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Inflammation of the Vena Portæ (Pylephlebitis). By Dr. John
WALLER, of Prague. Translated from the German, by
The author, before entering upon the subject of his treatise, details the history of five cases of inflammation of the vena portæ, with their post mortem appearances. These cases are very minutely and too lengthily narrated to fit them for the narrow limits which this Journal prescribes for non-original matter. The translator has therefore deemed it prudent to communicate the results which the author has drawn from his and other cases; and it is hoped that this sketch may give an impulse to our American medical practitioners to direct their observations to a disease which, although hitherto overlooked, cannot be rare in a country where diseases of the portal system are as prevalent as they are in the western and southern parts of America.
Anatomical Character.-Referring to what Rokitansky has said in his Treatise on Inflammation of the Vena Portæ, the author confines himself to the results drawn from the cases detailed.
Vol. I. No. 1.-1
1. The changes in the parieties of the vena portæ, were, in all the cases, trifling, and stood in no proportion to the morbid changes of the contents of the vena. The circumstance, that in one case the parieties of the superior mesenteric vein were whitish-gray, shrivelled, obliterated, and almost cartilaginous in some places, renders it probable that the inflammatory action proceeded from thence. The lumen of the tube of the vein was, in all cases, dilated by the products of inflammation contained in its canal, the trunk of the vein was very much distended by its contents, and its morbid condition perceptible by the eye from its external appearance.
2. Changes in the blood itself of the vena portæ; (a) blood coagulations of different degrees were found in four cases; (6) pus was absent in three cases; (c) acute medullary sarcomatous depositions were found in two cases. Concerning the extent of the inflammatory action in the portal system, it was found that in the first cases only was the spleen free; in the second and fifth were the branches of the vena portæ in the liver, its rami and trunk, but not the splenic and mesenteric vein; in the third case, the splenic vein, one branch of the inferior mesenteric vein, the trunk to its finest ramifications; in the fourth case, the vena portæ in its whole extent, implicated in the morbid process. That we have to deal, not with a primary but a secondary phlebitis, called forth by bloody coagulation, is evident, among other reasons, from the entire absence of anatomical changes in the parieties of the vena portæ, whilst the marks of inflammation of its contents are so obvious. The coagulation of blood was, in all cases, the first change, no matter whether this took place spontaneously or whether it was produced by pus or its elements. In these coagulations, takes place partly an imperfect, partly a perfect excretion (or separation) of fibrini in the canal of the vein; the longer the disease continued the more complete was the change of the lymph. Coagulations with pus, as a sequence to the suppurative phlebitis, manifested itself in the first secondary inflammation of the parieties of the superior mesenteric veins; in the other cases, death took place before any sequelæ could develop them. selves. The time within which, after the coagulation of the
place, can be various. Concerning the duration of the disease, there appeared, in the first case, even after the fortyseventh day of sickness, no inflammation of the vena portæ, with the exception of one part of the superior mesenteric vein; whilst in the fourth case it was observed in the course of four days. It appears, therefore, that the acuteness and the intensity of the disease of the blood exercise a certain influence.
Symptomatology.—To find the vena portæ and its branches, by means of physical examination is, by their anatomical position, impossible; we must, therefore, depend on the other phenomena observed in the reported cases, and here we have, before all others, to consider the objective local symptoms. Among these is the abdominal distention, which is caused either by meteorism or accumulation of serum, the most prominent. Neither meteorism nor ascites appear to have diagnostic value in pylephlebitis, because there can, in no case, be shown a direct connection of it with inflammation of the vein; meteorism depended on the pyæmia and on the peritonitis, which existed simultaneously; the ascites depended on cancer and granulation of the liver. The size of the liver was enlarged in all the five cases. The cause of this enlargement was—in the first two cases, besides numerous abscesses in the liver, a distention, with pus and plastic coagulations, of the ramifications of the vena portæ; in the third case a large quantity of pus in the branches alone of the vena portæ ; in the fourth and fifth cases, besides the blood coagulations and cancerous depositions in the portal ramifications, and abundant cancerous deposition in the substance of the liver. It follows from this that, although the increase of the volume of the liver is intimately connected with inflammation of the portal ramifications, we cannot, from this symptom, infer, with certainty, the existence of this disease, because many other diseases have the same symptom. Icterus was observed in four cases-in the first two and the last two; it was not observed in the fifth case. In the first and second cases were found numerous abscesses in the liver, which contained pus mixed with bile. In the fourth case was granulated liver and sarcoma, the cause of the icterus. In the last case, the hue of the skin was such as is observed in scirrhous dyscrasia. Now, whether the jaundice hue of the skin arose in consequence of pylephle
bitis without abscesses of the liver or not, in none of the cases related can jaundice be the consequence of pyæmia alone; jaundice cannot, therefore, be regarded as a pathognomic symptom. Enlargement of the spleen has been mentioned already by Schoenlicn as a diagnostic symptom, and was found in four of our cases. Anatomy informed us of mechanical hyperæmia as the cause of this enlargement in the first three cases, to which, in the second case, was added partial plastic exudation; in the third case, moreover, an abundant secretion of pus in the smallest beginning and in the trunk of the splenic vein. In the fourth case the enlargement was deducible from granulation and scirrhus of the liver; and in the fifth case, at last, was the spleen even smaller-its skeleton, however, hypertrophied. Enlargement of the spleen can obviously be produced by inflammation of the vena porta, and furnishes, in connection with the other symptoms, no unimportant diagnostic sign in those cases where a minute examination of the size of the spleen by means of pecussion is permitted by the condition of the thoracic and abdominal organs. Balling and Schoenlein mention nausea, vomiting, and even vomiting of blood, as symptoms. The author observed in but three of the recorded cases vomiting of whitish or yellowish fluid; it was occasioned in one case by encephalitis; in another by chronic catarrhal affection of the stomach and pressure of the scirrhous liver upon the stomach; in the third case, where vomiting took place but once, was no sufficient explanation by a post mortem examination discovered. Vomiting can, therefore, in the cases recorded, not be considered as a symptom of pylephlebitis. The alvine evacuations are seldom normal; they were tardy in the first case; sero-mucous diarrhæ, which was at times deep green, tormented the patient of the second case; constipation was in the third ; then yellow, greenish discharges, which were sometimes mixed with streaks of blood, appeared in the fourth case; and in the fifth were muco-serous or dark, soft evacuations. Only the third case showed in the mucous membrane of the small and large intestinal canal partial acute catarrh ; in the fourth case, chronic catarrh in the same parts and also in the stomach--the intestinal canal of the other patients showed no particular abnormity. The diarrhæa of the second patient
must, therefore, be considered as a symptom of pyæmia; and the constipation of the third must be ascribed to encephalitis. The chronic catarrh of the fourth, and the dark, ruft evacuations of the fifth, existed prior to the advent of the phlebitis. The variously constituted alvine evacuations, as well as the hæmoptysis, can accompany peryphlebitis ; yet they never stand in immediate connection together, but manifest themselves only by means of the mechanical hyperæmia of the intestinal mucous membrane or of other complications. The distention of the venæ epi and hypogastricæ, produced by mechanical hyperamia, which Schoenlein has defended as a symptom of our phlebitis, has not been observed by the author. Pain, the subjective local symptom, was not at all present in the fourth case, was experienced by times, and increased on pressure in the first case, and in the second case was the whole epigastrium sensitive, the inguinal iliac regions very painful; in the third and fifth cases was pain also severe. In all of these cases existed complications which, besides the inflammation of the vena portæ, caused pain. It is, therefore, not certain whether the inflammation of the vena portæ is accompanied by pain or not. Ascites has, by Cruveilheir, been considered as a symptom of pylephlebitis ; neither the author nor other observers had opportunity to confirm this; sure it is, that obliteration of the vena portæ, by whatever cause produced, has ascites as a consequence. The edema of the lower extremities, which was present in cases No. four, and five, (in the two last already prior to the inflammation of the vena portæ) and was absent in cases No. one and three, is, for anatomical reasons, not to be regarded as depending on inflammation of the vena portæ ; because the veins of the lower extremities lose themselves, not in the vena portæ, but in the vena cava inferior. Occasional pulsation of the right jugular vein, pulsation in the abdomen and in different places of the body, fainting, dry cough and the like, which Balling regarded as symptoms of this disease, cannot be regarded as such by the author, because he himself has neither observed them nor can he explain their connection with the disease. In relation to the functions of the vascular system, Baczynski thinks to have observed in the inflammatory stage the symptoms characterizing inflammatory fever, and in the second stage a sinking (depression) of the