Inflammation of the lymphatics begins by the wound appearing fretful, inflamed and suppurative, by a cord or cords being felt sometimes above or proximad, and at other times below or distad to the wound, but not precisely in the course of the vein. These cords appear of a delicate rosy red colour, are exceedingly tender to the touch, and have frequently one or more tumefied points on the inner or ulnar margin of the biceps muscle, in the course of the brachial vessels; similar tumours are also often seen on the fore-arm, between the elbow and the wrist joints. The glands of the axilla become early affected, and there is general tume faction of the arm, with acute pain in the wound, in these corded lines and tumours, accompanied with considerable symptomatic fever. Either before or after the inflammation of the lymphatics, the con tiguous cellular substance becomes very early in volved, frequently producing extensive suppuration of both, which also spreads to the axillary glands, in which case there is more or less cedematous feeling. According to the extent of the affection, the treatment requires to be either entirely local, or both local and general. The same remedies, with the exception of blisters, arc to be employed as in inflammation of the vein, and need not again be described.
Inflammation of the fascia of the arm commonly takes place, when the operator has carelessly trans fixed the vein and wounded this membrane; but this accident may occur in the most skilful hands, for occasionally the most prominent vein at the bend of the arm, and the one any surgeon would select, runs beneath or centrad to the fascia of the biceps. The symptoms of this affection are acute pain in the arm, extending to the shoulder, whenever the fore arm is moved, which latter is in some degree bent on the arm, with the fingers also bent and contract ed. There is great tension, some degree of tume faction in consequence of anasarca, and slight erysipclatous inflammation; there are also generally sympathetic spasms over the whole body.
As suppuration quickly supervenes, with thick ening of the fascia, and consequent contraction of the elbow joint and fingers, the treatment should be extremely prompt, this affection being strictly ery sipelas phlegmonodes, consequently the same means should be used as for inflammation of the vein: and in the event of contraction resulting, the fascia of the fore-arm must be divided either at its connexion with the biceps muscle, or what is preferable, im mediately below or distad on the pronator and flexor muscles, avoiding the course of the veins and nerves, and even the ulnar artery in case of a high division of the brachial. When there is great tension during the inflammatory stage, accompanied with severe pain, the fascia even then should be divided.
A nerve at the bend of the arm is extremely liable to be wounded in venesection, in consequence of the twigs of the internal and external cutaneous nerves, and even some of the spiral nerve entwining the different veins. When a nerve is wounded, the patient feels acute pain the moment the lancet pierces the vein, and inflammation of the wound fol lows, the nervous symptoms immediately com mence, and acute pains are experienced darting along the arm, to the neck and head, and even down along the fingers; convulsive twitchings ensue, accompanied with restless nights, being disturbed by frightful dreams. When inflammation of the wound does not take place it heals up, and some days, even weeks, elapse before the convulsive symp toms begin, and in this case, which is the more rare of the two, it resembles tetanus more than the other. On some occasions it assumes the appear ance of neuralgia. If the convulsive symptoms have been severe, in a few days spasms occur which dart from the head along the back and bring on trismus or locked jaw, which puts an end to the patient's sufferings.
The treatment of this affection in the first noticed case, requires to be very prompt. The wounded nerve must be divided close above or proximate to the wound, the arm enveloped in an opiate poultice, having half an ounce of opium dissolved in half a gallon of water, and if this should not give relief to the patient, the actual cautery should be applied to the wound. The patient ought to be bled in the other arm, or jugular vein to syncope, put in the warm bath, have powerful cathartics given, followed by large closes of opium, and have tobacco glyster administered. The bleeding to be repeated as frequently as circumstances require; and if all these remedies fail to subdue the tetanic symptoms, a vein of the opposite arm should be opened, and a solution of opium injected into the circulating system.* We have already mentioned the most common cause of inflammation of the skin supervening to venesection at the bend of the arm, and it may also arise from the same causes as those producing inflammation of the vein and lymphatics; and we have already stated, that the variety of inflamma tion which generally occurs here is erysipelas. This variety then, or type of inflammation, for it appears nothing else, has been divided by authors into a number of species, as may be seen by consult ing the works of Cullen, Bateman, Pearson, Smith, Pinel, and James, for it attacks the same structure as the phlegmonous, thus the velum pendulum palati is as often affected with erysipelatous as with phlegmonous inflammation; the former named cynanche maligna, the latter cynanche tonsillaris. —We shall confine ourselves to erysipelas, and erysipelas phlegmonodes.