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.