Various theories have been formed in reference to this disease of the puerperal state, from its symptoms in the living subject; and very different views have been even propagated with regard to its anatomical relations. The ancient and modern dicta that were based upon anatomical investigations may almost all be viewed as the result of preconceived notions, and of examinations, undertaken with a view to establish favorite theories, or conducted without the necessary distinction between essential and accidental circumstances being observed. It is only of late that the subject has been examined in the dead body with an unprejudiced and discriminating judgment, and that an anatomical basis has been obtained, which, though it may not be applicable to all conditions that are included under the head of phlegmasia alba dolens, and though it may not always have been properly interpreted, still appears to afford sufficient security.
Two lesions seem to be essentially connected with this affection. It either depends upon an inflammation of the veins of the inferior extremity, and especially of the crural vein, or upon an inflammation of the cellular tissue, which gives rise to the most various products. The latter form is particularly likely to cause the characteristic symptoms which a so-called sero-lymphatic or sero-purulent product, i. e. fibrinous or purulent exudation diluted by a large amount of serum, induces. It is characterized by very slight reddening and vascularity, and must be considered as an exudative process. In this shape it often extends to the crural fascia, the neurilemma, the lymphatic vessels, and is sometimes complicated with exudations in the synovial capsules of the knee and the hip-joint. As we have already observed, it gives rise to the most various products, and terminates accordingly in tedious oedema, in sclerosis, suppurative fusion, and gangrenous destruction of the cellular tissue. It proceeds from a primary or secondary dyscrasia of the female, and is in either case generally combined with various other puerperal processes. This form of phlegmasia alba may, like the one that originates in phlebitis, occur, if similar causes prevail, independently of the puerperal state, in unmarried women and men; and we find this to be particularly the case as a result of exanthematic and typhous processes, of the most various exudative processes, of cholera, dysentery, inflammation of the lining membrane of the vessels, of endocarditis, etc. The disease may attack the upper extremities and even the trunk, though in the puerperal state it generally affects the lower extremities. It occasionally proves fatal by its sequelae, but more frequently by the associated puerperal processes. Crural phlebitis generally passes from the uterine to the internal iliac vein, and either attacks the deep-seated or superficial veins, or both. An inflammation of the lymphatic vessels is often superadded.
Summary of the Anomalies in other Organs, accompanying the above-described 'processes.
Besides the changes which occur in the original seats of the puerperal processes hitherto examined, there are so many, important, and various anomalies in other organs and tissues, that it is not sufficient merely to give a supplementary account of the anatomical results, but that as copious an explanation of them as possible, becomes necessary. We shall, in the first instance, describe and account for the general appearance of the body, and the individual organs, and then arrange the separate morbid processes as much as possible in groups, according to their mutual resemblance.
The dead subject presents a remarkable disfiguration of the countenance, tumefaction and discoloration of the external genitals, excoriation, ulcerative destruction of various characters, with or without laceration of the perineum, various vaginal discharges, tympanitic distension of the abdomen, a livid erythema of the common integument at different parts of the body, white and often large coalescing miliary vesicles on the thorax and abdomen. Yellow, greenish, bilious, feculent, chocolate-colored fluids escape from the mouth.
The abdomen presents, in most cases, even if the peritoneal inflammation has been slight or entirely absent, a tympanitic distension of the intestines; this symptom is most developed in universal peritonitis; the entire intestine is then so much distended by gases, that it causes impressions upon the uterus, and forces the epigastric contents of the abdomen into the cavity of the diaphragm, and with the latter into the thorax as far as the fourth and third ribs. The firmer the exuded (plastic) matter, the more firmly the intestinal coils and the other abdominal organs are agglutinated to one another and to neighboring organs. The coagulable lymph is chiefly contained in the lower segment of the abdominal and pelvic cavity, but also in the lateral parts, of the abdomen, between the mesenteries and in the vicinity of the large epigastric viscera, within spaces that have become more or less circumscribed by the adhesions. It not unfrequently causes, especially on the surface of the liver, shallow depressions, and gives to the superficial layer of this organ, if of a purulent and sanious character, a greenish, and to the spleen a blackish, tinge. The reddening and vascularity of the peritoneum are generally inconsiderable; but most evident at those parts, which are free from pressure, and take the form of narrower or broader striae. The membranes of the intestinal canal are all tumefied, the interstitial cellular tissue infiltrated, the layers easily distinguishable and lacerable. The intestine generally contains, in addition to a large quantity of gas, a yellow, serous, feculent fluid, which mounts up to the duodenum and stomach. This fluid is in part the product of an exudative process that occurs in the greater part of the intestinal mucous membrane, and which we shall have occasion subsequently to examine more closely. The duodenum and the stomach may also be found to contain a copious amount of yellowish-green or intensly green biliary fluid.