The postphlebitic state

Abstract

I N 1918 Homans’ reported his important observation regarding the disproportion between the degree of superIicia1 venous engorgement and the intractabiIity to treatment of certain uIcers of the Iower extremity foIIowing deep venous thrombosis. Since then a cIinica1 entity has emerged which has come to be known as the postphIebitic syndrome. In 1928 Homans presented a description of this condition which up to the present has not been surpassed: “One can hardIy see many patients suffering from uIcers of the Ieg without being struck by the number of those who present areas of edema, induration, discoIoration and uIceration for which varicose veins of the famiIiar types are cIearIy not responsibIe. Such areas are often extensive, unassociated with trauma and seem to have no adequate cause. They are the source of much pain and disabiIity, particuIarIy in the working cIass. “In questioning a considerabIe group of such patients it wiI1 be found that many have suffered at some time from a recognized thrombophIebitis, that is, a ‘miIk Ieg,’ or a simiIar disease occurring in the course of convaIescence from an operation or an acute fever such as typhoid or pneumonia. In some instances the connection between the Iate compIications and the thrombophIebitis is very direct and obvious, in others remote and obscure. As a ruIe venous stasis, as exhibited by diIated veins or bIueness of the extremity, is IittIe marked or aItogether absent. On the other hand, the condition which one is accustomed to associate with acute or chronic Iymph stasis, that is edema of the tissues, is aImost invariabIy present. The cause of these Iate resuIts is perhaps to be found in the nature of the origina thrombosis.” The diagnosis often wiI1 be obscure unIess one is aIert to such a possibiIity. Examination may fai1 to reveal superficia1 varicosities and a cursory history may not eIicit a story of an antecedent episode of thrombophIebitis. FaiIure to appreciate the specific nature of the condition often Ieads to its confusion with varicose veins and varicose ulcer. In order to establish a proper diagnosis it is frequentIy necessary to deIve into the remote recesses of memory to ferret out an episode of miIk Ieg or a fracture which may have occurred as much as twenty to fifty years before. Further questioning, however, wiI1 usuaIIy revea1 that there has been some residue of ankIe sweIIing during the intervening years. More diffrcuIt to evaIuate are those cases with cIear-cut varicosities but a history of treatment by muItipIe injections. The injection treatment of varicose veins was often very probabIy compIicated by deep venous thrombosis. At Ieast three processes seem to be invoIved in the pathogenesis of the postphIebitic state, nameIy, damage to the deep veins, invoIvement of the Iymphatic drainage and reffex vasospasm. The invoIvement of the deep veins can be demonstrated in various ways, such as by phIebography and by waIking venous pressures. Furthermore, destruction of venous vaIves as a resuIt of thrombophIebitis has been described in both cIinica1 and experimenta materia1 by Edwards and Edwards.3 AIthough Homans in his earlier work beIieved rather strongIy that an inffammatory process in the periphera1 Iymphatics was an important factor, its uItimate significance has been dif&uIt to evaIuate. He was one of the first4 to describe the marked edema present in the vascuIar bundIe at operation during acute thrombophIebitis. It is a common finding during expIoration for the purpose of femora1 vein interruption in the acute phase of the disease. Ochsner and DeBakey6 have pointed out the importance of reflex vasospasm during the acute episode. ParavertebraI procaine bIocks may have a markedIy moIIifying effect on the acute symptomatology. It is doubtfu1, how-