Phlebitis

PHLEBITIS DONALDC.

GEIST,M.D.

PHILADELPHIA,

HLEBITIS is an interesting and important disease. This paper consists of an analysis of 38 cases of phlebitis, with an effort to determine some of the important factors in its etioIogy. CommonIy spoken of as phlebitis, it wouId be more proper to calI the disease thrombophIebitis, for inflammation of the vein without thrombosis is a rarity. Xlost authorities are agreed that it is a lesion caused by infection and the disease has frequently been named infective or septic phIebitis. The origin of the infective agent and the reason for the marked involvement of a vein is quite obscure. SIowing of the blood-stream, changes in the waIIs of the vein due to bacteria and their toxins, and aIterations in the composition of the bIood are important predisposing factors. Propulsion of the bIood through the veins of the extremities is greatIy influenced by the muscuIar activity of the limb and when this is decreased the flow of the venous bIood is Iikewise sIowed. This, it is beIieved, pIays a great part in the cases complicating surgica1 operations and obstetrica deIiveries. The force of gravity and the action of the valves is aIso important. Both may we11 contribute to a slowing of the stream with increased tendency to localization of infection and later clotting and thrombosis. Differences in the arteria1 and venous circulation are marked. In the latter there is not the individuaIity of branches that one sees in the arteria1 system and there is a distinct separation into a deep and superficial system. This adds to the variation in the speed of propuIsion of the blood. Moreover, these peculiarities tend to cause changes in the voIume flow of the extremity which are irregular and scattered, and do not invoIve the entire Iimb as in obstruction to the arterial system. This may

P

5’9

PA.

expIain the scattered areas of vein which become invoIved at different times. Changes in the waIIs of veins are difficult to determine. Whether the infective agent attacks first the endotheIia1 Iining and spreads to the remaining coats or enters through the vasa vasorum and attacks the whoIe waI1 is much argued but littIe known. Some observers say that the inflammation begins in the Iymphatics about the vein and later involves the vein itseIf. This view is especiahy supported by Homans. The norma thinness of the venous waI1 is also of importance. Variations in the composition of the bIood have been claimed as factors in the etiology of phlebitis. This has especially been considered in the postoperative cases. AIIen found that the blood plateIets, choIestero1, bleeding time and coagulation time did not show definite changes postoperatively. Variations in the blood calcium were inconsistent. He did find constant changes in the fibrinogen, lipoids, red and white bIood ceIIs and the prothrombin time. Of these, AIIen considers the hbrinogen as the most important. The action of this substance was manifested by the increased size and strength of the cIot formed. The postoperative increase in the leucocytes he considered significant as they are known to furnish thromboplastic substances which play an important part in the bIood coaguIation. Actual demonstration of the organisms in either the venous wal1 or the thrombus formed has not been successful Brown cuItured portions of the inflamed vein and the thrombi but the cultures were negative. Blood cultures have been repeatedIy done but no growth secured. In this series of cases there were two positive blood cultures but in both the originaI disease, of which the phIebitis was a com-

520

American

Journal

of Surgery

Geist-PhIebitis

pIication, expIained the positive cuItures. AnaIysis of the cases in this series shows that the femaIe sex was invoIved more often than the maIe and married individuaIs more often than singIe. AI1 of the cases showed invoIvement of the Iower extremity and most of them were on the Ieft side of the body. The incidence of age was not concIusive. TABLE 1 INCIDENCE OF SEX AND PART OF BODY

MaIe.

.

Female.. SingIe. ... . Married. . Lower extremity.. Upper extremity.. Left side. Right side.. BiIateraI..

.. . .. . . . .. ... .. . . . .. .. .

8 30 20 28 38

o 18 12 8

TABLE 11 INCIDENCE ACCORDING TO AGE Under 10 yrs.. . I 10-20 yrs.. .. . 2 21-30 yrs . . . . . . . 10 31-40 yrs... . . 6 41-50 yrs. _. 6 51-60 yrs., . . 8 61-70 yrs. ... .. 4 Above 70 yrs. .... I

An effort was made to determine the presence of foci of infection and see if this pIayed a part in the etioIogy. Fourteen cases reveaIed evidence of foca1 infection, ten having diseased teeth and four diseased tonsiIs. It is evident that the majority of the cases were free from such foci. In two cases disease of the tonsiIs was marked. One is forced to question whether or not an individua1 whose genera1 resistance has been Iowered by operation and the disease necessitating operation is predisposed to phIebitis by such foci of infection. Brown has caIIed attention to a seasona incidence in cases of thrombophIebitis. Examination of the cases in this review shows that the majority occurred during the spring and faI1, when upper respiratory infections are more frequent and troubIesome. TABLE III SEASONAL INCIDENCE OF PHLEBITIS Winter.. . . . 4 Spring............................ 14 S ummer.. . .. . 7 FaII.............................. 13 TotaI for Spring and FaII.. . . 27

For the postoperative and postpartum cases we might expect to find evidence of infection. The postoperative cases numbered eighteen and of these, there was wound infection in three. In five, the origina condition necessitating operation was an acute inflammatory one. In the DostDartum cases, of which there were

eight, onIy two showed evidence of infection. Less than a third, therefore, of the cases occurring after operation or deIivery showed evidence of infective lesions. TABLE

IV

TABLE v TYPE OF OPERATION IN POSTOPERATIVE CASES PeIvic operations. .... Abdominal operations.. Vaginal and perinea1. . . TonsiIIectomy.. ... ...

INCIDENCE OF INFECTION

Acute appendicitis. Breast abscess. . . Wound infection, TotaI.. . .. . .

.. . . . ..

5 2 3 IO

6 8 3 I

TABLE VI TYPE OF CASE

.

Postoperative. Post-traumatic. Postpartum.. UnexpIained.. Total no. of cases..

.

.

12 .

. .

.

g

..

8

. .

.

g

. .

.

.

38

FataI puImonary emboIism and puImonary infarction are compIications of phIebitis. Th ere were no cases of fata puImonary emboIism in this series. Brown cIaims that the danger of emboIism with death is slight because of the inffammatory nature of the disease and the tendency of the cIot to be strongIy adherent to the vesse1 waI1. He does beIieve that the occurrence of smaI1 puImonary infarcts and a resuItant bronchopneumonia is common. One patient in this series deveIoped a bronchopneumonia which was of this type. In the tota series there were three deaths, none of which couId be attributed to the phIebitis aIone. TABLE MORTALITY

AND

VII

CACSES

Total no. of cases.. Numberofdeaths.................. Died of pneumonia.. Died of puerperal sepsis. Died of diabetes meIIitus.

OF

.

DEATH

.

. .

. . ... . . . .

38 3 I I

I

It must be concIuded, therefore, that phIebitis is an infective Iesion and that the presence of foci of infection and acute inff ammatory Iesions prior to operation and deIivery are important predisposing causes. More than this is not justified from an examination of the cases discussed. REFERENCES 1. BROWN, G. E. Arch. Surg., 15: 245-253, 1927. 2. ALLEN, E. V. Arch. Surg., 15: 254-264, 1927. 3. GRAHAM, E. A. SurgicaI Diagnosis. PhiIa.. Saunders, 1930. 4. ASHHURST, A. P. C. Principles and Practice gery. 1927. BROOKS. B. Arch. Sura.. 4: 188, 1422

of Sur-