Phlebitis.

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FINLEY ELLINGWOOD, M. D., CHICAGO

An inflammation of any portion of the structure of a vein which results in changes in the coats of the vessel, is denominated phlebitis.

The disease occurs as a complication of other conditions, and is not always diagnosed as an independent condition. In fact in many chronic cases it is not recognized at all, and while it contributes very materially to the prolongation of the disease, as a separate and distinct condition it receives no treatment. This at times becomes a serious error.

The disease may be either acute or subacute. A chronic form is not always recognized, as in this form structural changes are apt to produce obliteration of the lumen of the vessel, and result in conditions, that are otherwise recognized.

The location of phlebitis, or the conditions attending it, supply a variety of names for this disease. There is plastic, or hyperplastic phlebitis, the condition above described; gouty phlebitis which occurs during the course of gout; portal phlebitis, an inflammation of the portal vein; puerperal phlebitis, an inflammation of the, veins of the uterus, occurring during the puerperal state. Sinus phlebitis, an inflammation of the cranial sinuses. Umbilical phlebitis, an inflammation of the umbilical vein. Varicose phlebitis, an inflammation which involves varicose veins.

When the disease involves the inner lining of the vein only, it is called endo-phlebitis and was quite common in those days when blood letting was constantly resorted to as an antiphlogistic measure. The inflammation in these cases began at the point of incision of the vein, and extended to the neighboring parts. Phlebitis follows at times, the ligation of a varix, or the tying of the large veins, or injuries of the veins from punctures, gun shot wounds, or other traumatism. Inflammation of the veins of the uterus occur after delivery in some cases.

The symptoms are those of pain in the injured parts, soon followed by a knotty feeling, with a tense and painful cord-like condition, which follows the course of the vessel. There may be a chill with more or less fever and a greater or less degree of nervous symptoms. There is discoloration of the skin and an acute edema below the obstruction. There may be rapid and irritable pulse, dry brown tongue, dry skin, constipation, anorexia, and if pyemia develops there will be pain in the joints. Later the skin may become white, shiny, stretched and very hard. This condition like other inflammations may terminate by resolution, by suppuration, ulceration or gangrene. Occasionally the vessel becomes immediately occluded, a clot forms, and permanent obliteration results, the clot and veins ultimately contracting, to form a firm cord which is known as adhesive phlebitis. When this disease follows a septic traumatism it is apt to become dangerous, leading to direct blood infection and pyemia.

When this inflammation develops more gradually, as in the subacute forms, it is not dangerous. It is usually induced by previous disease of the coats of the vein, which have resulted in thickening, and in a deposit of fibrinous matter. The vein may be occluded and in the occluded structures an abscess may form which should be opened as an ordinary abscess.

The opening of the abscess even when the structures of the coats of the vein are cut clear through will not usually result in hemorrhage, because the vein is blocked by the intravenous products of the inflammation. The lumen of the vein does not communicate directly with the abscess. In occasional cases, the occlusion will break up, and the abscess will open directly into the vein, inducing acute pyemia, with a possible acute diffuse form of the phlebitis, in previously unattacked portions of the vein.

Perhaps the most common form of phlebitis is that known as crural phlebitis, an inflammation of the crural vein, due to obstruction from thrombus and occurring soon after labor.

This form is known by the various names of phlegmasia, alba dolens, white leg, milk leg, white swelling, The condition occurs, usually, during the second or third week after delivery. It involves the lower extremity of one side. The leg becomes greatly swollen or edematous and the skin assumes a white, shiny appearance. There is usually a mild chill with some fever and considerable heat in the part. Over the course of the vein there are a number of irregular prominences which can usually be plainly felt under the skin. In some cases, the swelling and the pain in the parts may be present for two or three days before the fever appears.

After a few days the heat subsides, the hardness and sensitiveness diminish, the patient becomes reduced in strength and is often anemic. The limb remains edematous for some time, often for a long period, the patient suffering from phenomena similar to those which occur in protracted fevers.

I have had considerable experience with phlebitis in several of its forms, and have learned to adopt those measures in its treatment which can be depended upon as reasonably satisfactory.

I was called at one time, to a distant city, to consult with a physician who had a case of fracture, in which, while the bone seemed to have united quite early, later the patient suffered from a chill, had quite a high fever, leg swelled rapidly, until the skin became stretched to its most extreme limit. The physician had not thought of phlebitis as a possible complication to an ordinary fracture. This was treated in the most careful manner and improved rapidly from the time treatment for phlebitis was instituted.

In the treatment of these cases the specific indications for some of our remedies are so plainly marked that these remedies would be selected at once by a specific prescriber and the best of results follow. The local aching, and severe pain in the surrounding muscular structures, immediately suggest macrotys. The aconite pulse is nearly always present with the fever, but occasionally indications for gelsemium are plainly apparent. Bryonia can be used in this disease, also, with a prompt response to its influence. In the subacute cases, collinsonia or hamamelis are most desirable remedies.

Where the indications are not plainly pronounced, I have used gelsemium. and macrotys as routine treatment. In nearly every case, a mild saline laxative which will thoroughly cleanse the intestinal tract and will neutralize any excessive gastric acidity, will be found essential. Subsequently, a light diet and close attention to the possible recurrence of gastric acidity, meeting such with an alkaline agent, not always necessarily laxative, will be the proper course.

Local measures contribute materially to the cure, whatever the variety of the disease, if it be near the surface. If in a limb, as in the crural form, the limb should be elevated, and should be thoroughly bathed with hot salt water, after which I usually apply a simple liniment at first, which consists of one part of ammonia, and four or five parts of olive oil. This should be applied very freely and the limb enveloped in cotton, the whole held in place by a loose roller. It should be dressed at least twice a day. In other cases the application. of hamamelis frequently is of much benefit. Occasionally gauze may be saturated with hamamelis and applied to the parts for hours at a time, the limb being kept very warm. This is especially valuable when the local aching and pain are very hard to bear. These become so severe at times, that a mild anodine is necessary. Here I resort to my favorite prescription, which contains one-sixteenth of a grain of morphine, five grains of sodium bromide and a little hyoscyamus or cannabis indica in each dose, repeating the doses frequently until an effect is produced, and then as needed.

As convalescence advances, it will be found that strong tonics will be needed in nearly every case. The stomach must be put into the best possible condition. For a few days the digestion should be assisted by artificial measures.

So common is anemia in most cases of phlebitis and especially in milk leg, that iron will be found essential. It is an excellent plan to combine equal parts of the tincture of the chloride of iron with dilute phosphoric acid, and to give this combination in from twelve to twenty minim doses, every two, three or four hours for perhaps two or three weeks. I had excellent results in one case from the syrup of the oxide of iron. Any unusual or erratic indications should be promptly met as they arise.

Ellingwood's Therapeutist, Vol. 2, 1908, was edited by Finley Ellingwood M.D.