On the origin of inflammation of the veins

Chapter V: Appendix: Of Cases

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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._

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.

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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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On the origin of inflammation of the veinsChapter V: Appendix: Of Cases

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