Divisions, traumatic and idiopathic. Causes, punctures, defective
blood supply in walls, debile coats, thrombus, infection,
overstretching, injury or disease of serosa, irritants in blood,
microbic infection. Lesions, exudation, cell growth, breaches in
serosa. Adhesive phlebitis, desquamation, granulation, occlusion.
Suppurative phlebitis, infection, pyæmia, erysipelas, metritis,
ulceration, neoplasms, phlebolites. Symptoms, local, firm, corded,
swollen vein, extends entad, venous congestion, dropsy, gangrene,
diagnosis from lymphangitis. Fever, venous congestion in vicinity.
Treatment, germicide, rest, cold, antiseptics, blisters.
Inflammation of veins as seen in the lower animals has usually been a
sequel of bleeding and is hence a purely surgical lesion. Animals as
well as man however are subject to idiopathic phlebitis which as
affecting the deeper seated veins may be held to be a medical subject.
The _causes_ of =idiopathic phlebitis= are varied. Injury to the walls
like the punctures made in bleeding; if they result in the exposure of a
raw, and above all an inflamed, surface to the blood, tends to the
formation of a thrombus, and of local inflammation. Even the
inflammation of the outer coat tends in the same way to thrombosis and
phlebitis, and the experiment of Nicasse showed that the dissection of
its sheath from a vein, thus robbing it of its vascular and nervous
supply promptly induced coagulation of the blood in the denuded part.
The debilitated or devitalized walls evidently give off fibrinogen and
fibrine ferment in amount that is incompatible with the maintenance of
fluidity. All other forms of direct injury to the veins, leading to
disturbance of the endothelium or cell enlargement or exudation in the
intima, will operate in the same manner. Sometimes as in puerperal
phlebitis the inflammation extending from the adjacent tissue to the
walls of the veins, determines thrombosis, and the invasion by pus
microbes determines suppuration. Bruises, overstretching, pressure with
overdistension, and the circulation in the blood of irritant matters may
lead to changes in the wall, thrombus, and inflammation. Such irritants
may be septic or other bacterial products, or they may arise from the
colonization of bacteria on or in the venous coats with the same final
result.
The _lesions_ in the vein are often primarily of the nature of exudation
and cell growth in the coat, without at first any change in the serosa
or endothelium. Later the changes implicate those, thrombosis follows
and one of various ulterior processes.
In =adhesive phlebitis= which is most frequent as the result of purely
mechanical injury, the endothelium is desquamated and granulations from
the denuded surface extend into the clot and finally occlude the vein. A
recovery takes place by the organization of this new product and the
contraction of the vessel into a simple fibrous cord.
In =suppurative phlebitis=, which occurs especially in connection with
infection (erysipelas, metritis), the inflammation, though starting in
the same way in the vascular coats, advances rapidly to suppuration, and
the intima, lying in contact with the resulting thrombus may become
itself the seat of the suppurating process. Cases of this kind are
almost of necessity in the nature of an infection and the danger is
greatly enhanced. Small abscesses formed in the vascular coats may burst
into the vein and passing on with the blood produce general infection
(pyæmia). Even when the pus enters the vein at a point covered by the
thrombus, it may escape by the partial loosening of the clot from the
serosa, or through the interior of a honey-combed coagulum and thus lead
to general infection. This is especially liable to follow in erysipelas
and metritis, in which the tendency as in the solid tissues is to
diffuse suppuration without any investing limiting membrane. There are
other forms of bacterial colonization of the vascular walls, of
ulceration, and of the extension of morbid growths into or through the
venous walls, producing inflammation more or less localized, and leading
or not to general infection. The presence of phlebolites in the vein is
a conceivable source of phlebitis, though no such case has been so far
recorded.
The _symptoms_ in localized cases of simple adhesive phlebitis may be
purely local. The vein if within reach may be felt like a firm, rounded
cord, which extends in a direction from the heart. If there are no free
anastomosis with neighboring veins on the distal side of the thrombus,
venous congestion and dropsy of the tissues ensue, and in some cases
moist gangrene. When, however, such anastomosis is abundant these
peripheral symptoms may be absent, especially if the affected vein
returns blood from a higher level than the heart, and then the symptoms
are confined to the vein and its immediate surroundings. From
lymphangitis which shows similar hard cords, it is distinguished by the
absence of an extended network of diseased vessels, by the lack of a
diffuse, doughy swelling, and by the fact that the adjacent lymph glands
remain free from inflammation, pain and swelling. In the more extended
cases there is fever, which may be of a very high type and may merge
into pyæmia. In deep-seated cases it may be difficult to identify the
disease, but it may be suspected if in the course of erysipelas or
metritis there is a sudden increase of fever with pain and swelling, and
distension of veins leading into the part.
The _treatment_ of idiopathic phlebitis is largely that of the
particular infecting disease on which it depends. In simple cases due to
trauma absolute rest and the application of ice and antiseptic
solutions, or where these cannot be applied, the use of antiseptics
internally, will be indicated. Hyposulphite of soda and sulphide of
calcium are especially indicated. From the early days of veterinary
medicine, flying blisters of Spanish flies, over the inflamed vein or
veins have proved very successful, and under the lead of Nonat the same
was in 1858 and since adopted with gratifying success in the human
subject. Abscesses formed in accessible situations should be promptly
opened and treated antiseptically, and swelling of the affected part
should be checked by elevated position, or if that is impossible, by a
smoothly applied bandage. Rubbing and active movement are dangerous, as
tending to detach clots which float off to start new emboli and
inflammations in the lungs.