means of a membrane which becomes quantity increases if the muscles of the organized. During this period the only limb be contracted ; if we compress the trace of infammation is the lumefaction vein between its radicles and the wound, of the lips of the wound within the vessel. the hæmorrhage is arrested; it is increased My own opinion differs from that of if pressure be made between the wound Travers : I readily admit that venous and the heart. When it is a question of a parietes exbibit no very marked disposition principal vein of a limb, or of one of the io secrete lymph ; still I have no question cavities, death may be the consequence of that lymph is secreted, and is the ultimate the loss of blood. Certain diseases of veins hond of union; that the membrane, de. cause the accumulation of so large a quanscribed by Travers as at first connecting tity of blood, that when they are opened the clot with the lips of the wound, and very abundant and dangerous hæmorrbage afterwards stretching across, is the result is the consequence. Many cases are on of the transformation of lymph.

record of fatal bæinorrhage following the Trarers has made experiments on the bursting of varicose veins. Although these ligature of veins, from which it resulted may not strictly be called cases of trau. that the internal tunic is not divided by maiic venous hæmorrbage, yet a wound the action of the ligature, but that it lest inflicted npon such a vein might, I apprea circular mark which some persons bad hend, produce similar results. mistaken for a solution of continuity, Treatment. — The means proposed for The external alone appeared to be cut. arresting venous hæmorrhage are less The part of the vessel nearest to the heart varied than those employed in wounds of becomes completely empty, the opposite arteries. The most important condition part is distended, the fluid coagulates for to fufil is to ascertain the cause. The a considerable distance, and the coagulum depending position of the part increases becomes adherent to the venous parietes. the lateral efforts of the column of blond, Externally, around the ligature, lymph is and is a cause of the continuance of a deposited, and the surrounding tissue is bæmorrbage. It is, therefore, of the ingilirated with the same fluid. Towards highest importance to ascertain whether the ninth day the venous tunics begin to respiration, position, or other circumstance, change, and, from the fifteenth to the tends to keep it up. It is always wise to twenty-fifth day, the ligature is detached, attempt to preserve the canal of ihe vessel, the extremities of the vessel are retracted, and this is often done when compression and an interval exists between them. In alone is susicient to restrain the hæmora young horse the ligature was not de. rhage. The application of the compresses tached before the twenty-fifth day; and in the common operatiou of bleeding at Travess ascertained that the extremities of the bend of the arm is a proof of that. If the vein had not suffered any other con- compression be not applicable or effectual, traction than that which resulted from the and the wound is very narrow, an attempt action of the ligature. The internal tunic may be made to get hold of the vein with was examined, the clots were carefully re- a tenaculum, passing it through the lips of moved, and no thickening of the parietes or the wound, placing a ligature around that any vestige of inflammation was discovered point, and thus preserving, as far as prac. in any part of the vein. According to ticable, the continuity of the canal. At Liston, no adbesion takes place until the the same time the cure must be assisted by Jigature has produced ulceration, and then the position of the part, which, by facili. the canal may become obliterated.

tating the passage of the blood, diminishes Veins, being more superficial and less its lateral pressure, and lessens the ten.. protected than arteries, are more fre. dency to escape. When a vein is com. quently wounded; but the hæmorrhage pletely cut through, it cannot continue to consequent upon such wounds has not be a channel of communication; it is, occupied much attention, though occa- therefore, proper to attempt to obliterate sionally the consequences are most serious; it. Sufficiently energetic compression especially when a large vein is about to may be applied to the part; and if that do penetrate into a splanchnic cavity; it may not suffice, each end may be included in a even be more dangerous than the wound ligature, It not unfrequently bappens, of the principal artery of a limb, because, after amputation of the lower limb, that a if the blood continue to flow, the patient vein continues to pour out blood upon the may die from loss of blood; and if, to surface of the lympb : in this case the suspend it, the section of the vessel be ligature is necessary, which, if the patient completed, the patient may die from mor- be in moderately good health, may be a tification, in consequence of blocking up less dangerous means than was supposed the only way by which it could return. by Travers; stillit is not an operation which

Venous hæmorrhage is recognized by should be heedlessly performed, because the following characters :--the blood is the occurrence of phlebitis after it has ondark; it wells out, or by a feeble jet; the happily been but too frequent.

163

PHLEBITIS.

on each cheek, short frequent cough, pain

in the chest, and difficult respiration; Injuries of veins may be followed by in. sometimes icterus, with pain over the liver, Bammation of those canals, which is an or in the right shoulder; sometimes vomit. extremely grave disease, the symptoms of ing and gastric irritation; and the breath which Arelæus briefly pointed out. This is very fætid, yielding a purulent odour. subject has occupied a very large portion Cicatrization of the wound is suspended ; of the attention of medical men since the suppuration becomes greyish, or even entime of John Hunter. In examining the tirely suppressed, and the subject dies exbodies of two horses which had died sud- hausted in two, three, four, or five weeks. denly, after bleeding, he found the internal The post-mortem inspection reveals two surface of the veins inflamed. Having species of lesion; those belonging to the occasion to open many abscesses, occurring vein or veins themselves, and those which in a man who had been bled at the bend are a consequence of phlebitis. We see of the arm, he found that they were de- the vein transformed into a reddish cord ; veloped in the course of the venous trunks, the cellular tissue connected with it is inbut that pus was also contained within the filtrated with a sero-purulent Auid: the reins. In another case, a person, having redness and vascularity of the external died on the eighth day after bleeding, he tunic is very decided, and very characfound the internal surface of the vein co- teristic. The interior of the vessel may vered with lymph. It is also developed contain blood or pus, the inflammation aíter parturition, excision, and ligature of may produce obliteration by means of the Fariees, amputation, lithotomy, &c. To cloi, the pus may be limited by a clot, the be well acquainted with the ordinary cha- vein may be perforated, or the pus may raeters of phlebitis, it should be observed circulate with the blood. In the latter after bleeding. Some hours after the ope- case, a large number of visceral abscesses ration, a prickling sensation is felt at are produced. the puncture, soon ii amounts to pain, The consequences of phlebitis had been the little wound gapes, its lips are slightly greatly discussed at a much earlier period, tamefied, and sanies or sanious pus escapes but the disease which gare rise to those from it. If all should go on well, this alarming symptoms, the consequence of gradually subsides, and, by the seventh or “ purulent absorption,” was comparatively eighth day, all is dissipaied. If, on the unknown; and even when ideas on the subcontrary, the disease proceed, pain is mani. ject were becoming more defined, a great fested along the vein, it soon becomes ten- struggle took place between the partisans of sire, and swelling extends to the whole phlebitis and those of purulent absorption. Limb. If the vein be superficial or pro- The difference between the doctrines was jecting, the skin is reddened along its not great: both started from the same point, course, the pain and tension increase, the a wound or operation—both admitachange course of adjacent veins is marked by a red. in the bloodboth maintain that this ness of the skin over them, the tumefaction alteration proceeds from the admixture of édereases, becomes cedematous, the inslam- pus with the blood; their difference consis:s Enatory action extends towards the heart, simply as to the manner in which the pus the vein appears like a hard knotted cord; gets access to the blood. The doctrine of notion of the limb is then paivful and phlebitis implies a direct passage-an im. difficult, the cord becomes thicker, ab- mediate admixture. The doctrine of purusesses are sometimes formed around it, lent absorption maintains that the passage sand erysipelatous redness is occasionally is indirect, and the admixture consecutive. i atense. But too often it happens that pus In the 'Transactions of a Society for the Sinds its way to the viscera, and the symp. Improvement, &c. (1793) are the ingenious Ens become very urgent. Severe rigors, experiments of Hunter on the subject of sometimes continuing for hours, are selt, phlebitis. He considered not only the lo. che skin becomes pale or yellow, and there cal effects of inflammation upon the interis rarely much re-action. After two or nal tunic of veins, but also the general Ehree paroxysms, typhoid symptoms are

effects. commonly developed. The eyes look hol. Phlebitis belongs at the same time to me. iw, the conjunctiva yellow; the tongue, dicine and surgery; there may be a trauhich continues moist, is not deeply coated matic phlebitis, and a spontaneous phle

mul the later stages of the disease; the bitis. The first effect of all phlebitis is to teeth and lips become fuliginous, the pulse, produce coagulation of the blood, and ad

1 first hard and frequent, becomes small hesion of the clot to the parietes of the

od feeble, tympanitis, or diarrhea, rarely vessel. This is observed whether the affec. delirium, supervenes, though there is a tion be traumatic or spontaneous. From

ood deal of stupor. In some cases there the interruption of the circulation in an se vague indications of visceral inflam- inflamed vein results the stagnation of the sation. Sometimes there is a lirid spot venous blood, and the effusion into the ad.

joining tissues of a certain quantity of Local signs.—The local signs of suppura serosity. Phlegmasia dolens after pariuri. tion in veins are, first, when slight, red tion, as well as after phlebotomy, may be patches apparent on the inner surface of considered as a characteristic sign of phle. the rein; when more intense, instead of bitis; and this ædema is usually propor- being thus marbled, it is uniformly red; it is tioned to the derangement of the venous thickened so that, when a section is made, circulation of which it is a consequence, the vessel remains open. The internal sur. Besides the ædema, phlebitis is charac. face is sometimes smooth, sometimes un. terised by the presence of a hard, painful equal or ulcerated. In the arm, two days cord, easily circumscribed, and following after bleeding, I have known the veins to exactly the course of the vein. The greater look fleshy, and much thickened, their innumber of cases of phlebitis, even when terior filled with pus, which is deposited left to themselves, do not pass that limit not between the vein and the clot, but at which has for result the coagulation of the the centre of the clot; and, by some per. blood, and its adhesion to the parietes of sons, it is believed to be a change which the vessel. This may be termed adhesive the clot itself undergoes—first it is gra. phlebitis, and this liappens as often as veins mous, tben sanious, then whitish, opaque, are cut through.

phlegmonous. This presence of pos at the Adhesive phlebitis is a simple animpor- centre of the clot, Cruveilhierbelieves to be a tant disease, and its effects are limited to phenomenon of capillarity; that, like a the affected point. Gradually the serum false membrane, the clot serves as a filter, contained in ihe clot is absorbed; then the through which the pus passes. Sometimes colouring matter; and only the uncoloured this apparent suppuration is no doubt a fibrine remains. Sometimes this becomes softening of the fibrine itself. Suppuraorganised; sometimes it is entirely re. tive phlebitis may not pass beyond this moved; but in both cases the vein is obli- stage, and its existence may not be mani. terated. Now and then it happens that a fested by any symptom. If it proceed far. canal is formed in the centre of the clot, ther the coagulum diminishes, and the pas and the blood circulates through it. The augmerts. Soon the vein is filled -- distend. formation of compact adherent clots occa. ed with the fluid; but it is rarely that pas sions no inconvenience, and does not even occupies uninterruptedly a large extent of manifest its existence, unless it occupy a the vein -the inflammation, varying in in. certain extent, and interrupt, to a greater tensity, at one point may be adhesive, at or less extent, the circulation of correspond. another suppurative. Other circumstances ing parts. Thus, phlebitis of the sinuses

If the disease continne to be local, of the dura mater is necessarily mortal in the vein is distended, knotted; this distenthis first period, because the venous circu. sion may be so great as to give rise to the lation of the brain is more or less com- idea of abscess: the renous parietes may pletely intercepted. Phlebitis of the fe. give way, the pus be effused into the surmoral vein, or the external iliac, produces rounding tissues, constituting abscess, and @dema of the limb, and may occasion gan. opening externally, the rein being destroyed grene.

to some extent, and not easily discovered. Suppurative phlebitis is, in its first stage, It is well to distinguish between inflamsimilar to adhesive. An adherent clot is the mation affecting the internal tunics of a first stage, suppuration is the second. There vein, and that of the external or cellular; arc conditions, which cannot be clearly de often they coincide, sometimes they may fined, under which a tendency to suppura- occur isolatedly. Rarely does infiamination tive phlebitis is determined, whatever care of the cellular tunic end in suppuration; may have been bestowed on the case; there still there are examples of it. Wben sapare others, in which it seems to be the con- purative phlebitis is limited by adhesive sequence of improper treatment. Certain phlebitis, only local phenomena are mani. miasmatic or individual peculiarities seem fested; that portion of the vein in which to determine it; among these are the causes the pus exists is cut off from the general which favour hospital gangrene, or typhus. circulation. Among other examples of this Some persons, however, believe the typhus, we may mention the following: -Soon after in these cases, to be a consequence of the parturition, a woman had phlebitis of one presence of pus in the veins.

of the superficial mammary veins. It was Though very intense, if properly treated, hard, cord-like, and painful, extending from adhesive does not often end in suppurative the external to the internal margin of the phlebitis. A great cause of this termina gland, a little above the nipple. A fuetion is an improper interference with tuating point was presented, it was opened, wounds-with parts already inflamed. At- and the vein was completely emptied; the tempts, for instance, made day after day to projection which it had forined being sucremove a sequestrum or a spicula of bone; ceeded by a groove. In fact, whatever exor the plugging up of a wound to arrest tent of a vein may be affected by sarpara. secondary hæmorrhage.

tion, provided it be limited by adhesive in

occur.

flammation, local accidents alone will be part of the economy, a consecutive phlelni. presented.

tis being developed at the point where the This pus may be absorbed, as in any or abscess is found? dinary collection, and carried of' by ordi. The first inquirers who sought to dis. nary means; it may distend and thin the cover the cause of death after great surgi. vein so as to allow of its destruction, and cal operations, have pointed out the existso cause abscess, which may be mistaken ence of internal abscesses in the principal for common abscess : but as soon as the viscera, particularly in the lungs and the barrier formed by the clot is broken down, liver. Modern inquirers having observed and the pus is mixed with the circulating the frequency and the gravity of these blood, typhoid symptoms are immediately lesions, did not hesitate to ascribe to these manifested, preceded by intense rigors, and causes the frequency of death; and whilst soon followed by death. Frequently we the surgeons of the last century continued find in a morning the condition of a patient to observe the wound, and exclusively desperate, whom we had left pretiy well sought, in the different appearances of the the preceding evening.

wound, the explanation of all the circumIf we examine the internal surface of a stances which succeed in the course of vein at different periods of phlebitis, we treatment, the better educated men of the never find upon its surface the ordinary present day, studying the local as well as traces of inflammation, that is to say, in ihe general condition, see in the different jection of the capillaries; the red colour, qualities of the pus, its quantity, and the which is seen, looks more like the effect of colour of the integuments, a pretty certain imbibition-probably a post-mortem result, index of the state of the viscera. and only seen in the first stage. As the It is very difficult to explain visceral colouring matter of the clot is absorbed, abscesses as a consequence of surgical opetbe red colour of the surface of the inner rations, though operations are often pertunic diminishes, and is entirely absent forined on persons whose general health is when pus exists in contact with it. It is good, and in whom we cannot admit that imporiant to carry this in our mind, be. visceral lesions, so grate as those we meet cause it is upon the absence of these signs with, can have existed before the operaof inflammation that the principal argu- tion. Stillas, on the one hand,'observation ment of those persons is based, who main- shews that a great many organic lesions taia that the pus found in a vein has not may exist in a latent state ; and as, on the been formed there, but in some other part other hand, visceral abscesses, conseof the system, from whence it has been quences of wounds, present by their mul. brought by absorption : but we cannot for. tiplicity, their seat, and other circumget that there are membranes which are not stances, a great analogy with suppurating susceptible of injection, neither in the tubercles, many persons have maintained healthy nor morbid conditiou; such are the that these abscesses were no other than the serous membranes, the cellular tissue, and result of the development of pre-existing the internal membranes of veins. In the tubercles. If this theory ought not to be absence of an adherent clot, and of pus in adopted as a general rule, neither should a vein, it is by the vascularity of the ex• it be repulsed in all cases. Our own lernal tunic, the cobesion and fragility of opinion is, that it should not be admitted the external cellular tissue where lympb as a general role: unquestionably, in has been deposited, that we discover iraces most cases, around these abscesses phlegof venous inflammation.

monous inflammation may be detected, General symptoms.— The general symptoms without tubercles or tubercular intiliraof phlebitis, as we have seen, are those tion. which are usually attributed to purulent Visceral abscesses being generally conse. absorption; namely, extremely marked catire to wounds, it was natural to admit typhoid symptoms, uuder which ihe patient between thein a relation of cause and effect; sinks with more or less rapidity. Upon the question to consider is, how a wound examination after death, we find circum- which suppurates, determines purulent colscribed purulent collections in the lungs, lections in the lungs, the liver, and so on? liser, spleen, brain, muscles, synovial and The first idea which was adopted was a serous cavities; and, what is most singular, pure and siniple transport of pus from the often unaccompanied by any local appre- wound into the viscus, or idetastasis. This ciable sign in the affected 'organ. Now, doctrine was supported on the following what bappens here? Is there a development grounds:- The diminution or suppression of preexisting tubercles? Is there purulent of external suppuration, which is the con. absorption-pus being taken up, as pus, stant prelude to the formation of interual from the surface of a wound, and deposiied abscess, the absolute identity of the pus iu diffcrent organs ? or, Does the presence on the surface of the wound, and thai in of these collections presuppose the exist- the abscess, the absence of general and eace of sappurative phlebitis in some other local symptoms to indicate visceral inflam

.

mation; the rapidity with which these ab. visceral abscess in all respects similar to scesses are formed; the presence of pus in those which succeed to wounds or surgical the veins, and in the right cavities of the operations; and these abscesses are a con. heart, in ihe midst of coagula. If we admit sequence of capillary inflammation in the this doctrine, we must go a step farther, organ where they are found. If we inject and ask, bow is the pus conveyed from the an irritating fluid into the femoral vein, if wound to the heart? Reasoning rather the collateral vessels do not carry tbe fluid than facts has been used to answer that into the circulation, (in which case death question. The veins, it is said, absorb and rapidly follows), at the end of thirty-six convey it; the lymphatics bave, it is said, hours the limb is tumefied; and at this performed the same office; and some per- time, if the animal be destroyed, numerous sons believe that both participate in it. clots will be found in the muscular and Velpeau, Marechal, and Legallois, admit, cellular lissue of the limb, and the larger thai pus secreted in the substance or upon veins are distended with adherent coagula. the surface of the body may be absorbed, If the animal survive this period, pus or circulate with the blood, and be deposited softened fibrine replaces the clots wilbia in the substance of this or that organ, with and without the vein. If we divide the out previous inflammation of that organ. muscles, small collections of pos are seen, The facts they invoke in support of their (it inay be expressed from the small seins opinion are undeniable as facis; what we with great facility), and the synovial surobject to is their mode of interpreting faces present purulent synovia. them. They have seen pus in the veins, In such cases the disorder may be local. in the righi cavities of the heart, in the It is important to ascertain what becomes inidst of clots of blood, in the lymphatics; of the pus, in local phlebitis, when it gets others have done so too, and even in the into the circulation; but as it is difficult lungs, liver, brain, spleen, muscles, syno. (if not impossible) to recognize pas when vial cavities, without any traces of sur

mixed with the blood, it is necessary to rounding inflammation. But this pus, so give to the demonstration all the exactness observed, may it not be formed at the point of a physical experiment; to find a liquid where it is found ? May not the pus in a which can always be recognized, and to viscus be a consequence of circumscribed follow its smallest molecules: that liquid inflammation of that viscus? The diminu. Cruveilhier found in mercury. In wbattion of secretion on the surface of a wound, ever part of the venous system, other than may it not be the effect rather than the the abdominal, we introduce mercury, the cause of the internal lesion? Unquestion- globules will be found in the lungs : they ably that would be the most rational in. will not be found inflamed, but " enterpretation : such was the opinion of gorged.” If the animal survive some days, Quesnay, Morgagni, and Dance.

a reddish induration will be seen to surThe reasons which appear to us to round each globule; at a later period, pos favour the opinion tbat the pus is formed or tubercular matter, or a mixture of both, at the place where it appears are, that the will constitute their circumference. Cruformation of visceral abscesses is almost veillier has even placed a single globule in always accompanied by general symptoms, the medullary canal of the femur, and a of a more or less grave character, which month afterwards he has found that glo. cannot be explained by the state of the bule in the lung, divided into many wound. The absence of local symptoms smaller globules, each being the centre of in the situation of a viscus does not testify a tubercular abscess. Similar phenomena to the absence of inflammation of that vis. have been observed in the liver, as a con. cus. Unquestionably a certain pumber of sequence of a similar injection into the abscesses do not present, at the circum- abdominal venous system. From these ference of the cyst, any trace of inflamma- experiments, it results that the lungs are tion. As to the rapidity with whicb the for the general venous system, and the pos is formed, there is nothing astonishing liver for the abdominal system, an outlet in that, the duration of the disease being for foreign bodies, and a barrier whicb, in usually tive or six days at the least. many cases, they cannot pass. Thus the

Visceral abscesses are frequently idiopa. veins do not ill only the part of conduct. thic-forined in the substance of a viscusing the blood which has circulated through by inflammatory action. They are large the arteries back to the heart, but they tubercles, consequences of pneumonia or seem also to be capable of absorbing lobular hepatitis: ibis was Morgagni's foreign bodies. doctrine. We must proceed further, and Those experiments to which we have endeavour to ascertain the mode of forma. referred assist in the solution of another tion of pus in a viscus as a consequence of difficulty. How does the pus get from the wounds. Every foreign body introduced general into the portal venous system? into the venous system determines, when it This pus cannot be arrested in the lung cannot be carried off by the emunctories, like mercury, but passes in larger or