Case xxxiv.[46] Anne Biggs, æt. 39, confined March 18th, 1830, eighth child. On the evening of her confinement, her manner was much excited. On the 19th, she was incoherent, and complained of pain in the calf of the right leg, which was tender on pressure. The pulse being hard, she was bled to eight ounces. On the 28th, the leg was swollen and white; the pain in it much increased: towards evening the calf of the limb became black, while, at the tendo-achillis, the skin was hot, tender, dry, and mottled. The bowels were much opened, the head giddy, the pulse quick and strong. She was again bled, to twenty-six ounces, and twelve leeches were applied to the temple. On the 21st, there was nausea, vomiting, and diarrhœa. On the 23rd, she complained much of the confusion in her head, the leg was tolerably easy, but the upper and inner part of the thigh was very tender. On the 24th, the diarrhœa continued, and there was increased weakness. A hard swelling, about half as large as an egg, appeared at the wrist, and one of the orifices made by venesection was black and painful. She died in the evening.
Post-mortem appearances. All the ventricles of the brain were dilated with serum, and there was a good deal of effusion into the arachnoid and pia mater. The viscera were perfectly healthy, except the heart and spleen: the latter was very large, and on pressing it, a large quantity of dirty red pulpy matter exuded. The lining membrane of the right auricle and ventricle, when washed, had a dark red hue. The femoral vein, just at the ingress of the saphæna, and the superficial vein in the back of the leg, had their coats much thickened, so as to cut like arteries. Their lining membrane was similar to that of the right cavity of the heart. When they were divided, purulent matter, mixed with thin light-coloured blood, escaped. The cellular tissue forming the sheath of the femoral vessels, and on the calf of the leg, shewed marks of recent inflammation; but there was no appearance of pus in these situations. None of the glands in the groin or ham were enlarged. The inferior vena cava appeared healthy.
E. CASES OF PURULENT DEPOSITS, CONNECTED WITH INFLAMMATION OF THE VEINS AFTER DELIVERY, RECORDED BY DR. ROBERT LEE IN THE MED.-CHIR. TRANSACTIONS.
Case xxxv. Mrs. Mayhew, æt. 33, was delivered on the 2nd March 1829. On the 5th, there was a discharge of blood from the uterus. From the 6th to the 20th, she made no complaint of uneasiness in any region of the body, though her strength rapidly declined. The countenance was of a dusky yellow hue. The heat of the surface slightly increased; the respiration hurried, particularly on bodily exertion, and the pulse above 130, and feeble; the tongue pale and glossy, with loss of appetite. The lochial discharge had a peculiarly offensive smell. She died upon the 28th of March.
Post-mortem appearances. When the uterus was laid open, there was found to be a portion of the placenta, about the size of a nutmeg, in a putrid state, adhering to its inner surface. The substance of the uterus, to the extent of an inch around this, was of a peculiarly dark colour, almost black, and as soft as a sponge. On cutting into it, about a teaspoonful of purulent matter escaped from the veins, and a small additional quantity was pressed out from them.... On opening the capsular ligament of the right knee-joint, about six ounces of thin purulent matter escaped, and the cartilages of the femur and tibia were extensively eroded. There was no appearance of inflammation, however, on the exterior of the capsular ligament. The right wrist was swollen, and the cellular membrane around it was unusually vascular, and infiltrated with serum.
Case xxxvi. Mrs. Pope, æt. 40, was delivered, on the 26th of Oct., of her fourteenth child, and appeared to recover favourably until the 3rd of Nov., when she was suddenly attacked with a severe rigor. This was followed by intense head-ache, vomiting, general soreness of abdomen, and suppression of lochia. Nov. 6th. Great prostration of strength; laborious respiration, with pain at the bottom of the sternum, and frequent hacking cough; pulse 135, extremely feeble; skin hot and dry.... Occasional retching and vomiting. Several hard, lumpy cords were found running up in the inside of the thigh, in the direction of the superficial veins. 7th. Delirium; general debility greatly increased; the surface of the body was covered with a yellow suffusion; the middle finger of the left hand was much swollen around the second joint, and the skin covering it was of a dusky red colour.
Case xxxvii. Mrs. Edwards, æt. 35, was suddenly attacked, three weeks after delivery, with pain in the calf of the right leg, and loss of power in the whole right inferior extremity. On the 5th day from the attack, a considerable swelling, without induration, had taken place from the ham to the foot, and great tenderness was experienced along the inner surface of the thigh to the groin. The extremity became universally swollen, painful, and deprived of all power of motion. The temperature along the inner surface of the limb increased; the integuments were pale and glistening, not pitting upon pressure. The femoral vein, from the groin to the middle of the thigh, was indurated, enlarged, and exquisitely sensible; pulse 80; tongue much loaded; thirst; bowels open. On the 23rd day from the attack, the disease was apparently declining. The femoral vein could no longer be felt, but there was still a sense of tenderness in its course down the thigh, and she experienced considerable uneasiness between the umbilicus and pubes, as well as in the loins. She now, for the first time, began to have rigors, accompanied by a quick pulse, loaded tongue, and thirst. From this period to the 31st day, the swelling of the limb and tenderness in the course of the femoral vessels subsided, but she experienced attacks of acute pain in the umbilical region, loins, and back, which assumed a regular intermittent form. Every afternoon there was a rigor of an hour's duration, followed by increased heat, and profuse perspiration: the skin was hot and dry; pulse 125; tongue brown and parched; bowels open. These febrile attacks gradually declined in severity, and she appeared to recover till the 43rd day, when she had a long and violent fit of cold shivering. The countenance now became expressive of great anxiety, and the pulse extremely weak and feeble. 45th day. Vomiting; pain upon the left side, increased upon taking a deep respiration. 46th day. Another severe and prolonged rigor; skin hot and dry; pulse 140; tongue brown and parched; diarrhœa; respiration hurried, with frequent cough; surface of body presenting a peculiar yellow tinge. The conjunctiva of the right eye now suddenly became of a deep red colour, and so much swollen, that the eyelids could not be closed. On the day following, the left eye also became red and swollen, the surface of the body was cold and clammy, pulse 140, extremely feeble, with great debility, and repeated attacks of vomiting. From this date, the patient lived nearly three weeks, but for the last fortnight the vision in both eyes was entirely destroyed.
Post-mortem appearances. The left pleural cavity contained upwards of two pints of a thin, purulent fluid. The inferior lobe of the left lung was of a dark colour, and soft in texture. In its centre, about an ounce of thick cream-coloured pus was found deposited in its dark and softened texture. This was not contained in any cyst or membrane, but was infiltrated into the pulmonary tissue. The coats of the vena cava inferior were considerably thickened; its whole cavity was occupied by a coagulum, terminating above in a loose pointed extremity. The left common iliac vein was plugged up, by a continuation of the coagulum from the cava. The coagulum was continued beyond the entrance of the internal iliac, which it completely closed, and terminated in a pointed extremity about the middle of the external iliac. Neither the remainder of the vessel, nor the femoral vein, exhibited any morbid changes. The right common iliac vein was contracted to more than one-half its natural size; it was firm to the touch, of a greyish blue colour; to its internal coat adhered an adventitious membrane of the same colour, containing within it a firm coagulum. The internal iliac was rendered quite impervious by dense, dark coloured bluish membranes; and, at its entrance into the common iliac, it was converted into a solid cord. The contracted external iliac contained within it a soft yellowish coagulum; its coats were three or four times their natural thickness, and lined with dark-coloured membranous layers. The right femoral vein, from Poupart's ligament to the middle of the thigh, was diminished in size, and almost inseparable from the artery. Its tunics were thickened, and its interior coated with a dense membrane, surrounding a solid purple coagulum strongly adherent to it.
F. CASE, SHEWING THE PERIOD AT WHICH A COAGULUM MAY GIVE WAY IN A WOUNDED VESSEL.
Case xxxviii. George Haydon, ætat. 37, received a wound about half an inch in length over the right radial artery, on March 5th, 1848. The hæmorrhage was arrested by pressure. On the 12th, a small slough formed in the bottom of the wound, the edges of which were inflamed and painful. On the 14th, slight bleeding from the wound occurred, which at first was arrested by the application of cold; but in the evening it recurred in considerable quantity, and again was checked by cold and pressure; during the night, however, profuse hæmorrhage again took place, and was only stopped by the application of the tourniquet above the elbow. On the 15th, the radial artery was tied; but as this did not prevent the hæmorrhage from returning, when the tourniquet was relaxed, the original wound was enlarged. The opening in the radial artery was now with some difficulty discovered; it extended two-thirds round the circumference of the vessel, leaving one-third undivided.