Thrombophlebitis is essentially a surgical condition, occasionally terminating favorably by suppuration and spontaneous evacuation, but calling for surgical intervention whenever it can be recognized and the parts are accessible. The principles of treatment of these conditions are positive and unmistakable. They comprise evacuation of the infective material and disinfection of the involved cavities and tissues. Thus, in sinus phlebitis—i. e., thrombophlebitis of the lateral sinus—it has been made practicable not only to open the sinus in the mastoid region, but to expose the jugular vein in the neck, to ligate it, and to wash through from one opening to the other, effectually getting rid in this way of a long mass of infected thrombi. Only by such bold and radical measures in many of these instances may life be saved.
EMBOLISM.
Embolism means the transportation of any material by which a bloodvessel can be occluded or plugged from one part of the vascular system to some other. The underlying idea is that of transportation or carriage. An embolus is anything so transported, without implying its exact character. The name is even applied to so unsubstantial an affair as a minute bubble of air, which, however, in a tube containing a circulating fluid is a possible source of considerable disturbance. A single bubble thus carried would, by itself, be a trifling affair, but when numerous bubbles are thus transported the result is such local disturbance as may lead to loss of function. Thus, air embolism, so called, may provoke profound, even fatal, disturbances, as, when, with the returning blood stream through the cranial sinuses or one of the large veins in the neck, when opened by accident or operation, air is sucked in, it is carried to the right side of the heart, whose action is perhaps completely perverted because of the new and strange substance which thus enters it, so different from that for which its lining membrane is prepared and to which it reacts. The entrance of air into veins, which constitutes in effect air embolism, has been in time past a bugbear to surgeons, but nevertheless is a source of probable danger when large venous trunks in proximity to the heart are thus exposed. Air embolism is certainly a rarity. On the other hand, those substances which figure most often as emboli are vegetations from the valves of the heart; drops of fat; fragments of tumors; pieces of softened and disintegrated thrombi; foreign bodies, as hooklets of echinococcus cysts; and, perhaps most often of all, the microorganisms clinging to some minute fragment of thrombus which has been dislodged. Embolism is also produced experimentally by the artificial introduction into the circulating blood of cinnabar or small particles of pith or other material. Emboli differ in number and size from the smallest appreciable up to the largest, which may be met with in the larger venous trunks. They are dislodged from their primary site sometimes by accident, as by rude manipulation, injury, etc.; sometimes by undue cardiac activity, as when detached from a valve wall; sometimes by the process of softening of thrombus and a subsequent introduction into the blood stream as a result of some trifling motion; or even by spontaneous processes. Emboli also differ in numbers according to the nature of the primary lesion. In cases of so-called fat embolism fluidified fat is taken into the returning blood stream, carried to the heart, churned up with the contained blood, and distributed to the lungs in such a way that myriads of minute fat masses are distributed throughout the capillaries of the lungs, and free circulation of blood through them is thereby impeded.
It will thus be seen that the relations between thrombosis and embolism are most intimate, but that either one may occur without the occurrence of the other.
Among the viscera, with the exception possibly of the brain, the disastrous consequences of such processes as those just described are more apparent and indicative than in thrombosis and embolism of the mesenteric bloodvessels—a condition not so rare as journal articles would imply, yet, nevertheless, one seldom recognized either during life or after death. Its principal symptoms consist of intense abdominal pain, bloody diarrhea, subnormal temperature, sometimes with vomiting, perhaps in the latter stages vomiting of blood. Shock is usually also extremely marked. The consequence of this condition is almost inevitably gangrene of the intestine supplied by that particular portion of the mesenteric vessels. The pain comes on within a short time after the occurrence, and under the peculiar circumstances gangrene may be practically determined within a few hours. Some two hundred and fifty cases of this kind are now on record, and the condition is one well worth the prompt attention of the surgeon, because only by surgical intervention—i. e., by resection of the necrotic mass of intestine—can life possibly be saved. That when a limited portion of the intestine is involved the gangrenous part may be successfully removed has been proved by several operators. (See [Chapter LII].)
It will thus be seen that embolism constitutes often a distinctly surgical condition for which unfortunately only radical measures are suitable. Many cases of gangrene of the toes and feet, extending to the legs, are produced by embolism of the femoral and popliteal arteries, similar conditions being noted less often in the upper extremities. Amputation offers the only resource in such instances, at the same time affording no guarantee against any similar embolic disturbance elsewhere. In only most exceptional instances is it possible, by resorting to moist heat, position, etc., to encourage circulation to such an extent as to obviate the necessity of amputation. (See [Chapter V].)
Fat Embolism.
—Fat embolism as a distinct, sometimes fatal, surgical condition has received of late so much study as to be entitled to consideration by itself. By this term is meant a plugging of small arteries by minute drops of fat, which, having been set free somewhere about the periphery, are carried into the venous circulation and thence distributed to various parts of the system. Inasmuch as the capillaries of the lungs are often their first lodging place, fat embolism here is most often met with, and consequently recognized and studied. But it may occur in the brain, the choroid, the kidneys, or other parts, provided only that there has been sufficient ris a tergo on the part of the heart to force the fat globules through the pulmonary capillaries and into the systemic circulation.
Fig. 2
