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

I. John Hunter expressed his belief that the blood has "the power of action within itself",[1] and that when it coagulates, it does so in consequence of an "impression" which it receives. Such an impression may be communicated by separation from the living vessels, or from "cessation of natural action"[2] in them. In certain circumstances also the living vessels themselves may be the means of exciting coagulation.[3] In others, the admixture of extraneous substances may either retard or hasten this operation.[4] The experiments made to determine the last point, Mr. Hunter informs us, "were rather imagined than fully carried out; and the subject rather broached and touched upon, than prosecuted".[5] In these experiments, different articles used in medicine were mixed with portions of blood taken from the body; and it was found that, in some cases, they altered both "the time," and "the firmness of the coagulation".[6] The circumstance of medicines being used in such experiments, conveys the idea, that, in instituting these researches, Hunter conceived that substances which would tend to produce such actions out of the body, might likewise produce some effect upon the blood in living animals. In endeavouring to prosecute the idea thus thrown out, I have been led to try the effect of different substances upon the blood, and to consider the changes which may be produced in that fluid, by the admixture of animal secretions. The experiments which will be hereafter detailed, not only confirm Mr. Hunter's notion, that foreign substances may induce actions in the blood when withdrawn from the body, but also show that some of these effects may be produced still more rapidly in the living vessels.

[1] HUNTER on the Blood. Ed. 1794, p. 21.

[2] P. 25. [3] P. 24. [4] P. 97. [5] P. 94. [6] P. 98.

In these experiments, pus was used in preference to any other fluid; first, because the power of coagulating the blood which it was found to possess, enables its influence to be traced within the body; and secondly, because, being an animal secretion, the results obtained are likely to be analogous to those produced by the admixture of other secretions with the blood.

When pus is mixed with blood, fresh-drawn from a healthy animal, it is found in a marked manner to favour coagulation. This effect does not take place immediately, as in the case of the mixture of an acid with the blood; and I have reason to believe, that where the blood has lost its natural power of coagulation, no visible change is produced in it by the addition of pus. It appears, therefore, that this effect depends rather upon a vital than a chemical influence. In some cases, the coagulation takes place in less than two minutes; in others, after a longer period; but in all the experiments made, the influence of pus, when added to blood, in promoting its coagulation, was sufficiently evident. Putrid pus was found to act more rapidly than healthy pus (Exp. 1, b), but the admixture of water was found to retard the operation; the result, in this respect, differing in some degree from the conclusion drawn from a similar experiment performed by Hunter.[7] The causes which usually favour coagulation out of the body, are rest, and separation of the blood into small quantities. These conditions are, in some degree, brought into play during the circulation of the blood through the capillaries; and when the influence of the admixture of pus with the blood is not sufficient to produce coagulation at once, we should naturally expect the effect to be more readily induced, where these two additional causes concur in favouring such an action. When the pus introduced is in any large quantity, the coagulation of the blood is at once determined, and the entrance of pus into the circulation thereby prevented. The experiments VI, VII, and VIII, appear to furnish evidence of the correctness of this opinion, and to show that the result may be produced more quickly in the vessels than elsewhere. In these cases, so sudden was the effect, that the mixture of blood and pus coagulated before it could traverse the jugular vein, as indicated by the induration and cord-like feeling of the vessel.

[7] Op. cit. p. 98.

In Experiment VIII, the obstruction formed was sufficient to resist even firm pressure, and in a great measure, if not altogether, to prevent the pus injected from finding its way along the vein. The coagulum was felt in the vessel during the operation, and was there found after death. One effect of the coagulation of the blood thus immediately produced, is necessarily to retain the vitiated blood in the part, and to prevent its being carried in the course of the circulation. This intention may be interfered with, either by accident or design. The coagulum, as in Experiment VI, may be broken up during the process of its formation, or after it has formed, and the parts of which it was composed carried forward with the circulating blood. In such a case, the vein in which the coagulum first formed, is found in its natural condition (except at the part where it may have been mechanically injured), and dark patches of congestion may be found in distant systems of capillaries. If the coagulum be allowed to remain, the vein in which it is formed soon becomes thickened; but, as the experiments cited prove, this thickening is the effect and not the cause of the stagnation of the vitiated blood in the vessel.

II. When blood coagulates in a serous cavity, a thin pellicle forms upon its surface, and, becoming thickened by deposition from the fibrin of the blood, forms a cyst, which completely circumscribes the effusion. This point has not probably received the attention which it deserves; and as it is believed to be of primary importance in the investigation of the present subject, a short space will be devoted to the purpose of fully establishing it, and tracing its connexion with other and subsequent changes. Every layer of lymph observed upon dissection, has perhaps too generally been considered as the result of inflammation; and hence there has arisen a confusion in the terms employed. That lymph may be derived from the blood directly, and deposited in the form of a membrane, without being secreted by any vessel, has been fully shown by a paper in the Medico-Chirurgical Transactions.[8] Such layers of lymph assume so much the appearance of others, derived by secretion from inflamed capillaries, that they have been described as identical. But the mode of their formation in the two instances is altogether different. In the one case, the process is a local one, confined to the blood itself, and subsequently to the membrane with which it happens to be in contact. In the other case, it is an effort of the constitution, accompanied by constitutional symptoms. The former of these processes was clearly described by Hunter. In describing the process of union by the first intention, "Coagulation", he says, "I imagine to proceed upon exactly the same principle as the union by the first intention. It is particle uniting with particle by the attraction of cohesion, which, in the blood, forms a solid; and it is this coagulum uniting to the surrounding parts which forms the union by the first intention: for union by the first intention is no more than the living parts when separated, whether naturally, or by art, forming a reciprocal attraction of cohesion with the intermediate coagulum, which immediately admits of mutual intercourse, and, as it were, one interest."[9] "When the blood has coagulated, so as to adhere to both surfaces and to keep them together, it may be said that union has begun."[10] "The uniting medium becomes immediately a part of ourselves, and the parts not being offended at it, no irritation is produced." "If the quantity of blood extravasated be large, the whole will not become vascular, but the surface only, which is in contact with the surrounding parts."[11] The process thus described in general terms may take place in serous cavities. In the third plate at the end of Mr. Hunter's work, is represented a coagulum of blood adhering to the tunica vaginalis. "The adhesion was firm, though it admitted of a separation at one end; when separated, fibres were seen running between it and the testis."