Further Researches on the Pathology of Phlegmasia dolens. By Ro-
bert Lee, M. D., F. R. S., &c.—At a late meeting of the Royal Medi-
cal and Chirurgical Society of London, Dr. Lee read a paper on this
subject. The author commenced his paper by observing that it was not
till the publication of the memoirs of M. Bouillaud, M. Velpeau, and
the late Dr. Davis, that'the true nature of this disease was known. Up to
this period various hypotheses had been advanced respecting the cause
of the swelling in the lower extremities of puerperal women—mere
speculations unsupported by facts; but the cases and directions of the
authors just enumerated demonstrated that the true nature of the dis-
ease consisted in an inflammation of the trunks and principal branches of
the veins of the lower extremities. In papers by the author, published
in the fifteenth volume of the Transactions, the actual condition of the
iliac and femoral veins was ascertained, and he had been led to infer that
inflammation of the veins gave rise to all the phenomena in puerperal wo-
men of phlegmasia dolens, and that it commenced in the uterine branches
of the hypogastric veins, and subsequently extended from them into the
iliac and femoral trunks of the affected side. Other cases had been recorded
in the Transactions, of crural phlebitis following ulceration of the mu-
cous membrane of the intestines. Experiments performed by Pirigott
in 1839, and by Reumert in 1840, on dogs, showed that the action of che-
mical and mechanical irritants was limited to the vein on which the ex-
periment was made, and the extension of the inflammation in the veins
was not common ; and Stanius, who had collated and tested all the facts
bearing on the subject, doubted whether inflammation of venous trunks
admitted of being excited by constitutional causes, independently of local
irritation. A series of experiments on the veins of the lower animals
similar to those just mentioned had recently been made, and a paper on
phlegmasia dolens had been read to the Society during the present ses-
sion, not founded on actual observation of the disease as it occurs in the
human subject, but upon experiments on the veins of the lower animals
in which phlegmasia dolens had never been observed. The object of
the present communication was to submit to the Society the observa-
tions which the author had made during the last twenty-four years in
inflammation of the crural veins. The paper contained the record of
forty-three cases of phlegmasia dolens. The first nine cases were ac-
companied by post-mortem descriptions, and preparations illustrating
the disease; and the author was led, from the whole of the facts thus
adduced, to the conclusions he had formerly expressed, “ that inflam-
mation of the iliac and femoral veins gave rise to all the phenomena of
phlegmasia dolens, and that the inflammation commenced in the uterine
branches of the hypogastric veins, and from them extended to the iliac
and femoral trunks of the affected side.” The next series comprised
the history of twenty cases, which the author thought furnished addi-
tional evidence in favor of this conclusion, though, in consequence of
the recovery of the greater number of the patients, an opportunity was
not afforded of determining by dissection the actual condition of the
crural veins. Nine cases followed, which demonstrated that phlegmasia
dolens might occur wholly unconnected with pregnancy and parturition,
and that in such cases the inflammation likewise commenced in the ute-
rine branches of the hypogastric veins, and followed a course similar to
what occurred in puerperal cases. In some of these the inflammation of
the uterine veins was produced by cancerous disease of the os and cervix
uteri; in others there was no organic diseases of any kind previously
existing. The concluding cases were five, in which crural phlebitis had
followed inflammation of the saphena veins, and of the deep veins of the
lower extremities from fracture of the tibia and fibula, and the pressure
of encephaloid tumors on the thoracic viscera. The author thought that
these cases and dissections, as well as those of the distinguished authors
whom he had cfuoted, proved in the most conclusive manner that inflam-
mation of the iliac and femoral veins was the proximate cause of
phlegmasia dolens, and that in puerperal women this inflammation com-
menced in the uterine branches of the hypogastric veins. It had like-
wise been demonstrated by morbid anatomy that phlegmasia dolens was
a disease which might take place in women who had never been preg-
nant, and even in the male sex, and that, under all circumstances the
proximate cause was the same.
Dr. Mayo inquired if, in the cases of phlegmasia dolens recorded by
Dr. Leo, any peculiarity antecedent to the inflammation of the veins
had been noticed ?
Mr. Streeter asked if Dr. Lee had statistical information to give re-
specting the comparative frequency of the disease ?
Dr. John Clark enquired if phlegmasia dolens, in the common accep-
tation of the term, and independent of other disorders, was always the
result of inflammation of the veins. He thought the disease generally
was very mild, and, in the experience of writers on the subject, not a
fatal one.
Dr. Mackenzie said, that in the discussion of such questions as that
which is now before the Society, it appeared to be important to distin-
guish between the facts which are alleged and the conclusions which
are drawn from them. Now, in the present case, the facts alleged are
that certain lesions of the crural veins are developed in the progress of
phlegmasia dolens. The conclusions are that such lesions constitute the
essence or proximate cause of the disease. He (Dr. Mackenzie) assented
fully and entirely to the first of these propositions, whilst he dissented
as fully and entirely from the latter; and as he was unwilling to enter
upon the discussion of this question in a controversial spirit, he would
make no reference whatever to the investigation which he had lately
submitted to the Society on the subject of this disease, but would con-
fine himself to a statement of such facts as were known to the profession,
which appeared to him to be opposed to the theory of the disease which
had been affirmed by Dr. Lee. The disease known as phlegmasia dolens
was a very complex malady. It was one which was characterized not
only by a morbid condition of the veins, but by a morbid condition of
the sensciry, the motor, the lymphatic, and the secretory organs of the
affected extremity also : and, accordingly, in all well-marked cases of the
disease there was exquisite sensibility of the limb, especially in the
track of particular nerves, loss of motor power, amounting sometimes to
perfect immobility of the extremity, inflammation and obstruction of
the lymphatic vessels and glands, and a general hot, tense, and elastic
swelling of the limb, not simply arising from oedema, but possessing
rather the character of active exudation than of passive effusion. Now,
could all these lesions depend upon or be deduced from mere inflamma-
tion and obstruction of the principal vein of the extremity ? Were they
ordinarily observed in cases of simple uncomplicated phlebitis ? Or, if
not, was there anything in the anatomical or physiological characters of
the veins to justify our deducing ci priori from it ? And if we replied
to these questions, as he submitted that we must, in the negative, he
should ask whether those who adopt this theory have undertaken any
particular investigation for the purpose of determining this point ? Or,
in other words, have they reproduced the lesion of the veins in a simple,
uncomplicated form, and observed such consequences to follow. Now,
to these questions we must also reply in the negative, and it must be
added that the whole matter rested purely on assumption. It had been
assumed that because the crural veins were found obviously diseased in
fatal cases of phlegmasia dolens such lesions constituted the proximate
cause of the disease. No further steps had been taken to establish the
truth of this doctrine, and that, therefore, had been taken as a matter of
assumption which ought to have been made a matter of demonstration.
Further, he would observe that the clinical history of the disease and
the progress of symptoms did not support this theory. It was quite
true that in some cases the first irritations commenced in the region of
the femoral vessels, but in others it was far otherwise; in some they
commenced in the back, in others in the hip, sometimes in the calf of
the leg, and more frequently in the popliteal region. Again, one leg
might be affected alone, or both concurrently ; or the disease, after
having attacked one, may pass on to the other, or a superior extremity
might be affected; and he had lately met with a case in which, after
symptoms of the disease had successively declared themselves in the left
lower and upper extremities, the malady ultimately established itself in
the right arm, the whole right upper extremity being hot, swollen, and
tense, the surface exquisitely painful, with loss of motor power, and a
tense, corded condition of the the basilic vein. Now, it appeared to him
that these facts were inconsistent with the theory that the proximate
cause of the disease was essentially inflammation of the crural veins.
They pointed to the existence of some more general and diffusive cause,
in regard to which it was probable that phlebitis itself was but a se-
condary affection. Again, he would point to the general experience of
the profession as being opposed to this theory. It was now upwards of
thirty years since it was first promulgated by his friend and teacher, the
late Dr. David Davis ; and although the facts upon which it rested were
well known, it was yet very far from being generally adopted. Thns, in
this country Dr. Burns affirmed that the nerves were as much affected
as the veins. Others regarded the lymphatic vessels as being princi-
pally affected; whilst many, dissatisfied with these restricted views of
the pathology of the disease, preferred the theory of the late Dr. Hull,
that it consisted in a general inflammation of the several organs and
structures of the affected limb. So again, on the continent, the greatest
difference of opinion existed respecting its nature and pathology; and
whilst many affirmed that it consisted essentially in inflammation of the
lymphatics, and others that it was a specific inflammation of the cellular
tissue, nearly all agreed that in its general characters it differed widely
from ordinary phlebitis. Now, this diversity of opinion existed not-
withstanding that all were aware of the facts upon which the phlebitic
theory of the disease rested, and it afforded a powerful argument against
it, because it tended to show that when tested by general experience,
and considered irrespectively of particular facts, and free from bias, it
failed to account rationally for all the known phenomena of the disease,
and consequently could be regarded as its proximate cause. Then in
the sequela of the disease circumstances are met with which are incon-
sistent with this theory. We know, for instance, that after an attack
of the disease, the crural veins were generally left impervious or oblite-
rated, and yet it would happen that successive attacks of the disease
might occur in the same extremity. Now, if it was true that the first
attack left them in the condition described, it was difficult to understand
how, having functionally ceased to exist, they could again take on func-
tional activity, and become the seat of active inflammation. So also it
happened after an attack of the disease, that the limb would be left for
many years, or even for the remainder of life, in a weak, sensitive, and
irritable condition, being easily affected by atmospheric and constitu-
tional influences. It was easy to reconcile these facts with the notion
that the nerves had been injured or damaged by the attack, but not with
the idea that the veins alone had been affected. On all these grounds,
then, it appeared to him (Dr. Mackenzie) that the phlebitic theory of
the disease was either defective or erroneous. But assuming for a mo-
ment that it was correct, he would yet observe that it left much which
was still to be explained. We had yet to learn the nature of that pecu-
liar inflammation of the veins which was so exceptional and so different
from ordinary phlebitis. Did it depend upon some peculiar disposition
on the part of the venous coats to take on diffusive inflammation, or did
it depend primarily upon the blood ? If we adopted the first of these
theories, we were bound to state the nature of the peculiarity, and the
laws of its development. For to be satisfied with merely giving it a
name and to speak of it as a “ specific” inflammation was not to advance
our scientific knowledge, but rather to take refuge, or to hide our igno-
rance under the shadow of a name. If, on the other hand, we accepted
the latter view, and regarded the venous inflammation as dependent upon
some morbid condition of blood, then, indeed, we might reasonably ac-
count not only for the peculiarities it presented, but for all the several
lesions of other organs, and the structural changes with which it was
associated. Upon this view also we might reconcile the conflicting
opinions respecting the nature of the disease which had been held by
different pathologists, and the variations which it manifested in its symp-
toms and progress in different cases. But in accepting this view we
must forego the theory that phlebitis was the proximate cause of the
disease, and regard it, as it really was, as a secondary rather than a pri-
mary phenomenon ; related to the other lesions of the extremity not so
much in the order of cause and effect, but as being like them a parallel
effect of some more general and diffusive morbific agent.
Dr. Lee, in his reply, entered into the literary history of the disease
under discussion, from the time of Mauriceau to the present. He par-
ticularly dwelt upon the facts originally published by the late Dr. Davis,
and showed at great length his (Dr. Lee’s) own labors in this disease.
In answer to Dr. Mayo, he said that there were no antecedent symptoms
calling for any treatment. He knew nothing of the comparative fre-
quency of the disease. In respect to the views advanced by Dr. Mac-
kenzie, he could only say that, whilst he (Dr. Lee) admitted that there
might be a blood disease present, it was consecutive to the inflammation
in the veins. That inflammation was in reality the proximate cause of
the disease. The scalpel had shown this; he thought that was sufficient,
and could not understand what further was required.—London Lancet.