PUERPERAL PHLEBITIS

BARTON COOKE HIRST, M.D.,PHILADELPHIA.

Reprinted from The Medical and Surgical Reporter December 33, 1894.

PUERPERAL PHLEBITIS.

BARTON COOKE HIRST, M.D.,PHILADELPHIA.

PUERPERAL PHLEBITIS.*

BARTON COOKE HIRST, M.D., PHILADELPHIA.

Of all the forms that sepsis can presentin a woman after labor, phlebitis, I shouldsay from experience in consulting practice,is least understood, most often mistakenfor something else and most frequentlymaltreated by the general physician. Andyet there is no form of sepsis that has somany distinctive and peculiar character-istics if they are known and looked for.The most misleading features in the dis-ease, from a diagnostic point of view, arethe late appearance of symptoms and theentire absence of local physical signs of in-flammation. I have known a septic phle-bitis develop as late as five weeks afterlabor, and in all cases uncomplicated byother forms of septic inflammation thewomb involutes well, is freely movable and.insensitive; the broad ligaments with theuterine adnexa are apparently normal,while the general symptoms of high fever,rapid pulse, profound prostration and me-tastatic developments may be most marked.It is this absence of local symptoms thatstrengthens the indisposition in us all toadmit sepsis as the cause of disease in ourpatients after childbirth.

Symptoms.—A typical clinical picture ofpuerperal phlebitis presents the followingcharacteristics: Evidence of disease ap-pears ten days or more after confinement;there may have been a slight evening riseof temperature from the beginning of thepuerperium, and during this time thepatient may have appeared somewhat rest-less or anxious with a flush on one or both

* Read before the Philadelphia Obstetrical So-ciety.

cheeks; the pulse also may have beensomewhat accelerated, but there is scarcelyenough in the woman’s condition to at-tract her physician’s attention. After avarying but considerable length of time,with the premonitory symptoms just de-scribed or with none at all, the tempera-ture rises high in twenty-four or forty-eight hours, a chill sometimes but notusually preceding the fever. The pulse israpid out of all proportion to the tempera-ture, there is a dusky flush on the cheekor cheeks and patches of red may appearon other parts of the body, particularly onthe chest. The tongue is very foul. Thepatient has an anxious, troubled, restlesslook, but if questioned may reply thatshe feels perfectly comfortable, or ifshe feels ill she cannot complain of anylocalized pain or discomfort. The abdo-men is not distended nor is it usually atall sensitive to pressure. A vaginal ex-amination is entirely negative. The dis-ease once begun runs a most tediouscourse. I have attended two patientswho were seriously ill, with high fever forfour months, and I think the womanlucky whose illness is not protracted be-yond three weeks. Another most dis-tinctive feature in the course of the dis-ease is the tendency to complete remissionof the fever and of all other symptoms formore than a week perhaps; then there isa recurrence of high fever, rapid pulseand profound prostration—in short, a re-appearance of all the old symptoms intheir original intensity, but the relapsedoesnot often last long. I have seen such a

relaose recar three times in an individualbeen ill three months before the

first remission.Complications .'—As is well the

commonest complication of phlebitis isphlegmasia, but the latter is by no meansa necessary consequence of the former. Ihave seen many a case run its course with-out a swelling in the leg or legs and anumber of cases besides in which thephlegmasia was a transitory, scarcelynoticeable phenomenon_ in the course ofthe disease. Phlegmasia is too large asubject to consider here, and I shallsimply refer to some interesting featuresof it that have struck me in my own ex-perience. I have the notes of sixteencases seen in private, consulting and hos-pital practice. In two instances therewas double phlegmasia. In one case theswelling first appeared seven weeks afterchildbirth. In two cases there was acombination of the cellulitic and of thethrombotic phlegmasia. In one case therewas an abscess in the popliteal space; inanother, in the calf of the leg. In severalcases the phlegmasia began as a pure pres-sure thrombosis, but in all these casesthe clot eventually became infected andthere was some septic fever.

It is a fact not generally appreciatedthat the thrombosis of phlebitis in thepuerperium is not necessarily confined tothe veins of the pelvis and to those of thelower extremities. Large veins far dis-tant from the seat of original infectionmay be affected. As an illustration, myfriend Dr. Fussell has told me of awoman under his charge in whom thelongitudinal sinus of the brain was foundsolidly blocked by a well-organized ante-mortem clot. She died four weeks afterconfinement, death being preceded bycoma and convulsions.

Another well-known complication ofseptic phlebitis is a metastatic septic in-flammation anywhere in the body. Thebrain, the eyeballs, the lungs, the pleura,the kidneys, the liver, the spleen, thesubcutaneous connective tissue may bethe seat of an abscess. I have seen ina puerpera the whole of one leg and aforearm riddled by the multiple abscessesof suppurative cellulitis.

Still another complication is profusehemorrhage from the veins of the placen-tal site. One of my students has recentlytold me of a case in which there were re-

peated alarming floodings in the course ofa puerperal phlebitis, following attempts atintra-uterine disinfection.

Treatment.—The treatment of puer-peral phlebitis is summed up in a shortsentence; Abstention from local interfer-ence and the freest possible use of stimu-lants and food. Any attempt at intra-uterine disinfection will make the patientdistinctly worse. There is imminentdanger of causing metastases or hemor-rhage by local interference. In one of mypatfents an intra-uterine douche was fol-lowed by a chill, aud within twenty-fourhours by suppurative pleurisy. In anotherthe temperature rose to 106.8° after cleans-ing the uterine cavity. This indeed is adiagnostic feature of considerable value, andis occasionally the only way to distinguishbetween saprsemia and phlebitis, as thefollowing clinical history I sawin consultation a lady who had been de-livered three weeks before. She had hada temperature of about 103° for twoweeks ; her pulse was rapid; there wasprofound prostration, and one of the mostdistinguished physical diagnosticians ofPhiladelphia had the day before detect-ed an incipient septic pneumonia. Theabdomen was flat and not tender. Theuterus was well involuted and perfectlymovable. There was a slight bloody dis-charge without odor. All this lookedvery much likephlebitis. I thoroughly dis-infected the uterine cavity, however, andwithin twelve hours the temperature fellto normal, the signs of pneumonia dis-appeared and the patient made an un-complicated recovery. Had this case beenone phlebitis, as it seemed to be, mylocal interference would have made thewoman much worse. But in spite of thisrisk I always carry out one thoroughdisinfection “of the womb, even in a casein which I feel pretty certain of the_ diag-nosis of phlebitis. The clinical historyjust related is sufficient for such a rule ofpractice. Having established the diag-nosis of phlebitis and having shown thefutility of local disinfection, my routinetreatment is as follows:

Milk, predigested if necessary, and pre-digested beef at regular intervals and inas great quantities as the patient can di-gest; whisky, as near a pint a day as shecan stand; or, if necessary, champagne inlarger quantities. Digitalis for the rapidpulse and quinine and iron by the bowel.

The patient is kept in bed for at least tendays after all symptoms disappear.Prognosis. —ln spite of alarming symp-toms and long continuance, the diseaseshould end in recovery in the vast major-ity of cases. I have only lost one of my

cases of phlegmasia and two other cases ofphlebitis, a mortality of about 10 ner cent.Among the women who recovered weresome as desperately ill as I ever saw, sothat I approach a case of this kind withconsiderable confidence as to the result.

Puerperal phlebitis /MAINPUERPERAL PHLEBITISBARTON COOKE HIRST, M.D., PHILADELPHIA.

PUERPERAL PHLEBITIS.BARTON COOKE HIRST, M.D.,PUERPERAL PHLEBITIS.*