PHLEOMASIA ALBA DOLENS.
This affection has been variously considered as due to a milk metastasis, as a disease of the lymphatic system, a rheumatic, or renal manifestation, a phlebitis, and by Virchow as the result of a physiological thrombosis. To-day it is believed to be a phlebitis, but of a peculiar kind. In the vast majority of cases it is followed by recovery.
It is a late accident of the puerperium, and rarely appears before the twelfth to the fcurteenth day, often later, and although at times it appar ently follows on pelvic or abdominal affections, most frequently it is pri mary, overtaking the woman at a time when she believes herself out of all possible danger. We have seen three cases where it did not appear till the twenty-first to the twenty-fifth day.
Hervieux mentions a sort of prodromic period, characterized by re peated chills, general malaise, more or less intense fever, anorexia, dis quietude. We have never noted it, and in our experience the affection always developer suddenly.
The first symptom is pain, either at the outset faint and heavy and slowly becoming acute, or else acute from the start. Sometimes this pain first appears in the popliteal region, sometimes in the groin, often at the ankle, and then progressively invades the entire limb, either ascending or descending. By following the line of the pain it is found to corre spond to the deep vessels of the limb, and frequently a hard cord is to be felt, even at the outset, corresponding to the inflamed vein. The in flammation of the vein is all the more pronounced to the touch the less in degree the swelling, which shortly seta in. The vein, in any event, can always be felt either in the popliteal space, or in the groin. The pain is aggravated by motion.
The edematous swelling of the limb is either slight or enormous. The limb may double in size, and it pits on pressure. The skin is tense, shiny as though transparent, and often looks as if it were the seat of a true reticular lymphangitis. At the same time slight fever appears, usu ally not preceded by a chill, but only by chilly sensations.
Ordinarily, the edema stops at the root of the leg, but it may extend to the hypogastrium. We have seen an example in a case of double phlegmasia. It is not rare to find the phlegmasia invading both the
lower limbs. Usually the second limb is seized when the process is on the point of disappearing from the first, although not infrequently both limbs may be affected at the same time, in the one limb the process being a trifle in advance of that in the other. In one of our serious cases the edema extended successively from below upward to the groin of the left leg, thence to the hypogastrium, thence to the groin of the right leg and down it. In this case then the edema followed an ascending course in the left leg, and a descending in the right, and for five to six days there was present in addition great depression and high fever, which made us anxious lest grave complications were going to set in. The patient, however, made a slow recovery. She has since been confined twice; in her second labor she had a slight phlebitis in one leg; in her third the phlegmasia reappeared on the twenty-third day, invaded both limbs, and disappeared only at the end of many months.
Recurrence, indeed, is very frequent at succeeding confinements, but in general, the phlebitis becomes more benign each time. The duration of the affection is very variable. Ordinarily the fever lasts only twelve to fifteen days, in mild cases, and the pain persists to a greater or less degree during the entire febrile state. As the latter disappears so does the pain. It is exceptional for the edema to vanish before the third week. Often it lasts for a long time, even for months or years, thus in terfering considerably with walking. In one of our patients it was only after the lapse of two years that the limb regained its integrity.
In the vast majority of instances the disease ends in cure, although a number of cases of death have been recorded. Death, when it occurs, results either from suppuration of the vein and consecutive purulent in fection, or else a clot is detached and the patient dies of embolism. The end is slow in the first instance, and very sudden, or nearly so, in the second.
Finally, in certain cases phlebitis is complicated by periphlebitis, a true phlegmonous inflammation of the leg and the thigh. We recently saw an instance after miscarriage at four months.