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

by M.D. Henry Lee

XII. The treatment of secondary inflammations naturally divides itself into local and constitutional, both as regards the primary lesion and the subsequent affections. The circumstances which interfere with union by the first intention in veins, have been shown to be the same as those which precede the formation of purulent deposits, in a large class of cases. Whatever then tends to favour the healthy reparation of a wounded vein, may be regarded as affording security against any subsequent disease; and the chief point in the local treatment is, perhaps, to prevent any accidental circumstances from interfering with the natural process of repair. When the powers of the constitution are enfeebled, even the natural motions of a part may interfere with recovery, and rest sometimes becomes an important object in the treatment. How necessary this is after child-birth, when the divided veins are being closed, every one who has attended such cases practically knows.

Again, after bleeding, the arm will inflame in a much greater proportion of cases, when the patient is obliged to follow his usual occupation, or when, from accidental circumstances (as from the pain experienced in Case i), the arms are kept in motion. It has occurred to me, to see the symptoms of purulent deposits set in, on the day following prolonged attempts to bring fractured portions of bone into position. In all such cases, any external violence (as in Experiment No. vi), or even the motion of the body, as in Dr. Davis's case (section iv) may loosen the coagula formed, either between the wounded edges, or in the cavities of veins.

In the treatment of the local injury, a valuable hint has been left us by Mr. Hunter, connected directly with the consideration of the pathology of the disease. "The way in which sore arms after bleeding come on, shows plainly that they arise from the wound not healing by the first intention"; and he recommends that the two sides of the vein should be approximated by a compress, until union of the divided edges has taken place.

It has been shown upon very high authority, that the sides of a vein do not unite after venesection (as has sometimes been presumed to be Mr. Hunter's opinion); but that the divided edges only of the vessel are agglutinated by the coagulum, which "serves as a bed to the new membrane." But the case is different, should this first attempt at union fail; the sides of the vessel may then become united, and its cavity for a time obstructed (section iv). The approximation of the sides of the veins would materially facilitate this action, which is the natural security, under the circumstances, against the admission of foreign matter. When an abscess is suspected to have formed in a vein, a similar mode of treatment is recommended by Hunter; the compress, in this case, being placed between the inflamed part and the centre of the circulation. In the pathological museum of the College of Surgeons, one of Mr. Hunter's preparations (No. 1728) exhibits such a case, where, from the imperfect union of a vein, the contents of the abscess had become mixed with the blood.

As the process of reparation has been variously described by authors, so the different theories propounded have led to different kinds of treatment. At the Veterinary College, even within the last few years, it was publicly taught, that a coagulum in a vein was a foreign substance, and ought to be removed; and the jugular vein in horses which had been bled, was sometimes slit up for several inches, in order to remove the coagula which formed in successive portions of its course.

That a coagulum in a vein may be an irritating substance has been fully proved (sections i and ii); but the irritation depends upon the accidental admixture of foreign matter: and the inflammation of the veins, produced by the contact of impure blood, requires to be carefully distinguished from the natural mode of union by the first intention.

To remove coagula which have formed round purulent secretion (if such could be recognised), might be to remove a cause of irritation; but to remove them in ordinary cases, is to remove the very means prepared by nature for the restoration and safety of the part. In operations involving large vessels, the local conditions which may influence the actions in the veins, appear not to have been fully determined; for while some surgeons regard the tying or cutting of a vein as a serious operation, others are in the habit of doing it without any unusual precaution. In operations upon hæmorrhoidal tumours, the veins involved are of some size, and in two of the instances recorded in the Appendix, a ligature applied to them was followed by purulent deposits. In the usual mode of passing a needle armed with a double ligature through the base of such a tumour, the hæmorrhoidal veins are necessarily sometimes wounded, and there is danger that, in tying the ligatures, the sides of a wounded vein may be drawn asunder. The vessel may thus be held open, and be in a similar condition to the vessels contained in bony structures.

A safe way of performing this operation, when admissible, is to destroy a portion of the mucous membrane with strong nitric acid. The blood in the vessels then becomes charred, and their cavities obstructed, till they are permanently closed by adhesive inflammation. Every means of treating a local injury which tends to produce healthy union or adhesion, may be considered in some sort as a preventive mode of treatment. Position, topical applications, bandages, and temperature, may all have their influence in producing these healthy actions; but, as the wounds which precede purulent deposits are generally characterized by feeble powers, those conditions which tend to invigorate the parts are principally indicated. "When action is greater than strength, whatever has the tendency to raise the power above irritability should be used: the object of this practice consists in bringing the strength of the constitution and parts as near upon a par with the action as possible, by which means, a kindly resolution, or suppuration may take place, according as the parts are capable of acting." The irritability of a wound frequently appears nothing else than a series of attempts to bring about an action, which it has not the power to accomplish: as soon as that is fulfilled, which the necessity of the parts demands for their healthy condition, irritation will cease. In such cases, everything that will confer strength to carry out the intended action, will prevent inflammation. But no local applications will be sufficient to produce this effect, unless the powers of the constitution are supported at the same time.

A heavy man received a wound in the back of his head from an iron spike; he was kept very low, complaining occasionally of want of food. Repeated hæmorrhage took place at intervals of a day or two, which no local applications could suppress, and he ultimately died from loss of blood. The wound was found to extend through the bone into the lateral sinus, which contained only some fluid blood. No inflammatory action had taken place within the skull, nor had any attempt apparently been made to close the wounded vessel. Any vitiated secretion in contact with the lacerated edges of the vessel would, in such a case, have free access to the circulation.

The constitutional treatment of cases, liable to be succeeded by purulent deposits, is most important; for during the healing of the primary wound, the system may be influenced by remedies, which may be subsequently quite useless. It is evident, observes M. Cruveilhier,[39] that the treatment of phlebitis ought to be concentrated on the first period of the disease, viz., that of the coagulation of the blood; for as soon as pus has become mixed with the circulating blood, medicine is generally of no avail. When there are indications of the extension of inflammation along a vein, the mode of treatment usually adopted in this country has been the administration of calomel and opium; and, in France, general bleeding, but especially the application of large numbers of leeches. "We may subdue inflammation of veins, whatever their situation, by general blood-letting, and especially by local bleeding, repeated sufficiently often and in sufficient quantities!"[40] It is true that patients recover after such treatment; but the published records of cases not unfrequently terminate with such a description as the following: "The patient was repeatedly bled, and with apparent relief every time, the blood being extremely sizy. Two days, however, previous to death, the vital principle was so exhausted as to need the use of cordials!!"