A System of Midwifery

by Edward Rigby

“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.