A System of Midwifery

by 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 œdematous 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 œdematous 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.