
and that, while the relief of one organ is sought by depletion or
mercurial remedies, additional vigour may be given to the latent evil,
so as to render it more ready to develope itself in some other part.
When purulent deposits occur, the sudden congestions, which indicate
their commencement, are not accompanied by any reparative actions, and
the lymph, which is effused in the second stage of their formation, is
not so disposed as to circumscribe and limit the inflammation; there
is, therefore, no natural process by means of which such collections
of fluid can be evacuated; hence, when situated near the surface,
they should be opened as soon as they are detected. It will sometimes
happen, that, after the symptoms of secondary inflammation of internal
organs have commenced, an abscess will present itself near the surface
of the body, and relief will be afforded to the part first affected;
at other times, an obstinate and violent diarrhoea will precede
recovery. Although the mode of treatment adopted may have little
influence either in bringing on, or checking, such salutary actions,
it is important to watch their occurrence, and perhaps still more
important, to be careful not to mistake a remedial action for a symptom
of the disease.
"What treatment," says Cruveilhier, "shall we oppose to purulent
infection? To this question experience is as yet dumb, while theory
would seem to point to diffusible stimuli and tonics; to ammonia,
quinine, and sudorifics; to hot external applications, to the vapour
baths, to purgatives, and especially to emetics; to tartarized
antimony, in large doses; to vesicatories, and to strong diuretics.
Calomel has been extensively employed, to create a fluxion from
the intestinal mucous membrane; but all these means have failed as
signally in my hands as in those of others; yet, when the injection
of putrid matters into the veins of living animals has been followed
by abundant and very fetid evacuations, they have usually got well.
It is a fundamental fact of pathology, that the intestinal canal is
chiefly affected in diseases caused by miasmata. I am certain that
diseases resulting from purulent infection would not be stamped with
the seal of incurability, and that nature, seconded by art, would
triumph in the majority of cases, if the pus, which is incessantly
renewed, did not incessantly renew the sources of infection. As soon
as constitutional symptoms manifest themselves, neither general nor
local bleeding affords any advantage. A portion of the _materies morbi_
is, no doubt, abstracted with the blood; but, as it is constantly
being reproduced, the constitution is only deprived of the power it
would otherwise have of resisting the disease."[43] In accordance with
this remark, M. Gaspard found that animals, which recovered after the
injection of a certain quantity of pus into their veins, often died
when the experiment was repeated. The recovery was usually preceded
by black, liquid, and extremely fetid evacuations, which often seemed
to afford immediate relief. When such evacuations have taken place in
other diseases, the gall-bladder has been found distended with black
bile;[44] and it appears probable that the liver, in these cases, is
one of the principal organs through which the cleansing of the system
is attempted. If the supply of morbid matter to the system could be
checked, mercurial action, in this stage of the disease, might be of
service, by enabling the liver, or other organs, to throw off their
vitiated secretions. When patients recover from purulent deposits
(Cases III and XXVII), they are often left in a debilitated and
languid state, in which ordinary tonics exercise little influence.
The consequences of the disease appear to hang about the system,
long after the cause which gave rise to it has ceased. The pulse
will sometimes continue irritable, and there will be a tendency to
derangement of the secretions of the skin, bowels, and other organs,
accompanied by occasional slight attacks of fever. In this condition,
an alterative course of mercury, combined with sarsaparilla, has been
found beneficial. These remedies, by stimulating the activity of the
excreting organs, may assist the constitution in throwing off the
disease; and their mode of action may be the same as in other cases,
where the system has been infected by an animal poison.
[43] Op. cit. p. 662.
[44] I have observed this condition after injuries of the spine which
proved fatal, by causing inflammation of other parts.
APPENDIX OF CASES.
A. CASES OF SECONDARY INFLAMMATION, ACCOMPANIED BY MORTIFICATION OF THE
SKIN.
CASE I. William Ford, 33, an apparently healthy man, was seized with
the symptom of strangulated hernia, at Harrow, December 28th. He was
bled in both arms; but, as the hernia remained unreduced, he was sent
to town, in a state of considerable restlessness and suffering. During
his journey, the hernia returned of its own accord. He left quite
relieved, and remained well till the 31st, when he had a rigor. On the
1st of February, there was a considerable degree of febrile excitement,
and the anterior part of the left arm was red, swollen, and painful
upon pressure. The tenderness and pain soon extended up the arm, in
the course of the cephalic vein: the redness assumed the character of
erysipelas. On the 3rd, he suffered from sickness, the matter vomited
being green and acid. He had two severe rigors, followed by great heat
of skin, and a quick full pulse. The orifice in the left arm discharged
a thin serous fluid. On the 4th, he complained of stiffness in the
right arm; also of being very feeble and faint. 5th. Wandered much
during the night. The right arm was a good deal swollen about the end
of the elbow-joint, and presented a patch of a bright red colour above
the condyle. The pulse was weak and tremulous; motions of the hands
were occasionally observed. He complained of pain in the ring-finger of
the right hand, and in the ball of the right great toe. The skin, in
both these situations, had assumed a red appearance. 6th. Was delirious
during the greater part of the night; countenance expressive of much
anxiety; pulse very weak; tongue covered by a brown dry fur; profuse
perspiration; complained of severe pain in the calves of his legs. He
died during the following night.
_Post-mortem appearances._ A small deposit of thick pus was found
on the external surface of the left cephalic vein. The blood was
coagulated in its cavity, its coats were thickened, and its lining
membrane appeared very red. This redness could be traced, though in a
less degree, through the whole extent of the vena innominata. On the
right side, the cellular tissue, both above and below the elbow-joint,
was greatly distended with serum. The cephalic vein of the right arm
presented marks of having been inflamed; but not nearly to the same
extent as upon the opposite side. The joints in which pain had been
experienced during life, were distended with turbid pus; deposits
of pus were also found in the anterior mediastinum, and between the
oesophagus and trachea. A large gangrenous spot was observed in the
skin of the calf of the right leg. The subjacent cellular tissue was
much distended with serum.
CASE II. Richard Mason had a small cancerous tumour removed from the
lower lip. The operation was performed in the usual way, and the wound
appeared to heal by the first intention; a small abscess, however,
followed by some ulceration, subsequently appeared in the neighbourhood
of the cicatrix. Nine days after the operation, he complained of sore
throat and general uneasiness, and three days afterwards he was seized
with rigors, followed by cold perspiration and coma.
_Post-mortem appearances._ A small deposit of matter was found,
situated beneath the fascia of the left thigh. The synovial membrane
of the left knee was highly inflamed, and contained a large quantity
of pus. On the right side, the skin of the whole inferior extremity
presented a dark livid appearance, with the exception of that situated
upon the fore part of the thigh. The same dark colour was observed
in the muscles of the limb, which were infiltrated with blood and
serum. The arteries and veins were discoloured, but in other respects
presented nothing remarkable. It was ascertained, that, two years
previously, this patient had suffered from diabetes; and upon examining
the urine found in the bladder, it was found to contain sugar.
CASE III. Jane Thornton, æt. 32, came under treatment on the 22nd of
March. A week previously, her right ancle had become red and painful,
and inflammation subsequently extended up the inner side of the leg.
When first seen, she was evidently much out of health, although no one
organ could be said to be particularly affected. On the 28th of March,
she was attacked with severe rigors, and experienced pains in different
parts of her limbs: the rigors were repeated for several days in
succession. The inflammation of the leg now entirely disappeared, and
she complained of pain in the right knee, which was slightly swollen.
On the 31st, her bowels became much relaxed; there was great general
depression, and much nervous agitation. Both knees were swollen. The
general symptoms now became somewhat relieved; but on the 4th April,
she was attacked with vomiting, which recurred frequently during the
day, and was accompanied with great depression, and severe pain in
the epigastrium. On the 5th, the sickness continued, apparently quite
uninfluenced by any remedies. She passed considerable quantities of
blood by stool: her countenance presented a dusky yellow hue: the pulse
was excited, without power, and the sense of depression was greatly
increased. On the 7th, the vomiting still continued, and she still
passed blood by stool. Some spots of a dark purple colour now made
their appearance upon her face. The hands both became slightly swollen;
and upon the right one, some small, dark, livid spots, similar to
those upon the face, made their appearance. She was much troubled with
hiccough. On the 9th, the countenance was very anxious, the complexion
more sallow: some more livid spots appeared upon the face and cheeks.
The right hand and arm were swollen and painful: some fresh livid
spots appeared, upon the knuckles. Complained much of faintness: had
extreme debility with occasional hiccough: pulse extremely weak: the
surface of the body was covered with cold perspiration. The sickness
had entirely ceased, and there was no blood in the motions: the tongue
was rather dry in the centre, but tolerably clean. 10th. She wandered
slightly during the night, and vomited once: some blood again appeared
in the motions; the right hand and arm were less swollen. 11th.
The countenance was anxious, the pulse about 90, and intermitting
irregularly. The vomiting recurred several times. The livid spots on
the right hand had not increased in size, but appeared like distinct
small black superficial sloughs of the skin; these all scabbed off,
without suppuration. 12th. The pain and swelling of the arm had nearly
subsided. The bowels acted very freely with the aid of medicine, and
she expressed herself much relieved. From this time the patient slowly
but gradually improved, with one or two slight intermissions, till the
beginning of May, when she again complained of pain at the inner part
of the right arm, above the elbow. Some hardness could here be felt in
the course of the basilic vein. Some small collections of matter were
now deposited upon the back of the right hand, resembling, in some
respects, the eruption of confluent small-pox. On May 11th, she had
regained much of her strength, but still felt some pain in the elbow
upon motion. She also complained of the joints of one of her fingers.
She now left London for change of air.
B. _The following Table is formed of Cases taken consecutively during
One Year._
--------------------------+-----------------+-------------------------
| Period |
Heads of Cases. | of secondary | Post-mortem
| inflammation. | appearances.
--------------------------+-----------------+-------------------------
CASE IV. Elizth. | A few days after| Dark-coloured serum,
Mackintosh, æt. 25. | the appearance | mixed with shreds of
Inflamed bursa patellæ; | of the | recently effused lymph,
erysipelatous inflammation| erysipelatous | in the cavity of the
in the neighbourhood of | inflammation; | left pleura; large
the right axilla; sudden | three days | quantities of
suppression of the | before death. | seropurulent fluid,
catamenia; rigor; periton-| | with recently effused
itis; tongue covered with | | lymph, in the
yellowish white coating; | | peritoneal cavity.
sickness; "catching pains"| |
in the epigastric region. | |
| |
CASE V. James Stevens, æt.| Twenty-seven | Bloody fluid in the
46. Punctured wound of the| days after the | cavity of the left
finger whilst opening a | injury; about | pleura; pus in the
rabbit; diffuse cellular | seven days | left elbow-joint.
inflammation of the right | before death. |
arm; spasmodic and | |
"catching pains", princip-| |
ally referred to the | |
epigastrium; expectoration| |
of bloody fluid. | |
| |
CASE VI. William | Twenty days | Cavity of the knee-
Collins, æt. 36. Bruise of| after the | joint containing a
the patella, caused by the| accident; | quantity of thick
wheel of a carriage; | three days | grumous fluid,
apparent recovery; erysip-| before his | apparently a mixture
elatous redness over the | death. | of blood and synovia;
same knee; rigor; rapid | | fibrous degeneration
pulse; hot skin, followed | | of a portion of the
by perspirations, pains in| | cartilage of the
the head, restlessness, | | patella; turbid serum
delirium. | | in the sub-arachnoid
| | cellular tissue;
| | bloody puncta in the
| | brain, larger and more
| | numerous than natural;
| | posterior part of both
| | lungs gorged with
| | blood.
| |
CASE VII. Maria Martin, | Several months | The skin of the upper
æt. 39. Caries and necro- | after the | part of the leg and the
sis of the tibia, with | occurrence of | whole of the thigh of a
large ulcer of the leg. | caries of the | mottled appearance,
| tibia; a few | caused by extensive
| days before | dark patches of
| death. | incipient gangrene;
| | the cellular tissue of
| | the limb infiltrated
| | with lymph and pus.
| |
CASE VIII. George Mason, | Nine days after | Increased degree of
æt. 42. Compound commin- | the injury; | congestion, both in the
uted fracture of the meta-| twenty-two | grey and white sub-
carpal bones; inflammation| days before | stance of the brain;
of the absorbents; erysip-| death. | substance of the pons
elatous redness of the | | Varolii and of the med-
skin; secondary abscess in| | ulla oblongata of a
the affected arm; rigidity| | pinkish colour, and
of the muscles of the | | presenting irregular
tongue; trismus; universal| | streaks of increased
affection of the muscles. | | vascularity; spleen
| | soft, and somewhat
| | congested.
| |
CASE IX. Sarah Leg, æt. | A few days | Effusion of serum and
50. Necrosis of a portion | before death. | lymph in the cellular
of the tibia, accompanied | | tissue, which surrounds
by a large foul ulcer. | | the pharynx and oeso-
| | phagus; inflammation
| | and ulceration of the
| | mucous membrane of the
| | larynx; slight inflam-
| | mation of the lungs;
| | the spleen of a greyish
| | red colour, more solid
| | and more easily
| | lacerated than natural.
| |
CASE X. Elizabeth Moleno, | Eight days after| The lining membrane of
æt. 42. Strangulated | the operation; | the right internal
femoral hernia of the left| four days | saphenic vein of a dark
side; operation; erysipe- | before death. | livid colour throughout,
latous blush around the | | the cavity of the
wound upon the third day, | | vessel filled with a
followed by sickness, cold| | large quantity of
perspiration, and | | coagulated blood mixed
delirium; several dark | | with puriform fluid;
patches upon the skin of | | pus in the common iliac
the right leg. | | vein; effusion of serum
| | around the veins of the
| | leg; liver large and
| | congested; mottled
| | degeneration of both
| | kidneys.
| |
CASE XI. Jane Cox, æt. 60.| A short time | Mortification of the
Scalp wound; erysipelas of| before her | skin of the lower part
the head and face; | death. | of the leg, ankle, and
transverse fracture of the| | foot; slight extravas-
external malleolus, | | ation of blood into the
followed by suppuration | | arachnoid cavity, and
of the ankle-joint. | | into the substance of
| | the brain; kidneys
| | coarse in structure, and
| | remarkably soft.
| |
CASE XII. Bartholomew | Five days after | Mortification of the
Sullivan, æt. 27. Lacerat-| the accident; | skin and cellular tissue
ed and contused wound of | eight days | of the right leg; the
the leg, followed by | before his | veins of the limb
diffuse cellular inflamma-| death. | healthy; spleen of a
tion, and inflammation of | | pale colour, and very
the absorbents; delirium; | | soft.
a separate large patch of | |
mortification, surrounded | |
by bright red congestion, | |
appeared in the right | |
groin the day before | |
his death. | |
| |
CASE XIII. George Foscutt,| Six days after | Hepatization of both
æt. 24. Fracture of the | the accident; | lungs, with secondary
femur into the knee-joint;| twenty-two | abscesses in the left
rigors; erysipelas of the | days before his | one; kidneys soft and
limb, ill defined and very| death; pain | coarse in texture, the
slow in its progress; | in the chest | left presenting a small
coma; abscesses in the | the day before | deposit of apparently
leg and thigh; mortificat-| his death. | tubercular matter;
ion of the skin on the | | spleen large, pale, and
dorsum of the foot, and | | soft.
over the left hip. | |
| |
CASE XIV. William Wright, | Erysipelas | Effusion of lymph in the
æt. 30. Fracture of the | appeared a month| pleura; secondary
patella; erratic | after the | abscesses in different
erysipelas; diarrhoea; | fracture of the | stages of formation in
abscesses in the leg, and | patella, and | both lungs, and deposit
in the knee-joint. | about the same | of lymph in one kidney.
| time before his |
| death. |
| |
CASE XV. Henry Bateman, | Three months | Recent effusion of lymph
æt. 19. Fracture of the | after the | upon the pleura;
fibula; diffuse cellular | accident; three | incipient secondary
inflammation of the leg; | weeks before his| abscess in both lungs;
suppuration in the knee- | death. | the tibia exposed, and
joint; necrosis of a | | its structure of a black
portion of the fibula. | | colour, and soft.
| |
CASE XVI. John Clark, æt. | Nineteen days | Effusion of lymph
45. Large scalp wound; | after the | between the dura mater
rigor; followed by | accident; three | and the bone, and of pus
paralysis of one side; a | before death. | and lymph in the cavity
portion of bone exposed, | | of the arachnoid; pus,
of a darkish green colour,| | mixed with blood, in the
and when removed of a | | superior longitudinal
putrid odour. | | sinus; deposit of lymph
| | in the structure of the
| | pia mater; recently
| | effused lymph in the
| | cavity of the left
| | pleura; secondary
| | abscesses of the left
| | lung.
| |
CASE XVII. Matthew Elmes, | The tenth day | Secondary abscesses, in
æt. 37. Injury of the | after his | various stages of
wrist; diffuse cellular | admission into | formation, in both lungs;
inflammation; abscesses in| the hospital; | suppuration between the
the cellular tissue, and | four days before| different bones of the
in the wrist-joint; lower | his death. | carpus; both kidneys
extremity of the radius | | large, coarse in texture,
denuded; pains in various | | and flabby; the spleen
parts of the body, | | soft, easily lacerated,
especially the head and | | and of a pale colour.
abdomen. | |
| |
CASE XVIII. Mary Hopkins, | Erysipelas | Low inflammation of a
æt. 19. Ulceration of the | appeared a week | portion of the left
cartilages, followed by | after | lung; dark-coloured
suppuration of the knee- | amputation; | patches of deposit in
joint; amputation; | sixteen days | the spleen.
erratic erysipelas over | before death. |
various parts. | |
| |
CASE XIX. John Wilkinson, | Pain in the | Turbid serum in the
æt. 56. Compound fracture | right side a | right pleural cavity;
of the right tibia; | week after his | incipient secondary
inflammation around the | admission. | abscesses in both lungs;
wound, with collections | | large cysts in the
of matter; slight | |
delirium; sickness. | |
| |
CASE XX. James Bryant, æt.| Twenty-four days| Bone exposed to the
20. Scalp wound, denuding | after the | extent of a shilling, of
the bone; puffiness of the | accident; five | a yellow colour, and
scalp upon the eighteenth | days before | with a very dark diploë;
day; rigors, followed by | death. | effusion of lymph and
profuse perspirations; | | pus between the dura
restlessness; delirium; | | mater and the bone,
projection of the | | extending to the base of
eyeballs. | | the skull, and through
| | the sphenoidal fissures
| | into the orbits; effus-
| | ion of pus into the
| | arachnoid cavity; incip-
| | ient secondary abscesses
| | in the lower lobe of the
| | left lung; spleen large,
| | and very soft, mottled;
| | degeneration of both
| | kidneys.
| |
CASE XXI. James Williams, | Ten weeks | Large cavity containing
æt. 41. Fracture of the | after the | foul matter, in contact
lower extremity of the | accident; | with the sacrum, which
left radius; diffuse | one week | was exposed; abscesses
cellular inflammation of | before death. | between the bones of the
the arm at the expiration | | left wrist and hand;
of four weeks; abscesses | | spleen soft, congested,
in the limb, one of which | | and grumous.
communicated with the | |
fracture; diarrhoea; | |
vomiting; tongue dry | |
and brown. | |
| |
CASE XXII. John Munday, | The eighth day | The mucous membrane of
æt. 36. Prolapsus ani; | after the | the whole of the large
hæmorrhoids; operation; | operation for | intestine of a very dark
rigor; anxiety of | hæmorrhoids; | colour; congested patches
countenance; great heat | the fourth | of it thrown up into
of skin; pulse 150. | before death. | prominent folds; recently
| | effused lymph upon the
| | right pleura; secondary
| | abscessesin both lungs.
| |
CASE XXIII. Esther Polley,| The tenth day | A double fracture of the
æt. 50. Lacerated wound of| after the | fifth metatarsal bone;
the foot; separation of a | accident; | inflammation of the
small portion of the base | the third | right pleura; secondary
of one of the metatarsal | before death. | abscesses in right lung.
bones; pain in chest; | |
rapid pulse; depression, | |
with delirium. | |
| |
CASE XXIV. Henry Lacy, æt.| The eighteenth | Yellow matter in the
26. Scalp wound, exposing | day after the | diploë of the parietal
the bone; fracture of the | accident; and a | bones, in the neighbour-
skull; signs of nausea; | week before | hood of the part where
pains in the head; | death. | the trephine had been
"soreness of the stomach";| | applied; effusion of
drowsiness and | | lymph upon the surface
insensibility; paralysis | | of the dura mater; pus
of one side; muscular | | and lymph in the poster-
twitchings; portions of | | ior half only of the
bone removed by the | | longitudinal sinus;
trephine, near the top of | | effusion of pus in the
the head. | | cavity of the arachnoid;
| | some bloody serum in
| | both pleural cavities;
| | incipient secondary
| | abscesses in the liver.
| |
CASE XXV. Thomas Meed, æt.| | Vessels on the surface
15. Injury of the leg; | | of the brain congested;
small suppurating sinus | | lateral ventricles
upon the outside of the | | distended with fluid; a
limb; erysipelas; | | thick layer of purulent
diarrhoea; coma. | | lymph upon the arachnoid
| | membrane at the base of
| | the brain; some slight
| | spots of ecchymosis on
| | the anterior surface of
| | both lungs.
| |
CASE XXVI. Thomas Daffey, | The tenth day | Incipient secondary
æt. 42. Hæmorrhoids; | after the | abscesses in the right
operations; rigors; | operation; | lung; liver studded,
sickness; great abdominal | and ninth | throughout its whole
pain; diarrhoea; hiccough.| before death. | extent, by secondary
This patient had been | | abscesses; mucous
salivated previous to the | | membrane of the rectum
operation for the | | of a dark greenish
hæmorrhoids. | | colour; effusion of pus
| | and lymph into the
| | hæmorrhoidal and inferior
| | mesenteric veins; cavity
| | of the left knee-joint
| | distended with pus;
| | spleen soft, pultaceous,
| | and thickly-studded with
| | dark-coloured blotches.
| |
--------------------------+-----------------+-------------------------
C. CASE XXVII. George Burton, æt. 22, a stout navigator, was first
seen September 18th, 1848. He had an enormous slough of the skin and
cellular membrane, covering the lower part of the abdomen on the
right side. He gave a most imperfect history of himself, and seemed
frequently incapable of comprehending the questions which were put to
him. The skin was hot and dry, the pulse 130. For several days, he
remained in the same apathetic condition. The bowels were particularly
obstinate, and the purgative medicines which were administered produced
no effect whatever.
When the slough separated, the surface of the external oblique muscle
was left as clean as if recently dissected. The skin was undermined
for some extent, and no attempt was apparently being made to limit the
progress of the disease, by the effusion of lymph. Fresh portions of
cellular tissue consequently became affected, and the whole surface
ultimately exposed was full six inches in diameter. _Sept._ 25th.
Complained of some pain in the chest and upper part of the abdomen;
has a constant short cough; perspires very freely. 26th. The pulse has
become weaker, but remains of the same frequency (130). It communicates
a peculiar jerking sensation to the finger. 28th. Pulse 96, weaker;
slight diarrhoea; he vomited several times during the day. 29th.
Restless, with delirium. 30th. Passed another restless night, but
became better in the course of the day; his appetite returned. _Oct._
5th. His appetite again failed; complained of a sense of distension in
the abdomen. 8th. An abscess was discovered at the lower and back part
of the right leg; the skin over this presented various shades of yellow
and brown, giving the appearance of having been extensively bruised.
About two ounces of discoloured pus were evacuated, together with a
considerable quantity of grumous blood. 10th. Has much improved since
the last report; the wound discharges dark semi-coagulated blood. 13th.
A second abscess now presented itself in the same leg, and the skin
covering it assumed the same discoloured appearance as in the first
instance. When opened, it discharged dark-coloured semi-coagulated
blood with the matter. He now rapidly improved in health, and at length
perfectly recovered.
CASE XXVIII. Samuel Todd, æt. 58, fell from a wagon fifteen miles from
town, and was brought up in an open cart, during a sharp frost. There
was a compound fracture of the left leg. Two days afterwards, he
suffered from cellular inflammation around the wound. On the 24th day,
he had a slight rigor, and complained of slight stiffness in the right
shoulder. He ate and drank well till within two days of his death,
which took place on the thirty-fourth day.
_Post-mortem appearances._ Both lungs contained secondary abscesses, in
various stages of formation. The left external iliac and common femoral
veins were blocked up with firm coagula, and confined by these was a
quantity of purulent-looking fluid; an adherent layer could, for some
distance, be peeled off the internal surface of these vessels.
CASE XXIX. James Howard, æt. 33, had a small abscess in the dorsum of
the right foot, which was followed by inflammation of the absorbents;
abscesses subsequently formed in the right thigh and groin. Two months
after the first appearance of the abscess on his foot, he was seized
with rigors, vomiting, and profuse perspiration. He complained also
of pain in the lower part of the left lung, and it was said that the
respiratory murmur was deficient in this situation. He died on the 23rd
day from the appearance of the symptoms of the secondary affection.
POST-MORTEM APPEARANCES. The skin and conjunctivæ were of a light
yellow colour; there were incisions in the right groin. In the cavity
of the right pleura, were some patches of recently effused lymph, of
a yellowish colour. In the lower lobe of the right lung, were several
patches of secondary deposit; these were found in different stages
of their formation, and some of them were of considerable size; some
of the pulmonary veins, in the neighbourhood of those which had
suppurated, were found to contain a fluid resembling pus. On the left
side was a small abscess, under the pleura costalis. The liver was
healthy in structure, rather larger than usual. Kidneys healthy. The
veins in the groin presented a healthy appearance.
CASE XXX. A gentleman was operated upon for hæmorrhoidal tumours in the
usual manner, and died shortly afterwards, with effusion of bloody
serum into one of the pleural cavities. The only peculiarity that
could be detected in the appearance of the rectum was, that the blood
was still fluid in one of the largest veins. This vein led directly
to an ulcer produced by the operation; and, even at its extremity, it
contained no appearance of coagulum.
D. CASES IN WHICH VITIATED FLUIDS WERE OBSERVED IN THE VEINS OF THE
UTERUS AFTER CHILD-BIRTH.
CASE XXXI.[45] On the second day after a natural labour, a woman had
prolonged rigors, which were followed by abdominal pain and much
perspiration. On the fourth day, she was affected with syncope and
bilious vomiting, accompanied by extreme prostration. On the fifth day,
the abdominal pain, which had subsided, re-appeared with agitation and
delirium. On the sixth, she had cold sweats, irregular pulse, rapid
breathing, and vomiting. She died on the following morning.
_Post-mortem appearances._ There was a small quantity of limpid serum
in the cavity of the peritoneum. Some of the uterine veins were found
to contain a turbid fluid. The heart was half filled with brown blood.
The lungs were congested, and the other organs natural.
CASE XXXII. A woman, twenty-two years of age, of a nervous temperament,
miscarried at the expiration of the first month. She was almost
immediately afterwards attacked by rigors and bilious vomiting,
accompanied by pains in the loins and in the hypogastrium. On the
following day, there was coma, with indications of extreme debility.
On the third day, consciousness returned. There was difficult
articulation, and moaning. The extremities became cold, the pulse
imperceptible, and death occurred upon the same day.
[45] This, and the two following cases, are taken from Tonellé. The
author is responsible for the accuracy of all the preceding cases.
_Post-mortem appearances._ The peritoneum was slightly injected, and
contained a small quantity of reddish serum. The cervix uteri was
covered with a layer of pus. Semi-transparent lymph was found in some
of the uterine veins. The brain, and other organs, were found healthy.
CASE XXXIII. A feeble girl, 21 years of age, was confined at the
expiration of the eighth month. On the fourth day, there was shivering
and prolonged fainting. The following morning, she had acute abdominal
pain, fever, and diarrhoea. On the seventh day, the symptoms had all
subsided, but on the eighth the abdominal pain returned, accompanied by
syncope. She died two days afterwards.
_Post-mortem appearances._ The peritoneum was slightly injected, and
contained about a pint of red-coloured serum. The uterus was large,
white, and firm, its veins half filled with fluid blood; its lymphatics
natural; its inner surface lined with a layer of fetid brown blood, but
otherwise healthy; the cervix covered with a grey, thin exudation. The
lungs, heart, brain, and other organs, were quite sound.
CASE XXXIV.[46] Anne Biggs, æt. 39, confined March 18th, 1830, eighth
child. On the evening of her confinement, her manner was much excited.
On the 19th, she was incoherent, and complained of pain in the calf
of the right leg, which was tender on pressure. The pulse being hard,
she was bled to eight ounces. On the 28th, the leg was swollen and
white; the pain in it much increased: towards evening the calf of the
limb became black, while, at the tendo-achillis, the skin was hot,
tender, dry, and mottled. The bowels were much opened, the head giddy,
the pulse quick and strong. She was again bled, to twenty-six ounces,
and twelve leeches were applied to the temple. On the 21st, there
was nausea, vomiting, and diarrhoea. On the 23rd, she complained
much of the confusion in her head, the leg was tolerably easy, but
the upper and inner part of the thigh was very tender. On the 24th,
the diarrhoea continued, and there was increased weakness. A hard
swelling, about half as large as an egg, appeared at the wrist, and one
of the orifices made by venesection was black and painful. She died in
the evening.
[46] Dr. Ferguson.
_Post-mortem appearances._ All the ventricles of the brain were dilated
with serum, and there was a good deal of effusion into the arachnoid
and pia mater. The viscera were perfectly healthy, except the heart and
spleen: the latter was very large, and on pressing it, a large quantity
of dirty red pulpy matter exuded. The lining membrane of the right
auricle and ventricle, when washed, had a dark red hue. The femoral
vein, just at the ingress of the saphæna, and the superficial vein in
the back of the leg, had their coats much thickened, so as to cut like
arteries. Their lining membrane was similar to that of the right cavity
of the heart. When they were divided, purulent matter, mixed with
thin light-coloured blood, escaped. The cellular tissue forming the
sheath of the femoral vessels, and on the calf of the leg, shewed marks
of recent inflammation; but there was no appearance of pus in these
situations. None of the glands in the groin or ham were enlarged. The
inferior vena cava appeared healthy.
E. CASES OF PURULENT DEPOSITS, CONNECTED WITH INFLAMMATION OF THE
VEINS AFTER DELIVERY, RECORDED BY DR. ROBERT LEE IN THE MED.-CHIR.
TRANSACTIONS.
CASE XXXV. Mrs. Mayhew, æt. 33, was delivered on the 2nd March 1829.
On the 5th, there was a discharge of blood from the uterus. From the
6th to the 20th, she made no complaint of uneasiness in any region of
the body, though her strength rapidly declined. The countenance was
of a dusky yellow hue. The heat of the surface slightly increased;
the respiration hurried, particularly on bodily exertion, and the
pulse above 130, and feeble; the tongue pale and glossy, with loss of
appetite. The lochial discharge had a peculiarly offensive smell. She
died upon the 28th of March.
_Post-mortem appearances._ When the uterus was laid open, there was
found to be a portion of the placenta, about the size of a nutmeg, in
a putrid state, adhering to its inner surface. The substance of the
uterus, to the extent of an inch around this, was of a peculiarly dark
colour, almost black, and as soft as a sponge. On cutting into it,
about a teaspoonful of purulent matter escaped from the veins, and a
small additional quantity was pressed out from them.... On opening the
capsular ligament of the right knee-joint, about six ounces of thin
purulent matter escaped, and the cartilages of the femur and tibia were
extensively eroded. There was no appearance of inflammation, however,
on the exterior of the capsular ligament. The right wrist was swollen,
and the cellular membrane around it was unusually vascular, and
infiltrated with serum.
CASE XXXVI. Mrs. Pope, æt. 40, was delivered, on the 26th of Oct., of
her fourteenth child, and appeared to recover favourably until the 3rd
of Nov., when she was suddenly attacked with a severe rigor. This was
followed by intense head-ache, vomiting, general soreness of abdomen,
and suppression of lochia. Nov. 6th. Great prostration of strength;
laborious respiration, with pain at the bottom of the sternum, and
frequent hacking cough; pulse 135, extremely feeble; skin hot and
dry.... Occasional retching and vomiting. Several hard, lumpy cords
were found running up in the inside of the thigh, in the direction
of the superficial veins. 7th. Delirium; general debility greatly
increased; the surface of the body was covered with a yellow suffusion;
the middle finger of the left hand was much swollen around the second
joint, and the skin covering it was of a dusky red colour.
CASE XXXVII. Mrs. Edwards, æt. 35, was suddenly attacked, three weeks
after delivery, with pain in the calf of the right leg, and loss of
power in the whole right inferior extremity. On the 5th day from the
attack, a considerable swelling, without induration, had taken place
from the ham to the foot, and great tenderness was experienced along
the inner surface of the thigh to the groin. The extremity became
universally swollen, painful, and deprived of all power of motion.
The temperature along the inner surface of the limb increased; the
integuments were pale and glistening, not pitting upon pressure. The
femoral vein, from the groin to the middle of the thigh, was indurated,
enlarged, and exquisitely sensible; pulse 80; tongue much loaded;
thirst; bowels open. On the 23rd day from the attack, the disease was
apparently declining. The femoral vein could no longer be felt, but
there was still a sense of tenderness in its course down the thigh,
and she experienced considerable uneasiness between the umbilicus and
pubes, as well as in the loins. She now, for the first time, began
to have rigors, accompanied by a quick pulse, loaded tongue, and
thirst. From this period to the 31st day, the swelling of the limb
and tenderness in the course of the femoral vessels subsided, but she
experienced attacks of acute pain in the umbilical region, loins, and
back, which assumed a regular intermittent form. Every afternoon there
was a rigor of an hour's duration, followed by increased heat, and
profuse perspiration: the skin was hot and dry; pulse 125; tongue brown
and parched; bowels open. These febrile attacks gradually declined in
severity, and she appeared to recover till the 43rd day, when she had
a long and violent fit of cold shivering. The countenance now became
expressive of great anxiety, and the pulse extremely weak and feeble.
45th day. Vomiting; pain upon the left side, increased upon taking
a deep respiration. 46th day. Another severe and prolonged rigor;
skin hot and dry; pulse 140; tongue brown and parched; diarrhoea;
respiration hurried, with frequent cough; surface of body presenting a
peculiar yellow tinge. The conjunctiva of the right eye now suddenly
became of a deep red colour, and so much swollen, that the eyelids
could not be closed. On the day following, the left eye also became
red and swollen, the surface of the body was cold and clammy, pulse
140, extremely feeble, with great debility, and repeated attacks of
vomiting. From this date, the patient lived nearly three weeks, but for
the last fortnight the vision in both eyes was entirely destroyed.
_Post-mortem appearances._ The left pleural cavity contained upwards
of two pints of a thin, purulent fluid. The inferior lobe of the left
lung was of a dark colour, and soft in texture. In its centre, about an
ounce of thick cream-coloured pus was found deposited in its dark and
softened texture. This was not contained in any cyst or membrane, but
was infiltrated into the pulmonary tissue. The coats of the vena cava
inferior were considerably thickened; its whole cavity was occupied by
a coagulum, terminating above in a loose pointed extremity. The left
common iliac vein was plugged up, by a continuation of the coagulum
from the cava. The coagulum was continued beyond the entrance of the
internal iliac, which it completely closed, and terminated in a pointed
extremity about the middle of the external iliac. Neither the remainder
of the vessel, nor the femoral vein, exhibited any morbid changes.
The right common iliac vein was contracted to more than one-half its
natural size; it was firm to the touch, of a greyish blue colour; to
its internal coat adhered an adventitious membrane of the same colour,
containing within it a firm coagulum. The internal iliac was rendered
quite impervious by dense, dark coloured bluish membranes; and, at its
entrance into the common iliac, it was converted into a solid cord.
The contracted external iliac contained within it a soft yellowish
coagulum; its coats were three or four times their natural thickness,
and lined with dark-coloured membranous layers. The right femoral vein,
from Poupart's ligament to the middle of the thigh, was diminished
in size, and almost inseparable from the artery. Its tunics were
thickened, and its interior coated with a dense membrane, surrounding
a solid purple coagulum strongly adherent to it.
F. CASE, SHEWING THE PERIOD AT WHICH A COAGULUM MAY GIVE WAY IN A
WOUNDED VESSEL.
CASE XXXVIII. George Haydon, ætat. 37, received a wound about half
an inch in length over the right radial artery, on March 5th, 1848.
The hæmorrhage was arrested by pressure. On the 12th, a small slough
formed in the bottom of the wound, the edges of which were inflamed and
painful. On the 14th, slight bleeding from the wound occurred, which
at first was arrested by the application of cold; but in the evening
it recurred in considerable quantity, and again was checked by cold
and pressure; during the night, however, profuse hæmorrhage again took
place, and was only stopped by the application of the tourniquet above
the elbow. On the 15th, the radial artery was tied; but as this did not
prevent the hæmorrhage from returning, when the tourniquet was relaxed,
the original wound was enlarged. The opening in the radial artery was
now with some difficulty discovered; it extended two-thirds round the
circumference of the vessel, leaving one-third undivided.
G. CASES SHEWING THE ORGANISATION OF THE OUTER LAYER OF EXTRAVASATED
BLOOD; REPORTED BY MR. HEWETT.
CASE XXXIX.[47] A middle-aged man received a severe injury of the
chest; he lived eleven days after the accident, and during this time
he never presented a single inflammatory symptom. The cavity of the
left pleura was found completely filled with bloody fluid, and was
subdivided into two compartments, by a portion of coloured fibrine,
presenting a honeycombed appearance, which passed from the ribs to
the lung. The lower compartment was itself subdivided into several
others, by layers of coloured fibrine intersecting each other. Large
portions of loosely coagulated blood were found in all the cavities;
some of these clots were of a rusty colour, others approached nearer
to the natural colour of the blood. The lung was compressed against
the spine, and the whole surface of the pleural sac was coated by a
false membrane, about two lines in thickness, formed by coagulated
fibrine. The fibrine which lined the pleura pulmonalis and pleura
diaphragmatica, presented on its inner surface a smooth and polished
appearance, and in colour exactly resembled the yellowish fibrine found
in the clots of the heart of this patient. So uniform was the coating,
and so continuous was it throughout its whole extent, that it looked
at first merely like thickened pleura; but this appearance was easily
destroyed, by peeling off this adventitious membrane from the serous
tissue, which there presented the same appearances as the pleura on the
opposite side, with the exception of not being quite so smooth: there
was neither thickening nor the slightest increase of vascularity in
this pleura. A large rent, from which the hæmorrhage had proceeded, was
found in the substance of the lung.
[47] Med.-Chir. Transactions, vol. xxviii.
CASE XL. A man was attacked with diffuse cellular inflammation of
the inferior extremity, which terminated in two days with extensive
gangrene of the skin. In the superficial and common femoral veins
were extensive coagula; these did not completely fill the veins, but
slightly adhered at different points to their internal coats. These
clots still retained, in some places, the colouring matter of the
blood, whilst at others the colourless fibrine alone remained; in both
veins, the clots were enveloped in a perfectly transparent, smooth, and
polished membrane, presenting the appearance of a serous tissue. In the
structure of these membranes were several distinct arborescent vessels,
minutely injected;[48] some of these vessels were of sufficient size
to allow of the blood being made, by gentle pressure, to circulate
through them; but no communication could be traced between these
vessels and the coats of the veins. The membranes were easily peeled
off from the surface of the clots with which they were in contact.
The interior coats of the veins presented their natural colour and
polished surfaces, except at the points where the slight adhesions
above-mentioned existed.
[48] Mr. Gray, the Curator of the Museum of St. George's Hospital, has
recently shewed me the outer layer of an effusion of blood into the
arachnoid cavity, injected from the middle meningeal artery.
FINIS.
RICHARDS, PRINTER, 100, ST. MARTIN'S LANE.
* * * * *
Transcriber's Notes
Page 81, Case XXVII. Aug 5th follows September 30th. This has
been changed to Oct 5th.
Italics are represented thus _italic_.
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