some areas the wall is thicker, opaque and less vascular, and beneath these areas the contents is thicker, more jelly-like, and contains fine flakes. In other portions the fluid is thin and straw colored and in certain lobules is mucilaginous, and in a few it is blood-stained.

Diagnosis.-Parovarian cyst.

Subsequent History. The patient had a rise in temperature immediately after the operation, the temperature ranging from 100° to 102° the first two days. The pulse also was rapid, the rate being from 120 to 146. In a few days she improved and had an uneventful convalescence. The gauze from the culdesac was removed by installments on the fifth and sixth day. The stitches were removed on the ninth day, and the patient sat up in bed on the twelfth day. On the fifteenth day she left the hospital on a cot; everything was well healed, and the patient was feeling well. desired to go home to regain her strength.

case.

Remarks.-There are a few interesting points in connection with this First, the question of ascites. This does occur with ovarian cysts, but still is rather rare when compared to its frequency of occurrence with solid tumors of the ovary. To the operator it usually gives a suspicion that the disease may be of a malignant nature. Another interesting point is the occurrence of the cystic growth attached to the omentum and intestine. In the gross it looked as if it might be a part of the original cyst, but yet it had no connection at all with the tumor. Of course, the question came up as to whether this might be a secondary focus.

The peritoneum showed something of interest also. It suggested somewhat the condition known as pseudomyxoma peritonei, only it did not have the usual rich deposit over the entire peritoneum. Still there was some deposit in certain areas by which the intestines were glued together.

The pathologic examination did not reveal any evidences of malignancy. It is always of interest to watch such cases as these, and both the patient and a relative were requested to keep the department informed as to the patient's condition at regular intervals. So many more per cent of ovarian tumors are malignant than was formerly supposed, that it is always wise to give a guarded prognosis, especially if there are some signs which give a suspicion of malignancy.

THROMBOPHLEBITIS AND ITS RELATION TO PHLEGMASIA ALBA DOLENS.*

MELVIN D. ROBERTS, M. D.
HANCOCK, MICHIGAN.

PATHOLOGICAL conditions of the veins have received scant attention in comparison with those of the arteries. In a general sense the same disease processes are found in the veins as in the arteries, but owing to the thinner, weaker structure of the vein walls, inflammatory changes are much more common to the veins than to the arteries. Inflammatory processes may *Read before the Upper Peninsula Medical Society, at Calumet, August 3, 1909.

originate within or without the veins. Owing to the thinness of their walls, we may assume that all three coats are affected at the same time.

Phlebitis may be regarded as a lymphangitis of the vein wall, as the inflammatory processes extend along the lymph spaces and vessels with which the wall is richly supplied. As soon as the phlebitis extends to the intima of the vein, thrombosis results. This condition is known as phlebothrombosis. As the origin is from without, the condition is also termed extravascular. In those cases where the phlebitis results from the thrombosis, the condition is known as thrombophlebitis, and is also termed intravascular and hematogenous.

The relation that thrombophlebitis bears to phlegmasia dolens is an interesting one, and is a condition over which considerable divergence of opinion exists as to its etiology. My interest in the subject was aroused by the following case, in the treatment of which I am reasonably sure every antiseptic and aseptic precaution was observed:

The patient, Mrs. C., aged twenty-five years, is of German-American parentage, and married about one year. At the time of her marriage her weight was one hundred and thirty-five pounds, and she has always been in excellent health. She first consulted me on August 28 of last year. The symptoms were those of a slight bowel disturbance incident to a change in climate. Her first menses appeared at the age of seventeen, have always been regular, the periods occurring every twenty-five days. The usual length of period was five days, the amount and color being normal. The last menses appeared on August 12, 1909.

During gestation her health was normal, there being but very little nausea, which appeared about the sixth week, and continued for a short period. She was not confined to the bed for a day during her pregnancy. In fact, she was very active, took outdoor exercise, was cheerful, not nervous, and felt perfectly well up to the beginning of labor pains. On the 25th of May the patient began to feel occasional nagging pains, which lasted. throughout the day until about 6 o'clock, when they became more regular. These pains lasted all night, but were rather weak, until the following morning, when they became stronger, until about 10:45 A. M., the patient. was delivered of a nine pound female child.

Following the birth of the child there was considerable flooding and as it continued rather freely, it seemed best to express the placenta, although great care as to asepsis was taken in this procedure. The placenta was expressed by a modified Credé method. All clots were removed and the hemorrhage soon ceased through kneading the uterus, and by the administration of one dram of the fluid extract of ergot. An examination of the parts revealed a small laceration of the perineum, which was repaired at

once.

On the following day the patient seemed to be doing nicely. Both patient and child were under the supervision of an experienced nurse. The patient's breasts began to fill upon the third day, accompanied by a slight

rise in temperature (101.5°). The fifth day the patient complained of an aching and pain in each calf. Slight swelling was observed in the left leg upon the seventh day. At this time the temperature was 101°, pulse 130. Vaginal douches of bichlorid solution, one to two thousand, were instituted, followed each time by a douche of sterile water. The lochia was scant, and of a disagreeable odor. On the eighth day, as the pulse was rather weak and irregular, the child was removed from the breast, and the mother was given one-fortieth grain of strychnine ter in die, and two-drop doses of tincture of digitalis, every two hours.

On the ninth day, as the temperature remained rather high, I feared perhaps part of the placenta might have been retained, so after anesthetizing the patient I curetted the uterus. The result was negative except that the lochial discharge became freer. As the cervix was somewhat lacerated, it curetted thoroughly. During and following the operation a thorough douching with bichlorid solution, one to four thousand, was given.

On the tenth day the stitches were removed from the perineum, and good repair had resulted. The temperature remained from 100° to 101.5°, until the fourteenth day, when all pain and the slight swelling in the left leg had disappeared.

On the fifteenth day the patient felt very well; temperature and pulse very good, and I considered her to be making a recovery. In the following three days, however, the temperature began to ascend (100° to 101.5°, with the pulse 100 to 115), until upon the nineteenth day there was intense pain and some swelling in the right leg. The symptoms were similar to those of the left leg until the twenty-fifth day, when the pain ceased, the swelling had disappeared, and the temperature had fallen to 99° and the pulse to 90.

On the twenty-seventh day stimulants were dispensed with, and the child was returned to the mother's breasts the following day. The breasts had been kept secreting by artificial means. The pulse and temperature reached normal on the thirty-first day. As far as local treatment was concerned, this consisted of elevation of the limbs and absolute rest.

The differentiation between phlebitis with secondary thrombosis, and thrombosis with secondary phlebitis, is in the majority of cases impossible. Neither the nature of the primary affection, the character of the fever, the pain, nor the late appearance of the symptoms in the course of another disease can be considered pathognomonic signs. Some writers upon this subject refer to one or both varieties under the common head of phlegmasia. So, in considering this condition, and in giving a résumé of the theories of those who have made a study of this pathologic process, it will be convenient. at one time to refer to thrombophlebitis, at another to phlebothrombosis, or at times to refer to the subject under the name of phlegmasia.

The question is, "What are the causes of thrombophlebitis in the veins. of the lower extremities, and its resulting symptoms commonly known as phlegmasia, and what is the treatment for the condition?"

Thrombophlebitis of the femoral vein is undoubtedly associated with phlegmasia, but the etiology of the condition is a subject upon which few authorities agree. Fortunately phlegmasia is a rather rare complication, and it is not the ill fortune of every physician to have met with it. I have been able to collect the reports of seventeen cases, and out of that number, nearly one-half of the physicians advanced theories as to its etiology other than that commonly accepted at the present day. It seems only fair to say, that in comparing the various theories, there is truth in all; but it seems to me that the contention arises from the fact that some try to class the etiology of all cases under one head, whereas, if one admits that there are causes instead of one cause alone, the subject becomes much more logical and much less confusing.

In order to refresh our mental picture of this condition, let us review briefly the symptoms of phlegmasia. As a greater part of these cases follow childbirth, let us reckon from the time of delivery in ascertaining the time that may elapse before the first symptoms are noted. Although phlegmasia may antedate delivery, it usually occurs from the tenth to the thirteenth day. It may occur subsequent thereto, as late as the seventh week.

The typical symptoms begin with a stiffness and heaviness in the leg, usually the left, with pain especially in the calf of the leg. This is soon followed by swelling which gradually ascends from the ankle to the groin. There is likely to be tenderness along the course of the femoral vein, which may be marked by a line of inflammatory redness. Other superficial veins. may have a like appearance. The lymphatics may be involved. Moderately high, irregular, and continued fever, associated with a rapid, compressible pulse accompany the swelling. These two symptoms disappear commonly before the swelling subsides. The limb presents a white, swollen, glistening appearance, and is hard, elastic, and does not pit on pressure. There are the usual symptoms of gastric and intestinal disturbance, foul tongue, loss of appetite, nausea and vomiting. Profound physical depression is present, sometimes great restlessness and sleeplessness. The face may present a dusky flush.

The condition with the above typical symptoms has long been recognized, but the causative factors have as long been a problem among medical

men.

Theories as to the Etiology of Phlegmasia.-As early as 1784 White advanced the theory that the condition was due to an obstruction, or some morbid process of the lymphatics, and the glands of the parts attacked. In 1817 Davis, in an autopsy, found evidence of extensive inflammation of the veins. In 1829 Lee succeeded in tracing the inflammation into the uterine branches of the hypogastric veins, and gave it the name of crural phlebitis. In 1843 Holmes advanced a theory more nearly that which is generally accepted today, but it did not meet with popular approval. In 1847 Semmelweiss called attention to puerperal infection. This was followed by the work of Pasteur and Lister, who in giving the nature of puerperal infection,

pointed out the way later in the '70's to Mackenzie and Tyler Smith who advanced the theory that phlegmasia results from contagious infection. Smith considered that a woman so attacked escaped a greater danger of diffuse phlebitis or puerperal fever. Tillbury Fox concurred in this theory, but King held the condition to be a primary affection of the lymphatics, and the venous manifestations merely secondary to the original malady. About this time Mackenzie came to the conclusion, from a series of experiments, that phlegmasia is aggravated by a vitiated condition of the blood. Andral and Gavarret found the fibrin of the blood diminished during the first six months of pregnancy, but during the later months greatly augmented, assuming the characteristics of blood present in inflammatory conditions.

A modern writer holds that the condition of the bowls exerts an important influence over the blood, lymphatics, and tissues in general. He supports this theory by stating that a chronic catarrhal condition of the bowels. may extend to the pelvic tissues during gestation, producing a semicellulitis, and an atonic condition that is too weak to support a reparative action. In this condition, after the separation of the placenta, the uterus is not properly cleansed of its lochia, forcing the system to the other alternative of absorbing it. He further states that the time of incubation depends upon the degree of cellulitis, lymphangitis, quantity of septic absorption, the placental separation, and the resisting force of the tissues. With the appearance of the disease it should be remembered that it begins by increasing the inflammation of the already inflamed lymphatics and pelvic tissues.

Another author points out that the veins of the uterus and of the surrounding connective tissues are prone to thrombosis by reason of the sluggish circulation, pressure during pregnancy, and the altered constitution of the blood during the puerperium.

The Varieties of Phlegmasia.-There are two distinct varieties of phlegmasia, the one primarily thrombotic and the other cellulitic.

The cellulitic variety consists of a septic inflammation of the connective tissues of the pelvis and thigh, spreading from the perineum and the deeper pelvic fascia. This form offers a satisfactory answer to the theory of lymphatic infection and extension. It also explains some of those cases, perhaps, where it is claimed that no thrombosis is present. The cellulitic variety gives rise to the extravascular infection of the vein, the result being, in most cases, phlebothrombosis. This form of thrombosis is rare. In this variety the swelling extends from above downward.

The more common variety is that of thrombophlebitis. There are cases where the thrombosis is primary, and no infection exists. Thrombosis has occurred before delivery, and those cases may be said to be due to the pressure to which the vessels of the extremities are subjected during pregnancy, along with the stagnation of the blood current, and the relative increase of fibrin in the blood stream.

Thrombophlebitis Not Following Delivery.-It is certain that the condition of the blood favors thrombosis, and that thrombophlebitis of the