On the origin of inflammation of the veins E-Book

Lee

• Herausgeber: Science & Technology Publishing
• Kategorie: Geisteswissenschaft
• Sprache: Englisch

Seitenzahl: 139

Veröffentlichungsjahr: 2025

Beschreibung

On the Origin of Inflammation of the Veins and of the Causes, Consequences, and Treatment of Purulent Deposits is a seminal medical treatise by Henry Lee, first published in the mid-19th century. This comprehensive work delves into the intricate pathology of venous inflammation, a subject of great importance in the era before the widespread understanding of infection and sepsis. Drawing on clinical observations, case studies, and the medical literature of his time, Lee meticulously examines the origins and mechanisms of phlebitis, or inflammation of the veins, exploring both local and systemic factors that contribute to its development. The book provides a detailed analysis of the causes of venous inflammation, including trauma, surgical interventions, and the presence of foreign bodies, as well as the role of constitutional predispositions. Lee discusses the progression of the disease, highlighting the formation of purulent deposits—collections of pus that can occur in various organs as a result of septic emboli traveling through the bloodstream. He investigates the clinical manifestations and complications of these deposits, such as abscesses in the lungs, liver, and other tissues, and the often fatal outcomes associated with widespread infection. In addition to its thorough exploration of pathology, the treatise offers practical guidance on the diagnosis and management of venous inflammation and its sequelae. Lee reviews contemporary treatment methods, including bloodletting, the use of leeches, topical applications, and surgical interventions, while also considering the limitations and dangers of these approaches. He emphasizes the importance of early recognition and intervention to prevent the spread of infection and improve patient outcomes. Rich in historical context and medical insight, On the Origin of Inflammation of the Veins and of the Causes, Consequences, and Treatment of Purulent Deposits stands as a valuable resource for historians of medicine, clinicians interested in the evolution of vascular pathology, and anyone seeking to understand the challenges faced by physicians in the pre-antibiotic era. Lee's careful observations and reasoned arguments reflect the scientific rigor and curiosity that characterized the best medical writing of his time, making this work a significant contribution to the understanding of infectious disease and its management.

Leseprobe

ON PHLEBITIS.

——"Whose effect

Holds such an enmity with blood of man,

That, with a sudden vigour, it doth posset

And curd, like eager droppings into milk,

The thin and wholesome blood."

Hamlet.

PLATE SHEWING THE FIRST MORBID APPEARANCE PRODUCED BY THE STAGNATION OF VITIATED BLOOD IN THE CAPILLARIES OF THE LUNGS.

Surface of Lung with Pleura removed Section of Lung

ON THE ORIGINOF INFLAMMATION OF THE VEINS,ANDON THE CAUSES, CONSEQUENCES, ANDTREATMENT OF PURULENTDEPOSITS.

BY HENRY LEE, F.R.C.S.ASSISTANT SURGEON TO KING'S COLLEGE HOSPITAL, ETC.

"There is more to be learnt of the use of the blood in the animal economy from its coagulation than from its fluidity."—Hunter.

LONDON: HENRY RENSHAW, 356, STRAND.

1850.

LONDON. RICHARDS, PRINTER, 100, ST. MARTIN'S LANE.

PREFACE.

Since the period when Humoral Pathology fell into merited disrepute, comparatively few attempts have been made, to define with any degree of accuracy, the conditions under which morbid secretions may find their way into the circulation. The diseases produced by the presence of vitiated fluids in the general system, and in parts of the body at a distance from their original source, have received more attention; but they are still far from occupying that position in our systems of medicine and surgery which their importance deserves.

The difficulty of tracing diseased secretions after they have become mingled with the blood, or of recognising their presence in the vessels, has rendered the investigation of their actions often tedious and inconclusive; while, on the other hand, the changes of structure in solid parts, readily appreciated by the senses, have been more calculated to arrest the attention, and to afford that ready solution of the origin of the symptoms which, whether imaginary or real, has a tendency to relieve the mind from farther doubt and suspense. Hence it has happened, that the pathology of the solid parts of the body has received a very disproportionate share of attention.

Most of the observations which have tended to advance our knowledge of the effects of the introduction of diseased fluids into the blood, have been recorded under the name of Phlebitis or Inflammation of the Veins; and I have retained this title, although it is obviously inadequate to express those constitutional affections which form the most important and characteristic features of these complaints.

The introduction of pus into the system has justly been regarded as the most important of this class of diseases. But the theory of the circulation of pus globules with the blood, supported as it has been by much ingenious reasoning, and most conveniently adapted to explain the formation of purulent deposits, has yet never obtained general belief. The stoppage of the pus globules in the capillary tubes, has appeared to many accustomed to the practical observation of diseases, too mechanical a solution of the origin of these abscesses; and it has become necessary to determine, with more precision than has hitherto been done, the actual conditions under which pus in substance can be received into the circulation.

The simple experiment of mixing some pus with healthy, recently drawn blood, will at once shew that such a combination cannot circulate in the living body. It will be found that the blood coagulates round the globules of pus, and forms a solid mass which will adhere to the first surface with which it comes in contact; and it will be evident, that it is not till the coagulum thus formed is broken up or dissolved, that its elements can circulate with the blood.

It appears not a little surprising that this, perhaps the simplest and the most instructive experiment that can be performed in reference to the subject of the formation of purulent deposits, should not have been resorted to in preference to others which have been difficult in their execution, and inconclusive in their results.

It has been remarked by Sir Charles Bell, that we can seldom rely upon the answers that are extorted from living animals by experiments which go counter to the natural feeling of mankind; and that it is our duty, if experiments are performed, at all events to prepare for them by the closest previous application of our reason, and so to narrow the question as to be certain that advantage may be gained by our proceedings. Had the simple experiment mentioned above, illustrating the action of pus upon blood out of the body, been duly considered, it might have saved some of the vague and useless experiments which have been performed upon living animals in the investigation of the present subject.

Sept. 1850.13, Dover Street, Piccadilly.

PART I.

ON INFLAMMATION OF THE VEINS:

WITH EXPERIMENTS ILLUSTRATING THE EFFECTS OF A VITIATED CONDITION OF THE BLOOD.

I. John Hunter expressed his belief that the blood has "the power of action within itself",[1] and that when it coagulates, it does so in consequence of an "impression" which it receives. Such an impression may be communicated by separation from the living vessels, or from "cessation of natural action"[2] in them. In certain circumstances also the living vessels themselves may be the means of exciting coagulation.[3] In others, the admixture of extraneous substances may either retard or hasten this operation.[4] The experiments made to determine the last point, Mr. Hunter informs us, "were rather imagined than fully carried out; and the subject rather broached and touched upon, than prosecuted".[5] In these experiments, different articles used in medicine were mixed with portions of blood taken from the body; and it was found that, in some cases, they altered both "the time," and "the firmness of the coagulation".[6] The circumstance of medicines being used in such experiments, conveys the idea, that, in instituting these researches, Hunter conceived that substances which would tend to produce such actions out of the body, might likewise produce some effect upon the blood in living animals. In endeavouring to prosecute the idea thus thrown out, I have been led to try the effect of different substances upon the blood, and to consider the changes which may be produced in that fluid, by the admixture of animal secretions. The experiments which will be hereafter detailed, not only confirm Mr. Hunter's notion, that foreign substances may induce actions in the blood when withdrawn from the body, but also show that some of these effects may be produced still more rapidly in the living vessels.

In these experiments, pus was used in preference to any other fluid; first, because the power of coagulating the blood which it was found to possess, enables its influence to be traced within the body; and secondly, because, being an animal secretion, the results obtained are likely to be analogous to those produced by the admixture of other secretions with the blood.

When pus is mixed with blood, fresh-drawn from a healthy animal, it is found in a marked manner to favour coagulation. This effect does not take place immediately, as in the case of the mixture of an acid with the blood; and I have reason to believe, that where the blood has lost its natural power of coagulation, no visible change is produced in it by the addition of pus. It appears, therefore, that this effect depends rather upon a vital than a chemical influence. In some cases, the coagulation takes place in less than two minutes; in others, after a longer period; but in all the experiments made, the influence of pus, when added to blood, in promoting its coagulation, was sufficiently evident. Putrid pus was found to act more rapidly than healthy pus (Exp. 1, b), but the admixture of water was found to retard the operation; the result, in this respect, differing in some degree from the conclusion drawn from a similar experiment performed by Hunter.[7] The causes which usually favour coagulation out of the body, are rest, and separation of the blood into small quantities. These conditions are, in some degree, brought into play during the circulation of the blood through the capillaries; and when the influence of the admixture of pus with the blood is not sufficient to produce coagulation at once, we should naturally expect the effect to be more readily induced, where these two additional causes concur in favouring such an action. When the pus introduced is in any large quantity, the coagulation of the blood is at once determined, and the entrance of pus into the circulation thereby prevented. The experiments vi, vii, and viii, appear to furnish evidence of the correctness of this opinion, and to show that the result may be produced more quickly in the vessels than elsewhere. In these cases, so sudden was the effect, that the mixture of blood and pus coagulated before it could traverse the jugular vein, as indicated by the induration and cord-like feeling of the vessel.

In Experiment viii, the obstruction formed was sufficient to resist even firm pressure, and in a great measure, if not altogether, to prevent the pus injected from finding its way along the vein. The coagulum was felt in the vessel during the operation, and was there found after death. One effect of the coagulation of the blood thus immediately produced, is necessarily to retain the vitiated blood in the part, and to prevent its being carried in the course of the circulation. This intention may be interfered with, either by accident or design. The coagulum, as in Experiment vi, may be broken up during the process of its formation, or after it has formed, and the parts of which it was composed carried forward with the circulating blood. In such a case, the vein in which the coagulum first formed, is found in its natural condition (except at the part where it may have been mechanically injured), and dark patches of congestion may be found in distant systems of capillaries. If the coagulum be allowed to remain, the vein in which it is formed soon becomes thickened; but, as the experiments cited prove, this thickening is the effect and not the cause of the stagnation of the vitiated blood in the vessel.

II. When blood coagulates in a serous cavity, a thin pellicle forms upon its surface, and, becoming thickened by deposition from the fibrin of the blood, forms a cyst, which completely circumscribes the effusion. This point has not probably received the attention which it deserves; and as it is believed to be of primary importance in the investigation of the present subject, a short space will be devoted to the purpose of fully establishing it, and tracing its connexion with other and subsequent changes. Every layer of lymph observed upon dissection, has perhaps too generally been considered as the result of inflammation; and hence there has arisen a confusion in the terms employed. That lymph may be derived from the blood directly, and deposited in the form of a membrane, without being secreted by any vessel, has been fully shown by a paper in the Medico-Chirurgical Transactions.[8] Such layers of lymph assume so much the appearance of others, derived by secretion from inflamed capillaries, that they have been described as identical. But the mode of their formation in the two instances is altogether different. In the one case, the process is a local one, confined to the blood itself, and subsequently to the membrane with which it happens to be in contact. In the other case, it is an effort of the constitution, accompanied by constitutional symptoms. The former of these processes was clearly described by Hunter. In describing the process of union by the first intention, "Coagulation", he says, "I imagine to proceed upon exactly the same principle as the union by the first intention. It is particle uniting with particle by the attraction of cohesion, which, in the blood, forms a solid; and it is this coagulum uniting to the surrounding parts which forms the union by the first intention: for union by the first intention is no more than the living parts when separated, whether naturally, or by art, forming a reciprocal attraction of cohesion with the intermediate coagulum, which immediately admits of mutual intercourse, and, as it were, one interest."[9] "When the blood has coagulated, so as to adhere to both surfaces and to keep them together, it may be said that union has begun."[10] "The uniting medium becomes immediately a part of ourselves, and the parts not being offended at it, no irritation is produced." "If the quantity of blood extravasated be large, the whole will not become vascular, but the surface only, which is in contact with the surrounding parts."[11] The process thus described in general terms may take place in serous cavities. In the third plate at the end of Mr. Hunter's work, is represented a coagulum of blood adhering to the tunica vaginalis. "The adhesion was firm, though it admitted of a separation at one end; when separated, fibres were seen running between it and the testis."

It might seem unnecessary to dwell upon this process further, had not some of the highest authorities in surgery, both here and on the continent, described it as identical with adhesive inflammation. Thus Bichat[12] says, "The cicatrization of wounds in veins after bleeding is a result of inflammation." Now, it is submitted, that when the blood coagulates, either in serous cavities or in veins, the process of union is not usually one of inflammation, or one in which the powers of the constitution are called into increased activity. It is true, that in both cases, inflammation may take place, and lymph, as the result of such inflammation, may be secreted; but this is only when, to use Mr. Hunter's language, the "primary intention" has not been fulfilled.[13]

When a membranous layer of lymph is deposited from effused blood, it adheres with some firmness to the surface with which it is in contact; but, as there is at first no vascular connexion established between them, it may be separated, leaving the part to which it adhered in its natural condition. Lymph derived from adhesive inflammation, on the other hand, when separated, leaves the surface upon which it was formed rough and uneven. Coagulated fibrin, when recently deposited, may thus be distinguished from effused lymph.

The changes which blood undergoes when effused in serous cavities, may likewise take place when it is detained in injured or exposed veins. The coagulation of the blood in such cases (Exp. vii and viii) serves as a bond of union between the sides of the veins (which may be either temporary or permanent), so as to prevent the entrance of any foreign matter into the circulation. When the blood thus coagulates in veins, changes may be produced analogous to those mentioned as occurring in serous cavities. If the quantity of blood be large, a thin pellicle is at first formed upon its surface (see Preparations 1523-25 and 1525-64, in the Museum of Guy's Hospital). This membrane becomes thickened and adheres to the internal surface of the vein (see plate No. 13, Cooper and Travers' Surgical Essays, Part i, and Prep. No. 1736, in the Pathological Museum of the College of Surgeons). It then becomes vascular, and finally so firmly united to a part of the circumference of the vessel as to be inseparable from it, without lacerating its lining membrane.

If the wounded vessel be small, or if the animal be strong and robust, the whole of the blood in the vein may at once coagulate and become united to its sides. The usual economy of nature, however, is here exercised, with a precision proportionate to the strength of the patient. A simple wound in a vein, in healing by the first intention, will not obstruct the circulation through the vessel under ordinary circumstances. A coagulum will form, sufficient to unite together the divided edges, and the circulation of blood through the vessel will be uninterrupted; but if the wound does not readily heal, coagula may form, which encroach more or less upon the cavity of the vein. There are then three ways in which a coagulum may obstruct the circulation through a vein. 1. By the outer layer of the coagulum forming a membrane, which contains the more fluid parts of the blood. 2. By the whole of the blood contained in the vessel forming a solid coagulum. 3. By a coagulum adhering to the injured side only of the vessel.

In whichever of these ways the process of repair is commenced, it may be interfered with, and the union dissolved. This is practically known to farriers; who, when they want to bleed a second time from the same orifice, break down the "union by the first intention" by a blow upon the vein. During the time that the parts are united only by the fibrin from the blood, any violence must tend to produce the same effect. If the constitution is good, and the coagulating power of the blood unimpaired, the union may be frequently interrupted, and yet be as frequently re-established in the same way. When from any local cause, or from any constitutional peculiarity, the union by the first intention fails at the seat of the injury, it may yet be attempted at some distance up the vein; and then we have coagula formed at different distances along the vessel. If these coagula fill the vein, are firm, and remain undisturbed by violence, the union may be complete, and the vessel sealed at those parts, even although the original wound should suppurate. But it sometimes happens, that the same peculiarity of constitution, or the same local cause, which prevented the union at the original wound, may prevent complete union by the first intention at any other point of the vein; and then its canal is open to any secretion that may be introduced into it. Foreign matter may thus find its way along a vein; but still there is a provision against its being carried the round of the circulation. It has been already shown that the blood, when in a natural condition, has a tendency to coagulate around pus, and, probably, many other fluids, even out of the body (Experiments i, v),