be at once blocked up and the most dangerous consequences ensue, as occasionally observed in croup, and so on; but they prefer suppurative inflammation, and no such danger accrues.-J. F. S. The inflammation of serous membranes sometimes runs on to suppuration. This was noticed by HUNTER, who observes:-"In spontaneous suppurations, one, two, three, or more parts of the inflammation lose the power of resolution, and assume exactly the same disposition with those of an exposed surface, or a surface in contact with an extraneous body. If it is in the cellular membrane that this disposition takes place, or in the investing membranes of circumscribed cavities, their vessels now begin to alter their disposition and mode of action, and continue changing till they gradually form themselves to that state which fits them to form pus. *** From hence it must appear that suppuration takes place upon those surfaces without a breach of solids or dissolution of parts, a circumstance not commonly allowed; and, when got beyond the adhesive state, they become similar in their suppuration to the inner surfaces of internal canals." (p. 378.)] In inflammation of the Fibrous Tissues the pain is sometimes very severe, sometimes changeable, deep-seated, increased less by pressure than by the motions of the part, the warmth is much increased, the swelling, according to the difference in structure of the neighbouring parts, sometimes hard, sometimes soft, the redness slight, often scarcely discernible, but often far outspread. Its terminations are resolution, metathesis, gouty concretions, gangrene, and suppuration, which is confined to the cellular tissue connecting the fibres together, whereby a laminated arrangement is produced. Inflammation of the coats of Arteries (1) is either generally diffused, with violent pulsation of the heart and arteries and high fever; or it is confined to one spot, when the symptoms are commonly obscure. The acute partial inflammation of arteries commonly runs into adhesion; the chronic, which mostly depends on diseases with little power, into thickening, loosening, ulceration, deposition of calcareous masses, whence (2) commonly results the origin of aneurisms. [(1) Arteritis, as it is now generally called, is, probably, if idiopathic, an inflammation of the internal only, and not of all the coats of an artery, but, if traumatic, arising either from wound, from ligature, or more extensive pressure and the like, or if the inflammation have been communicated to the artery from neighbouring diseased parts then all the coats of the vessel become affected, and may pass through the various forms of inflammation. "The active and violent pulsations," says BOUILLAUD (a), which the arteries in the neighbourhood of a very acute whitlow perform are the type of those which characterize general arterial irritation. And he also observes, that there is besides the increased force of the arterial pulsations, a sensation of heat and uneasiness in the region which the inflamed artery occupies." (p. 411.) Redness, thickening and friability are the appearances described as presented by the internal coat of an artery under acute inflammation; the redness and thickening from swelling of the membrane occurring simultaneously. HODGSON (b) describes four cases, in the first of which the internal coat of the aorta was of deep red colour; a great effusion of lymph had taken place into its cavity, and become very intimately connected with the internal coat, and a plug of the lymph extending into the left sub-clavian artery nearly obliterated its cavity: these appearances accompanied a violent pneumonia. In three cases, viz. of carditis, pneumonia and bronchitis, he also saw it, but the effusion of lymph was less; in one case the aorta was throughout of a deep scarlet colour, and a little above the semi-lunar valves the coats of the aorta were distended with lymph. (p. 5.) He also quotes from PORTAL (c) a case of sudden subsidence of measles, in which "the aorta was throughout nearly its whole extent very red, and its walls swollen and soft, especially in the thoracic region, near the diaphragm, where it was covered with varicose vessels; the internal coat was swollen and softened." (p 127.) (a) Dictionnaire de Médecine et de Chirurgie (b) On the Diseases of Arteries and Veins, &c., Pratiques, vol. iii. Article Artérite. London, 1815, 8vo. (c) Anatomie Médicale, vol. ii. Paris, 1803. 8vo. Redness, however, is not always present in an inflamed artery, and it often exists when there is not any inflammation, when putrefaction has commenced, in consequence of the blood transuding. And BOUILLAUD says:-" It is right to observe, that the redness of the internal membrane of arteries, even in the case where one is disposed to refer it to acute arteritis, is not produced, at least in the great majority of cases, by a capillary injection, but rather by a kind of tinting or fixation of the colouring matter of the blood on the internal membrane. Under this new point of view the inflammatory redness differs not essentially from that which is called cadaveric." (p. 403.) In inflammation of the whole thickness of the arterial walls, the outer coat is generally red, in consequence of the active and free injection of the numerous vessels which everywhere penetrate them; and sometimes there is even a slight infiltration of blood. BOUILLAUD further observes, that "after the internal coat, or even all the coats of an artery has been some time inflamed, it is easily detached in large flakes, the subjacent cellular tissue becoming friable." I apprehend, however, that what he considers as flakes of the internal coat are really deposits of adhesive matter upon the coat, and not portions of the coat itself. The result of acute arteritis is then deposit of adhesive matter, and, as already mentioned in one of HODGSON's cases, sometimes sufficient to fill up the tube of the artery, though, from the friction of the stream of blood upon the deposited lymph, BOUILLAUD Considers that it is drawn into the stream, and that rather the "inflammation determines the coagulation of the blood circulating in the artery, and thus is easily explained how the secreted matter in addition to the mass of coagulum, may produce arterial obliteration." (p. 407.) Adhesion of the lining membrane, and obliteration of the arterial tube, is one of the results of arteritis; but, as will be presently shown, the effusion of adhesive matter, and even the coagulation of the blood in the inflamed vessel, do not always cause mortification of the limb, as DUPUYTREN would seem to consider; that condition depending rather on the number of the vessels affected with inflammation, and the quickness with which the adhesive deposit takes place, so that the supply of blood is cut off before the collateral circulation can come into play. The usual consequences of inflamed artery are seen in the application of a ligature upon an artery, in which case generally the collateral circulation is speedily established and no inconvenience to the limb is sustained, whilst, on the other hand, occasionally the circulation is restored so slowly that mortification to greater or less extent ensues. The following case of partial arteritis came under my own care, and for its previous history I am indebted to my intelligent friend CRISP of Walworth, whose patient he was. Thomas Batt, aged 21 years, a grocer's assistant, about five years prior to the present time, (August 1843,) had an attack of rheumatic fever which lasted six or seven weeks; and since has had several slight attacks of pleuritis, for one of which he was bled, but neither were so severe as to confine him to bed. The bellows sound was always heard over the region of the heart. On the 7th of August he was seen on account of slight pain in the chest, for which he was ordered some aperient medicine with vin. antim. potass tart. The pulse at the left wrist was then felt and nothing remarkable observed. August 9. A. M. Whilst putting on his waistcoat, he was struck with pain like the prick of a pin, about the middle of the left upper arm, and in the track of the brachial artery, which continued for about an hour, and during that time his arm "became dull and cold as low as the elbow." He saw his medical attendant at 10 A.M.; the arm and hand were then cold, and no pulsation could be felt below the arm-pit, at which part the artery was felt beating, but not forcibly, (90 a minute,) and over it great tenderness on pressure. The pulse of the right wrist was 100, and rather more powerful than usual. The ailing arm was ordered to be put in warm water for a quarter of an hour. P. M. In the same state as the morning; but has had five or six times a sensation of throbbing in the arm, with tingling and numbness of the fingers. 10 P.M. As he continued much the same, six leeches were applied to the arm-pit, and an opening draught given immediately. August 10, A. M. Caustic was applied to the leech-bites, which had bled all night and were still bleeding, so that he felt rather faint from loss of blood; but the pulse of the right arm is not much affected. No pulsation in the left wrist; but the hand less cold than yesterday. There is great tenderness over the commencement of the brachial artery. B pulv. colchic., pulv. antim., ãã gr.v. hydr. c. cretâ, gr. x. quintis horis sum. August 11. Much the same: the artery painful on pressure; the powders continued. August 13. No change since the last report, except that the tenderness over the brachial artery is less and the hand not so cold. His bowels being confined, an aperient draught was ordered immediately, and the powders continued. August 15. He came under my care at St. Thomas's, and, in addition to what has been already mentioned, he says, that he has long had a sense of weakness as if overworked, and that during the first day of the attack, the dullness and coldness continued extending down to the wrist, but unaccompanied with pain; that for the last two nights his arm has been affected with dull aching pain which has prevented his getting rest, but has subsided during the day. At present he is free from pain, except when the arm is bent or hanging down, under either of which conditions he has pain at the original spot in the middle of the arm. He has much tenderness on slight pressure from the middle of the arm upwards, and the arm-pit in the course of the artery, but none below. The pulsation in the brachial artery below the specially indicated part, is scarcely, if at all perceptible, and above it is slight; at the wrist, in the ulnary artery, there is not any pulsation, but the radial artery pulsates slightly. The pulse of the right wrist is distinet, full and quick. I ordered bleeding from the right arm to twelve ounces, milk diet, and liq. ant. potass. tart. mx. ex mist. potass. citr. 4tis August 16. He has been relieved by the bleeding; has less pain and more feeling in the arm. August 17. A careful examination by the stethoscope indicates regurgitation through the aortic valves. August 22. Complains of having had occasional shooting pain in the fore and middle fingers of the left hand, as if being cut off. No increase of pulsation at the wrist; the upper arm is less tender. He complains of having had pain in the sole of the left foot two days since, which yesterday extended into the great and second toe, so that he could not bend them without much pain; in course of the day the pain subsided at this part and attacked the dorsum pedis, where it yet remains, though less severe than yesterday. September 5. Pulsation in the left radial artery is now very distinct though small. September 26. On examination with the stethoscope, distinct bellows murmur with the second sound most decidedly over the aortic valves, and the first loud, short and clear: pulse jerking, regurgitation through the aortic valves, and dilatation of the heart. October 4. The pulsation at the wrist still continues steady. He complains of having cough with expectoration and want of rest at night; is languid and thin, and his health not improving. R pil. opii. gr. 1 o. n., which was, on October 24. Replaced with tinct. camph. comp. 3j ex mist. amygd. ter in die, and, on October 27. The opium was resumed. He has been gradually becoming more languid without any very distinct cause. November 3. He spat a little blood, which continued increasing by degrees till November 5. When he spat a large quantity, and died in the evening. During the last three days he has been so much exhausted, that it was absolutely necessary to keep him up with arrow-root and port wine four ounces daily. EXAMINATION. Chest. Some old pleuritic bands on the left side, but none on the right; the left pleural cavity containing a considerable quantity of serum. Pericardium universally adherent; its free portion separated from the visceral with great difficulty. Heart enlarged; its apex wide and rounded: both ventricles enlarged; the walls of the left thickened, and those of the right somewhat thinned. Valves on the right side perfectly healthy. On the left the sigmoid valve of the aorta thickly beset or fringed with vegetations. The curtains of the mitral valve thickened and containing points of cartilage and bone. Both aortic and mitral orifices contracted, mainly dependent on the thickening of their individual valves. Belly. Liver rather enlarged, dark-coloured, and in a state of hepatic venous congestion. Left Arm. Brachial artery high upon the arm over a space of from half-an-inch to an inch, of a red colour, and its coats thickened, containing at this point a plug of coagulable lymph adherent on one side to the lining of the vessel. Below this part the vessel was much contracted to the extent of three or four inches, beyond which it again resumed its original calibre, and there the orifices of three or four minute vessels were perceived. Adhesive matter may be deposited between the internal and middle coats of an artery, and even pus, of which an instance is mentioned by ANDRAL. The internal coat of the aorta "was elevated by half-a-dozen little abscesses, each about the size of a hazel nut and situated between it and the middle coat; the pus contained in these abscesses resembled the usual pus of phlegmon." (p. 379.) (2) The deposit of earthy matter in arteries generally involves only their coats, especially the inner coat; upon the exterior of which the earth is held to be deposited, in consequence of the thin internal coat being usually traceable and separable from it, so that the earth is not in immediate contact with the stream of blood. This, however, is not always the case, for the lining coat sometimes appears to be deficient, or hangs in shreds into the tube of the artery, so that the blood does actually flow in contact with the earthy matter, and the latter is occasionally deposited in such quantities that it completely fills up the cavity of the artery, rendering it impervious, and converting it as it were into a calcareous rod, the particles of which, however, are not in very intimate union: an excellent instance of such conversion of the femoral artery is in the Museum of St. Thomas's Hospital. The deposition of calcareous matter in the coats of arteries is not restricted to old persons; for PORTAL observes:-"The vessels of young persons rarely ossify; instances, however, have been noticed of ossifications in the arteries of some children, in whom the ossification of the bones had not proceeded far." (p. 133.) HODGSON also mentions, that "George Young possesses a temporal artery, which he removed from an infant of fifteen months old, in which the coats of the vessel are converted into a complete tube of calcareous matter." (p. 23.) The analysis of the earthy concretions made by BRANDE for HODGSON presented 65.5 of phosphate of lime, and 34.5 of animal matter in 100 parts; the latter consisted chiefly of albumen, with traces only of gelatin. No carbonate of lime was discoverable.-J. F.S. These earthy deposits are not bone as appears from the following statement of MIESCHER (a):—" Össifications of all the arteries very frequently occur which are situated between the innermost and proper tunic, in form of larger and smaller plates, of which the smooth surface turned towards the cavity of the artery, the colour, density and toughness very closely resemble true bone; but, when broken, they always had to me a foliaceous or squamous appearance, very like the scales of an oyster-shell; nor could I ever, though often seeking with the microscope, discover corpuscles or canalicules; the soft substance left after the addition of hydrochloric acid never presented any definite texture." (p. 46.)] Inflammation of the Veins, when partial, manifests itself by the symptoms of inflammation in general; but, when it spreads further and attacks the large venous trunks, then appear violent symptoms, such as a rapid pulse, depression, restlessness, delirium, and so on. The cause of inflammation of the veins is most commonly external injury. Its terminations are, 1st, thickening of the venous coats; 2nd, stagnation and formation of clots; 3rd, effusion of plastic lymph and obliteration; 4th, formation of pulsating swelling; 5th, suppuration and bursting of the venous walls; and, 6th, ossification. According to CRUVELHIER (b), the symptoms in adhesive phlebitis, as well as in circumscribed suppurative phlebitis, are entirely local, and originate in irritation of the internal coat of the vein, and in the mechanical obstruction, which, by stopping up the veins or the branches of the inflamed venous twigs, opposes the passage of the blood and of the lymph. The pain and fever depend on the inflammation, and the œdema upon the mechanical obstruction to the circulation. In the uncircumscribed suppurative phlebitis, the symptoms depend on infection of the blood. The patient passes suddenly and without intermission from a state not seemingly dangerous to stupor, prostration of power, and to death, like an animal into whose veins pus has been injected. [Inflammation of the veins or phlebitis as it is now generally called is far from an 1 which we have been describing, it must have been thrown out from the vasa vasorum, these vessels having separated it and poured it into the cavity of the veins, and it must there have coagulated immediately in this separation, therefore, from the blood, it must have undergone some change, arising from the action of the vessels; for, if this lymph was no more than the coagulating lymph, with its common properties, or the properties common to that which is circulating in the same vein which receives it, it would in such cases only continue to throw in more coagulating lymph, in addition to what was circulating, and therefore probably it would be carried along with the blood to the heart as a part of the common mass. From this we should infer that this coagulating matter is not simply the coagulating lymph such as it was when circulating, but somewhat different, from having undergone a change in its passage through the inflamed vessels, partaking of the disposition of those solids through which it passed. *** But this may be taken up in another point of view, and upon the same principle; the inflamed vessels may give a disposition to the blood as it is moving slowly along, to coagulate on its surface, and this is probably the more just idea of the two; as we find that the vessels both veins and arteries can give this disposition, and to a very great extent: we find, in the begining of mortification, the blood coagulating in the vessels so as to fill them up entirely, and this, preceding the mortification, seems to be for the purpose of securing the vessel before it is to give way; we, therefore cannot doubt of a coagulating principle being given to the blood from the vessels." (pp. 311, 12.) Accompanying the redness and cordlike feel there is more or less tenderness, and even actual and severe pain. The inflammation continues to extend towards the heart, presenting, as it proceeds, the same characters. Not unfrequently a chain of little abscesses take place generally at the protuberant valves, which burst of themselves, but are best laid open. The constitutional excitement varies considerably, sometimes is trifling, but sometimes very severe. With constitutional and local antiphilogistic treatment, leeching, fomenting and poulticing, the disease, however, is not unfrequently checked, the inflammation subsides, and the cordlike condition alone remains, which requires some time for its removal. If suppuration in form of little abscesses, as just mentioned, occur, the inflammation oftentimes ceases, and the case does well; but, if suppuration do not occur, then the disease becomes dangerous.-J. F. S. Attention has long been drawn to the severe form of phlebitis; for, more than fifty years since HUNTER (a) observed that "in all cases where inflammation of veins rises high, or extends itself considerably, it is to be expected that the whole system will be affected. For the most part, the same kind of affection takes place which arises from other inflammations, with this exception that where no adhesions of the sides of the vein are formed, or where such adhesions are incomplete, pus passing into the circu lation may add to the general disorder and even render it fatal." (p. 26.) And, having seen inflammation propagated along the jugular vein of horses into their chest, and followed by death, HUNTER Says:-" But what is the particular circumstance which occasions their death I have not been able to determine; it may either be, that the inflammation extends itself to the heart, or that the matter secreted from the inside of the vein, passes along that tube in considerable quantity to the heart, and mixes with the blood." (p. 25.) This suggestion of HUNTER'S was, without having seen a case, converted by ABERNETHY (b) into an actuality, when he ascribes the great sympathetic fever occuring in an extensively inflamed vein, not simply to the inflammatory excite ment, but also" because irritation will be continued along the membranous lining of the vein to the heart." HODGSON (c) copies this statement of ABERNETHY's; for, in the single case of inflamed vein which he gives, he says distinctly, that "the vena cava superior was healthy. The diseased appearances were not gradually lost, but terminated abruptly; the heart was healthy;" whilst "the external jugular and the subclavian veins were filled with pus, and when slit open were found to be much thickened and lined with lymph." (p. 514.) He considers that "the constitutional irritation which is accompanied with symptoms of greater debility than acute inflammation in general, may probably arise from the extent of the inflamed surface, but that it is not unlikely it may be an effect produced upon the nervous system by the pus which is secreted into the vessel being mixed with the circulating blood." (p. 518.) CARMICHAEL (d) holds that the symptoms presented in phlebitis "were no doubt owing to the formation of (a) Observations on the Inflammation of the internal Coats of Veins; in Transactions of a Society for the Improvement of Medical and Surgical Knowledge, vol. i. London, 1798. 8vo. (b) On the occasional Ill Consequences of Venesection; in his Surgical Works, vol. ii. (c) As above. (d) Observations on Varix and Varicose Inflam mations; in Transactions of the King's and Queen's College of Physicians in Ireland, vol. ii. Dublin, 1818. 8vo. |