PHLEGMATIA DOLENS.
_Nature of the disease.--Definition of phlegmatia dolens.--Symptoms.--
Duration of the disease.--Connexion with crural phlebitis.--Causes.--
Connexion between the phlegmatia dolens of lying-in women and
puerperal fever.--Anatomical characters.--Treatment.--Phlegmatia
dolens in the unimpregnated state._
_Nature of the disease._ Although we shall not be justified in stating
that the disease is one of the sequelæ of puerperal fever, inasmuch, as it
is occasionally met with, entirely independent of labour and the puerperal
state, still we must recognise a very close relation between these two
diseases, especially between it and the uterine phlebitis, since, in a
majority of instances, they both arise from the same cause, viz.
absorption or imbibition of a morbid poison. At the same time, we can by
no means agree with Dr. R. Lee, that "the swelling of the affected limbs
in phlegmatia dolens, and all the other local and constitutional symptoms
of this affection, invariably depend on inflammation of the iliac and
femoral veins;" and, therefore, do not consider his proposition
justifiable, "to substitute the term crural phlebitis in place of
phlegmatia dolens" (_Researches on the Pathology and Treatment of some of
the more important Diseases of Women_, p. 116,) for cases occur where the
disease has manifested itself to a very considerable extent without any
inflammation of the veins whatever. On the other hand, we willingly allow
that in many others it has been preceded by crural phlebitis, although we
most distinctly deny that it is ever identical with that disease.
_Definition of phlegmatia dolens._ We may define phlegmatia dolens to be
tumefaction of a limb from inflammation and obstruction of the main
lymphatic trunks leading from it. It is most frequently seen in the
puerperal state, attacking one or both extremities, and is then almost
always a concomitant or a consequence of puerperal fever. In the
unimpregnated state it is usually the result of some organic malignant
disease. "Women of all descriptions are liable to be attacked by it during
or soon after childbed; but those whose limbs have been pained and
anasarcous during pregnancy, and who do not suckle their offspring, are
more especially subject to it. It has rarely occurred oftener than once to
the same female. It supervenes on easy and natural as well as on
difficult and preternatural births. It sometimes makes its appearance in
twenty-four or forty-eight hours after delivery, and at other times not
till a month or six weeks after; but in general the attack takes place
from the tenth to the sixteenth day of the lying-in." (_An Essay on
Phlegmatia Dolens_, by John Hull, M. D. p. 132.)
_Symptoms._ As the phlegmatia dolens of lying-in women is almost
invariably preceded by symptoms of puerperal fever, many of its early
symptoms will differ but little from that disease. The patient is usually
attacked with rigours, followed by flushing, headach, and generally more
or less abdominal pain, with a quick pulse, or the disease has come on
when recovering from a severe attack of puerperal fever.
"The complaint generally takes place on one side at first, and the part
where it commences is various: but it most commonly begins in the lumbar
hypogastric or inguinal region on one side, or in the hip, or top of the
thigh, or corresponding labium pudendi. In this case the patient first
perceives a sense of pain, weight, and stiffness, in some of the
above-mentioned parts, which are increased, by every attempt to move the
pelvis or lower limb. If the part be carefully examined, it generally is
found rather fuller or hotter than natural, and tender to the touch, but
not discoloured. The pain increases, always becomes very severe, and in
some cases is of the most excruciating kind. It extends along the thigh,
and when it has subsisted for some time, longer or shorter in different
patients, the top of the thigh and labium pudendi become greatly swelled,
and the pain is then sometimes alleviated, but accompanied with a greater
sense of distention," (Hull, _op. cit._ p. 184.) The pain next extends
down to the knee, and if depending on a state of phlebitis is most severe
in the course of the femoral vein, which is felt hard and swollen, and
rolling distinctly under the finger when pressed upon: it is precisely in
the direction of this vessel that the greatest pain is felt on pressing
with the hand: if phlebitis be not present, the pain is diffused more
equally over the limb, and is more connected with the state of tension, or
otherwise, is confined chiefly to the groin or upper part of the thigh.
"When it has continued for some time, the whole of the thigh becomes
swelled, and the pain is somewhat relieved;" "the pain then extends down
the leg to the foot; after some time the parts last attacked begin to
swell, and the pain abates in violence, but is still very considerable,
especially on any attempt to move the limb. The extremity being now
swelled throughout its whole extent, appears perfectly or nearly uniform,
and it is not perceptibly lessened by a horizontal position, as an
oedematous limb. It is of the natural colour or even whiter, is hotter
than natural, excessively tense, and exquisitely tender when touched; when
pressed by the finger in different parts, it is found to be elastic,
little if any impression remaining, and that only for a very short time.
If a puncture or incision be made into the limb, in some instances no
fluid is discharged, in others a small quantity only issues out which
coagulates soon after, and in others a larger quantity of fluid escapes
which does not coagulate; but the whole of the effused matter cannot be
drawn off in this way. The swelling of the limb varies both in degree and
in the space of time requisite for its full formation. In most instances,
it arrives at double the natural size, and in some cases at a much
greater. In lax habits, and in patients whose legs have been very much
affected with anasarca during pregnancy, the swelling takes place more
rapidly than in those who are differently circumstanced; it sometimes
arrives in the former class of patients at its greatest extent in
twenty-four hours or less, from the first attack." (Hull, _op. cit._)
Phlegmatia dolens rarely or never proves fatal of itself; the patient
either dies in consequence of the puerperal fever which has preceded or
attended the affection, or from the system gradually sinking under the
injury which it has sustained. In those cases where the patient has
struggled through, the limb remains for a long time afterwards swollen,
stiff, and incapable of motion, from which it slowly and not always very
perfectly recovers.
_Duration of the disease._ "The duration of the acute local symptoms has
been very various in different cases. In the greater number, they have
subsided in two or three weeks, and sometimes earlier, and the limb has
then been left in a powerless and oedematous state. The swelling of the
thigh has first disappeared, and the leg and foot have more slowly resumed
their natural form. In one case, after the swelling had subsided several
months, large clusters of dilated superficial veins were seen proceeding
from the foot along the leg and thigh to the trunk, and numerous veins as
large as a finger were observed over the lower part of the abdominal
parietes. In some women, the extremity does not return to its natural
state for many months, or years, or even during life." (Lee, _op. cit._ p.
119.)
_Connexion with crural phlebitis._ We have already stated, that in
phlegmatia dolens the lymphatic circulation of the swollen limb has been
obstructed by inflammation and obliteration of the main lymphatic trunks
leading from it. To call this disease "crural phlebitis," because in a
case where the crural vein has been inflamed, the inflammation has spread
to the surrounding fascia, or cellular tissue, through which the larger
lymphatics of the thigh pass in their way to the abdominal cavity, is
manifestly incorrect, and tends to confound two diseases together, which
are of a very different character. From the situation of the crural vein
as it emerges upon the anterior and upper part of the thigh, and the
cribriform appearance of the inner side of the femoral sheath, and of the
cellular tissue which fills up the opening in the fascia lata at this
part, owing to the numerous lymphatic trunks by which it is perforated,
it would be nearly impossible that these structures should escape being
inflamed wherever the attack of crural phlebitis is at all severe; and
shows that although, as we have stated, phlegmatia dolens may occur
without crural phlebitis, it is very questionable if crural phlebitis can
exist to any extent without phlegmatia dolens.
To MM. Bouillaud and Velpeau, and also to Dr. Davis, are we chiefly
indebted for having first pointed out the fact, that the large venous
trunks of the thigh and leg are frequently found inflamed in this disease.
Great credit is also due to Dr. R. Lee for his indefatigable researches
into the history and anatomy of crural phlebitis, for they have taught
practitioners to be on the watch for the existence of the one disease
whenever the presence of the other has been determined.
"The sense of pain, at first experienced in the uterine region, has
afterwards been chiefly felt along the brim of the pelvis, in the
direction of the iliac veins, and has been succeeded by tension and
swelling of the part. After an interval of one or more days, the painful
tumefaction of the iliac and inguinal regions has extended along the
course of the crural vessels, under Poupart's ligament, to the upper part
of the thigh, and has descended from thence in the direction of the great
blood-vessels to the ham. Pressure along the course of the iliac and
femoral vessels has never failed to aggravate the pain, and in no other
part of the limb has pressure produced much uneasiness. There has
generally been a sensible fulness perceptible above Poupart's ligament,
before any tenderness has been experienced along the course of the femoral
vessels; and in every case at the commencement of the attack, I have been
able to trace the femoral vein proceeding down the thigh like a hard cord,
which rolled under the fingers." (R. Lee, _op. cit._ p. 117.)
_Causes._ We consider that the causes of crural phlebitis in the puerperal
state are of precisely the same nature as those of uterine phlebitis,
already mentioned, viz., the absorption or imbibition of putrid matter
contained in the uterus; and from reasons which are self-evident, it will
be easily understood why the former affection is so frequently preceded by
the latter, or at any rate, by some modification of puerperal fever. Mr.
Tyre, of Glouscester, in an essay published 1792, and quoted by Dr. Hull,
has taken a somewhat similar view of the subject, although he does not
appear to have confirmed it by actual observation. He conceived that "the
obstruction to the return of the lymph may commence in the primary
inflammation of a trunk or trunks; and, probably, this may be the case
more frequently than I have hitherto discovered, or suspected it to be."
He considered also that "the remote cause may still be sought for in
pressure, in the presence of absorbed acrimonious matter, or in
inflammation continued from some absorbent to the trunk or trunks," (_An
Essay on the Swelling of the Lower Extremities incident to Lying-in
Women_;) but he overlooked the fact, that this inflammation of the
lymphatic trunks, when passing through the cribriform portion of the
fascia lata, was a result of its having either extended from the inflamed
crural vein, or from inflammation of the peritoneum in the pelvis, and of
the subperitoneal tissues.
_The connexion between the phlegmatia dolens of lying-in women and
puerperal fever_ has been demonstrated even still more closely by Dr.
Hull, a fact which later experience, and a more intimate knowledge of
these two diseases has tended to confirm. "It is, perhaps, in every
instance, accompanied by considerable marks of pyrexia, and is very
frequently preceded by coldness and rigours, which are succeeded by a hot
stage, and during this, the pain, stiffness, heat and other inflammatory
symptoms invade the loins, hypogastrium, inguen, or some part of the lower
extremity, just as they attack the peritoneum in puerperal fever." We may
safely assert, that, whenever this disease attacks a lying-in woman, it is
invariably preceded by some form of inflammatory puerperal fever, the
inflammation having either been transmitted along the vein, or along the
subperitoneal tissues, until it reached the above-mentioned cribriform
portion of the fascia lata, so that every lymphatic trunk which passed
through it would necessarily be implicated in the inflammatory process,
and thus rendered impervious. The opinion, therefore, of the inflammation
passing along an absorbent until it reaches the main trunks of the
lymphatics, appears to be objectionable, as we find it to have been rather
transmitted by communication of adjacent parts, although occasionally it
attacks the neighbouring glands, producing enlargement and suppuration of
them.
_Anatomical characters._ The details of a dissection which Dr. Lee has
reported with great minuteness, show marks of severe inflammation to such
an extent around the crural vein, that it is evident the greater part, if
not all, of the large lymphatic trunks in that neighbourhood had been
rendered impervious by it. "The common iliac, with its subdivisions and
the upper part of the femoral veins so resembled a ligamentous cord, that
on opening the sheath the vessel was not, until dissected out,
distinguishable from the cellular substance surrounding it. On laying open
the middle portion of the vein, a firm thin layer of ash-coloured lymph
was found in some places adhering close to, and uniting its sides, and in
others, clogging it up, but not distending it. On tracing upwards the
obliterated vein, that portion which lies above Poupart's ligament, was
observed to become gradually smaller, so that in the situation of the
common iliac, it was lost in the surrounding cellular membrane, and no
traces of its entrance into the vena cava were discernible. The vena cava
itself was in its natural state. The entrance of the internal iliac was
completely closed, and in the small portion of it, which I had an
opportunity of examining, the inner surface was coated with an
adventitious membrane. The lower end of the removed vein was permeable,
but its coats were much more dense than natural, and the inner surface was
lined with a strong membrane, which diminished considerably its caliber,
and here and there fine bands of the same substance ran from one side of
the vessel to the other. The outer coat had formed strong adhesions with
the artery and the common sheath: the inguinal glands adhered firmly to
the veins, but were otherwise in a healthy condition." (_Op. cit._ p.
123.)
In the other case there is also inflammation of the cellular tissue which
fills up the femoral ring, but instead of having been a consequence of
crural phlebitis, it has extended to this part from puerperal inflammation
of the peritoneum and cellular tissue beneath.
In our midwifery hospital reports (_Med. Gaz._ Oct. 24. 1835,) we have
given the details of an interesting case of this sort which came under our
notice during the former year, and which are rendered peculiarly valuable
by a most elaborate dissection of the parts after death, by Mr. Nordbald,
who was house-surgeon at the time. The patient was single, excessively
deformed in her back, and with the peculiarly unhealthy appearance of
persons thus afflicted; her labour had been perfectly natural, but on the
following day she was seized with rigours, followed by flushings, a quick
pulse, and abdominal pain: these symptoms were in great measure relieved,
and she appeared to be slowly improving. On the ninth day after labour,
she first complained of pain at the outside of the left thigh, extending
from the ilium to the knee, very exactly in the course of the
inguino-cutaneous nerve: it was tender to the touch, but there was no pain
on pressing the femoral vein at the groin. On the following day, the pain
and swelling of the thigh had increased, but still no pain was to be
detected on pressing the femoral vessels: leeches were ordered, but she
sunk immediately after their application, and died early the next morning.
Upon examination after death, the body was found "much attenuated; the
left thigh one third greater in circumference than the right; abdomen
tympanitic, not tense; parietes very thin; the lower part of the ileum,
caput coli, and arch of the colon contain air; a streak of inflammation is
delineated along the anterior surface of the colon from the centre of the
arch, throughout the descending portion of this intestine, to the left
iliac region; it is marked by a transverse band of capillary vessels,
minutely injected in the thickened peritoneum, along the whole of this
course. A few convulsions of the small intestines were smeared with recent
lymph, and one fold was found to adhere closely to the left side of the
pelvic peritoneum at the point of reflexion of the ligamentum latum uteri.
A few small portions of coagulable lymph were also found loose amongst the
intestines. At the posterior surface, and left side of the body of the
uterus, soft lymph and pus were effused for the space of an inch beneath
the peritoneal covering of this viscus, the membrane itself being highly
vascular from inflammation, but still showing the effusion through its
texture; the fundus of the uterus, where it has the Fallopian tube and
round ligament attached, was similarly affected, though in a slighter
degree; lymph and pus were effused here also. From these two points, the
inflammation appears to have spread to the rest of the serous membrane:
from the first indicated point it has progressed along the posterior fold
of the broad ligament to the surface of the rectum and colon; from the
second situation the round ligament and Fallopian tube have formed the
continuous line of its progress. On raising the peritoneum from the iliac
fossa, the cellular membrane which envelopes the round ligament, where
this cord is about to pass under the epigastric vessels, after quitting
the peritoneal cavity, was found infiltrated and condensed with lymph and
pus. The whole of the cellular membrane (which it will be borne in mind is
the fascia propria of Sir Astley Cooper, and which fills the _femoral_
ring, and moreover forms the medium of transmission for the lymphatics of
the thigh) was in the same condition, densely matted by lymph, and
containing pus in the interstices.[146] The lymphatic glands in the groin
were slightly enlarged, and some serous fluid was effused into the
surrounding tissue; the femoral vein and artery were free from disease;
the inner coat of the former vessels, as well as the internal and external
iliac veins and vena cava, had not the slightest trace of increased
vascularity or thickening. The chain of glands from the femoral ring along
the course of the iliac vessels and aorta _on the left side_, were
enlarged, soft, and vascular; several of these lymphatic bodies contained
between the layers of the meso-colon were found enlarged, and to contain
soft lymph. The uterus was of the size usually found at this period; its
tissue dense; the section shows the sinuses still large; the openings on
the internal surface plainly indicated by adherent coagula."
We had been led at that time to suppose that phlegmatia dolens and crural
phlebitis were identical, and that, therefore, this was not a veritable
case of the disease, because no traces of inflammation of the veins were
to be found. The history of the disease; its connexion with the puerperal
fever which had preceded it, the examination after death, and the inflamed
state of the cellular tissue which was perforated by lymphatic trunks on
their way from the thigh to the abdominal cavity, plainly show that it
was not only a case of phlegmatia dolens, but that the proximate cause of
this affection is obliteration of the lymphatics, whether from
inflammation of the adjoining vein, or of the layer of cellular tissue
through which they pass.
_Treatment._ As the earlier part of the disease, when occurring in
lying-in women, is invariably accompanied with some form of puerperal
fever, the treatment of this stage will be according to the rules we have
already laid down in the preceding chapter. It is especially towards the
wane of the attack, that any sensation of pain, or even tension about the
hip or groin should be regarded with suspicion, and a careful examination
of the part immediately instituted. The painful spot should be immediately
covered with leeches, and if any pain or swelling be perceptible in the
course of the femoral vein, this must be similarly treated in order to
allay the inflammation; after this, cold evaporating lotions must be
applied; and although we have not yet given it a trial, we would recommend
the application of ice over the femoral ring. If she has not taken calomel
to such an extent as to affect the system, it may now be given for that
purpose; and when the pain has ceased, the part may be covered with a
plaster of camphorated mercurial ointment. As the disease, in most
instances, is a local affection consequent upon a general one, which has
been more or less subdued, by the time that this has appeared, it will
frequently be necessary to combine the local depletion and exhibition of
mercurials with mild tonics, in order to sustain the powers of the system
already somewhat exhausted by the debilitating effects of the puerperal
fever. The diet should if possible be nourishing, and we shall frequently
find that the general symptoms improve under the use of beef-tea, meat,
jellies, &c.
When the acute stage of the disease is past, more powerful tonics, as
quinine, will be required; and now we may direct our attention to reduce
the swelling of the limb; it may be gently rubbed with the compound
camphor liniment for the purpose of stimulating the absorbents. Dr. Hull
has given a useful formula for the same object:--"[Symbol: Recipe]. Ung.
Adipis Suillæ, [Symbol: ounce]jss; Camphoræ, [Symbol: dram]iij; quibus
liquefactis admisceantur Ol. Essent. Lavend. gtt xij; Tinct. Opii,
[Symbol: dram]ij. Fiat Linimentum, quotide ter quaterve utendum." (_Op.
cit._ p. 161.)
Phlegmatia dolens occurring in the unimpregnated state, is generally in
connexion with some malignant disease of the uterus: it has been chiefly
observed in cases of carcinoma uteri, and has evidently been produced by
the absorption of the fetid discharges which attend this loathsome
disease. In all the instances which have come under our knowledge, the
swelling of the leg has been preceded by crural phlebitis; the veins have
been felt through the emaciated integuments like a hard cord running along
the inside of the leg, acutely painful to the touch. A fact connected
with these cases, and for which we are indebted to our late friend and
colleague Dr. H. Ley, tends greatly to prove the manner in which the
disease is produced. The symptoms of it have never been observed so long
as the patient was able to keep up, for by this means a free escape was
allowed to the acrid discharges, which are so profuse in the last stages
of cancer: but when her strength has been so broken down by loss and
suffering that she was obliged to keep her bed, the horizontal position of
her body no longer allowed the vagina to drain itself of the fetid
secretions with which it was filled, and absorption and venous
inflammation have been the result.
In our published lectures, we have mentioned two cases of phlegmatia
dolens, which had been under our care at St. Thomas's Hospital, and where,
in both, the disease had been thus produced during the ulcerative stage of
cancer uteri: the interest of them was somewhat increased by their having
been admitted at the same time, and by their happening to lie next to each
other in the same ward: in one, the attack of crural phlebitis was severe,
and the swelling of the limb very considerable; in the other, the
affection was less severe: we did not take any notes of the cases, and
must, therefore, refer to a similar one which has been recorded by Mr.
Lawrence, and in which, the appearances after death were accurately
detailed. The patient came under his care, on account of shooting pains in
the loins and hypogastric region, which was tender upon pressure; she had
incontinence of urine, and a sanious discharge from the vagina.
On examination, instead of the os tincæ and cervix uteri, a large
irregular ulcerated excavation was found at the posterior end of the
vagina. Shortly afterwards, increased uneasiness was experienced in the
lower part of the abdomen, the right lower extremity swelled in its whole
extent, with pain in the course of the femoral and iliac vessels, and all
the other symptoms of phlegmatia dolens. The disease was treated by
leeches and other antiphlogistic means, and the pain abated considerably;
it, however, returned, and in about three weeks after, she died from a
violent attack of uterine hæmorrhage. On dissection, the fundus uteri was
found somewhat enlarged and firm, the cervix had been destroyed by that
kind of phagedenic ulceration, which is commonly called cancer of the
uterus. The hypogastric vein was closed in consequence of previous
inflammation of its coats, and the same change had taken place in the
internal iliac, the common iliac, the external iliac, the femoral and
profunda veins, as well as in the internal saphena, all of which were
completely impervious. The affection terminated above at the junction of
the common iliac with that of the opposite side, the latter vessel being
quite natural. The saphena vein was closed for a length of about four or
five inches, beyond which it was natural. The right spermatic vein was
closed in its lower half. The coats of the affected vessels, and the
surrounding cellular substance were a little thickened, and their cavities
were plugged by a closely adherent and tolerably firm substance of a light
brown colour; at some parts, the vessels and their contents were of a dark
livid hue. (_Med. Chir. Trans._)[147]