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.