On the origin of inflammation of the veins / and of the causes, consequences, and treatment of purulent deposits

by M.D. Henry Lee

The intellect is seldom affected during the first stages of the complaint; but subsequently, in severe cases, restlessness, delirium, and coma, seldom fail to succeed each other. These symptoms are all peculiar, both in regard to the rapidity with which they make their appearance, and also the sudden manner in which they occasionally disappear. The disease may seem, within a few hours, to leave a part which it has first attacked, and to fall upon a different organ in some remote part of the body.

X. The post-mortem appearances observed in those who die in consequence of the introduction of vitiated fluids into the blood, cannot, for the most part, be distinguished from similar changes produced by other causes; yet there are some effects which are peculiar, and may be directly associated with the reception of foreign matter into the circulation. The most characteristic circumstance, attending the extension of disease to different organs of the body through the medium of the blood, is that several parts of these organs, or even different organs, will be simultaneously attacked. The disease will appear at once in various spots, which will become rapidly disorganized, while the surrounding textures will remain unaltered, either in structure or colour. The appearances observed upon dissection will vary according to the part attacked, and the stage of development in which the disease is found.

The lungs are the organs in which the successive changes may best be observed. When puriform fluid has entered the circulation, the first appearance produced in the structure of the lungs, is that of one or more congested or dilated veins[33] of very small diameter. This will be followed by a well defined spot, of much darker colour than the surrounding texture. Several of these spots will probably appear at the same time, and each one of them will soon become surrounded by a hard spherical patch of purple congestion. Effusion of lymph will now take place, commencing in the centre of each affected portion, and gradually extending towards its circumference. If the disease continue, each spot will suppurate, and the different parts will become softened and broken down, in the same order in which they were previously solidified.

The liver frequently becomes the seat of secondary inflammation. In the early stage, brownish-red spots may be observed scattered through its substance. These, as they extend, assume a bluish or slate-colour; and the structure of the liver thus affected is found to have lost its consistence, and to be very easily broken down by pressure. Every part affected here, as in the lungs, proceeds rapidly to suppuration; and the usual appearance presented after death, is that of several small circumscribed abscesses, around which the structure of the liver has been condensed only to a very small extent. It sometimes happens, that the larger veins in the liver become inflamed. These vessels, being held open by the firm structure of the part, are not so readily obliterated as in other situations; and it consequently happens, that the lymph and pus poured into them become irregularly mixed with the blood, more or less perfectly coagulated, which they contain: a very peculiar mottled appearance, resembling granite, is thus occasionally produced.

Affections of the spleen, produced by the introduction of foreign matter into the blood, are probably not so readily recognised as similar affections in the lungs and liver. For, although the spleen is often found to be diseased in those who die from infection of the blood, yet it is comparatively seldom that secondary abscesses have been found in it. In the accompanying table, containing twenty-three cases, some morbid appearance, not recognised as peculiarly the result of secondary inflammation, was observed in the spleen in no less than eight instances. So large a proportion of cases renders it probable, that the alterations observed have more than an accidental connexion with the disease of which the patient died, although they presented no characters which could be said to be peculiar to that disease. In well-marked cases of secondary affections of the spleen, one or more well defined, but frequently irregular indurations, of a chocolate colour, may be recognised; such patches are usually seen soon after the commencement of the complaint, and in a very short time become softened or broken down. The rapidity with which they lose their original character, may probably account for their being comparatively seldom observed in post-mortem examinations.

Deposits of lymph are sometimes met with in the kidneys; but these are of small extent, of a light colour, and resemble lymph deposited in consequence of ordinary inflammation. The patches of congestion, so characteristic of this disease in other organs, are not here observed. This may depend upon the peculiar disposition of the capillary system of the kidney. The blood has to pass through the Malpigian tufts, and may be purified, or altered in character, before it reaches the proper venous system of the organ.

In cases where purulent infection of the blood has been purposely produced, portions of the kidney will not unfrequently be found inflamed and firmer than natural; but, if the origin of the disease were not known these appearances could not be distinguished from those produced by inflammation of the kidney from other causes.

The skin is liable to be affected in three different forms. (See Cases [i], [ii], [iii], [ix], [x], and [xxxiv]). The first of these occurs very rarely, and consists of small deposits of matter in the structure, or upon the surface of the skin, resembling in many respects the pustules of small-pox. The second form is also of rare occurrence, and consists of small congested spots on the surface of the skin. These are generally of a dark purple hue, but I have seen one case in which they were of a bright red colour. In this instance, a secondary abscess had formed in the knee-joint, and some pustules appeared upon the skin in the neighbourhood. A fortnight before the death of the patient, a number of small bright red spots made their appearance in different parts of the thigh and upper part of the leg; some of these were three or four lines in diameter while others were so small as not to be seen without attention; they appeared in accurately defined spots, of a brighter colour than the mucous membrane of the lips, and continued unchanged in appearance till death. The third form presents itself much more frequently than either of the others, although it has not hitherto much attracted the attention of pathologists, in connexion with purulent or other infection of the blood. It commences very suddenly, and frequently without any particular attention being directed to the part. A large circular patch of congestion, livid or purple in the centre, but becoming of a lighter colour towards the circumference, will form, usually upon some part of the lower extremities. The skin of the calf of the leg is perhaps more frequently attacked than that of any other part. In the centre of the congested portion, mortification very rapidly takes place, and is indicated by the part assuming a black or dull leaden colour. In some cases, it would be difficult to say where the mortification ceases, and the congestion begins; but in other instances, there is a distinct line of demarcation formed: a zone of bright red congestion will then occasionally surround the mortified part.

Some modifications of this third form of affection of the skin may be met with occasionally in the course of the disease. Blotches assuming a livid or dusky red appearance (which gradually fades into the colour of the surrounding skin), will present themselves in different parts (Case [xxxvi]), and terminate in thick exfoliation of the cuticle, or in small sloughs of the skin. In some instances, the superficial portions only of the skin are destroyed, and the parts beneath appear comparatively unaffected; small circumscribed portions of the outer layer of the skin will exfoliate, and the subjacent parts will heal without suppuration, by a process similar to that of scabbing (Case [iii]).

It is remarkable in this disease, that the most vascular parts are those which soonest lose their vitality. Thus, in the case last referred to, portions of the surface of the skin perished, while the deeper layers recovered; again, it is not unusual to observe the whole thickness of the skin destroyed, without any corresponding affection of the cellular membrane beneath. The quantity of blood sent to a part would thus appear to favour mortification in this disease. The reason of this peculiarity will be considered in the next section.