The principles and practice of modern surgery

by Roswell Park

In all forms of phlebitis, whether acute or chronic, the three venous coats are practically involved in the same manner. With enlarged knowledge of the lymphatics it is difficult to separate an acute phlebitis from a lymphangitis of the venous wall. Only in this way can descending phlebitis be accounted for, the infection travelling apparently against the blood stream. This accounts for the discoloration along the subcutaneous veins when they become involved, the same red lines appearing in the skin as when the lymphatics are involved. The relations between the intima and the blood have been mentioned above. In cases of acute phlebitis in which the intima is involved there is coagulation of the contained blood, the clot and the vein wall undergoing changes which simulate a thrombophlebitis.

Acute Phlebitis.

—Acute phlebitis is of infectious origin. It may be seen in connection with injury, erysipelas, childbirth, and the superficial and deep infections, as from a hypodermic injection, a pin-prick, etc. It is also seen in typhoid, pneumonia, diphtheria, and gonorrhea. In most of these instances it is difficult to trace the path of infection. I have seen death from pyemia following gonorrhea, where the earliest recognizable disturbance occurred in the peri-urethral and prostatic veins. I believe it to have been my report on these cases, in 1885, which first called attention to the fact that gonorrhea might terminate fatally by the pyemic process.

When the venous system has become involved in a septic process of this kind neither its fate nor that of the patient can be regarded as secure. Occlusion, with serious circulatory disturbance, may permanently impair function, while there may be speedy death from pyemia. This is nowhere more true than in those portions of the venous system having rigid walls without valves, to which is given the name “sinuses” (cranial), in which exactly similar processes may occur, which by virtue of their location will always give rise to the gravest anxiety. To phlebitis occurring in these channels there has been given the somewhat distinctive name sinus phlebitis. It nowise differs from the same condition elsewhere, save that it is of almost invariably extravascular origin. It takes but a small venous branch, lying in the midst of an infected area, to commence the process that may extend from the basal sinus to the vena cava.

In most of the surgical infections acute phlebitis has an extravascular origin, the lymphatics of the outer wall communicating the infection to the inner coats, and so distributing it that coagulation occurs, after which the path of infection from the containing veins to the contained clot is direct. The thrombi thus formed may completely or only partially occlude the vessel. As a continuation of the lesion we have infiltration and separation of the coats of the vein from each other, and finally their necrosis. Thus in the terms of the pathologist an acute phlebitis may lead to a phlebitis desicans, and this to phlebitis gangrænosa. In every case where the patient survives such conditions as these the veins lose their identity and become obliterated by the very violence of the process in which they have participated.

A somewhat different type of acute or subacute phlebitis is produced by intravascular irritants, namely, toxins or bacteria circulating in the blood, or to some chemical or thermic agency which may produce thrombosis, such as extremes of heat and cold. These, too, may lead to partial or complete occlusion, and the latter may be followed by calcification or the formation of phleboliths. The destructive character of the entire process will, therefore, depend upon the nature and virulence of the exciting cause. As between fatal septic infection, local gangrene of a part as the result of involvement of the majority of its veins, or comparatively slight and temporary disturbance, such as edema, there may be degrees of activity, with results varying between fatality and evanescent discomfort.

Chronic Phlebitis.

—This is of the proliferative type and is followed by more or less organization. Phlebitis obliterans is sometimes seen in connection with syphilis and other chronic intoxications, and with various operations upon the veins.

Symptoms.

—Phlebitis may occur without known cause or may follow as an expected result from deep or surface lesions. The deeper the involved veins the more obscure the case. Involvement of superficial veins, especially in acute cases, is easily made known by the dark-bluish or dusky red cord which occupies the place of the previously healthy vein. As its contained clot becomes firmer the clot becomes harder. This is accompanied by more or less fever, with extreme tenderness, often pain. If a single vein only be involved the disturbance will be quite local; if thrombosis be general there will be edema of the parts to which the vein is distributed. Involvement of certain veins implies the establishment of a collateral circulation through others. If there be no others available then danger from venous insufficiency threatens, and it may not be possible to avert gangrene. “Milk leg,” or so-called phlegmasia alba dolens (“painful white swelling”), is an expression of portal, pelvic, and femoral thrombophlebitis. In many instances in which it does not kill it may cripple the individual for life. Phlebitis of the deep veins can be inferred rather than detected. Phlebitis of the hemorrhoidal veins frequently follows inflammation and suppuration of piles, while that of the pelvic veins, especially the perivesical, frequently follows gonorrhea and prostatitis. Mesenteric phlebitis and pylephlebitis frequently follow the ulcerative infections of the intestines, while in the newborn a phlebitis of the umbilical vein plays an important part in the mortality of infants. The cranial sinuses are likely to be affected in connection with middle-ear disease, while in acute osteomyelitis there are distinctive pictures of the lesion in the veins of the bone and the marrow. No matter where the lesions may centre they are of the most serious character. The role of the veins in the production of metastatic foci has been described in the chapter on Pyemia. The danger attending the liquefaction of a thrombus and the escape of its fluid debris into the general circulation stamps an acutely infected clot with a dangerous character. This fact justifies such measures as are now pursued in connection with the cranial sinuses and mastoid disease, where there is not only a sinus exposed by removal of a portion of the temporal bone but the jugular opened low in the neck and the entire intervening channel freed from its putrefying contents by the probe and the irrigating stream. In other words, a recognition of the pathology of thrombosis and sepsis may lead to the performance of difficult operations.