DISEASES OF VEINS - As in the diseases of arteries, we meet with inflammation and dilatation of the veins; but in this part of the vascular apparatus the inflammatory action is a very common and very serious dis order ; the enlargement is of very secondary importance. Vari cose veins, indeed, even if they were not entirely regarded as a surgical disease, could hardly claim any place in a treatise on diagnosis, and we shall therefore confine our attention to phlebitis.
The lining membrane of the veins would seem to take on in flammatory action in connection with two very distinct conditions of the contained blood, and it cannot be doubted that the inflam mation is itself of a different kind in each. In the one there is a tendency to the formation of pus, in the other fibrinous clots are formed, which more or less plug up and obstruct the veins. This subject has of late years been very closely investigated, and opinions are yet much divided on the sequence of events. With reference to diagnosis we have only to do with the condi tions as seen at the bedside, and the facts elicited in the history of each ; the first becomes known to us by the existence of a form of blood-poisoning; the second is familiar to us in plaleg masia dolens.
§ 1. Pyemia, or purulent contamination of the blood, has already formed the subject of a previous section. (Chap. VIII., § 5.) When occurring in a patient who has an open suppurating wound, it might be alleged that the pus has actually entered into the open mouths of vessels ; unphilosophical as this view must appear, it is evidently wholly inapplicable to those cases in which suppuration has been going on in a closed cavity, whether'serous or synovial, or even in one formed by the artificial walls of an abscess ; and it is equally untrue of pytemia supervening upon diffuse cellular inflammation. In such cases we cannot doubt that the disease has commenced by inflammation of a suppura tive kind attaching the lining membrane of the vessel, whence the pus mingling with the blood is carried forward into the cur rent of the circulation. With an open wound its advent is
marked by shivering, followed by perspiration : and we may justly conclude that in the other instances the same phenomena do attend it, but here they are obscured by the previous existence of rigor, and the liability to its recurrence when suppuration has commenced : hence it is not till the prolonged sweating of pytemia, and the secondary inflammation of internal organs have declared themselves, that we can have any certain evidence of suppurative phlebitis having taken place.
One point deserves attention, that the fact of empyema having followed pleurisy, of suppuration having occurred in synovitis, of a large suppurating abscess having formed, or of the existence of diffuse cellular inflammation, all alike point to a certain crasis in the blood which predisposes to suppurative phlebitis, and that this is only a further development of the same tendency to trans formation of effused plasma into pus.
§ 2. Phlegmasia do lens is seen in its most characteristic form in women after delivery ; but it also occurs not unfrequently in ansamic or chlorotic females ; if it ever exist in males, it is cer tainly very rare. It is marked by pain and swelling of some por tion of the leg, or even of the entire limb, which has a blanched, bloodless aspect; it is firm and elastic, and except in the absence of redness, much resembles the condition of erythema; it has not the hardness of erysipelas, nor the doughy feeling of anasarca. At the lower part of the limb, beyond the limits of tension and tenderness, cedema may be readily recognized by pitting on pres sure; and indeed there is a certain amount of serous effusion throughout, which is caused by the obstruction offered to the re turn of the blood through the inflamed vein; this combination of inflammation and cedema is that which gives its peculiar features to the disease.