Edward Rigby

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:—“?. Ung. Adipis SuillÆ, ?jss; CamphorÆ, Ziij; quibus liquefactis admisceantur Ol. Essent. Lavend. gtt xij; Tinct. Opii, Zij. 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]