Remarks upon Phlegmasia Dolens, or Milk Leg, in Typhoid Fever, Especially as Observed among Soldiers
Boston Medical and Surgical Journal
Gentlemen: -This morning 1 shall call your attention to phlegraaaia dolens, phlebitis, or milk leg, in typhoid fever, especially as it is illustrated by cases in the ward occurring among soldiers. The first two cases among those who kindly consented to come before you were brought here from camp suffering from typhoid fever, and passed through the attack of fever without its being marked by any special event; but, at the end of the fever, they developed the peculiar complication, milk leg. J
... ion, milk leg. J shall give you only a summary of the history of these cases : Case I. A. E., twenty-one years of age. When admilted to the Pennsylvania Hospital, September 16th, lie was brought from cam]), where he had been ill for about six weeks. He stated that when his illness had lasted for two weeks, he got out of bed and was up for two days, during which time he had improper diet. Ho then was obliged to return to bed, and a few days later he had intestinal hemorrhages. He remained in bed for four weeks and slowly convalesced. The temperature was normal on admission, the tongue clean. The heart, liver and spleen were not enlarged, nor did they show anything abnormal ; at the base of the right lung, prolonged expiration, increased vocal frcniitiis and resonance were observed, but no rales. The abdomen was tender all over ; the urine contained no albumin and no casts. There was a bed sore over the sacrum. The patient Was emaciated, anemic, and weak. The Widal blood-test gave the typhoid reaction. Double epididyinitis appeared on the 24th, but soon yielded to warm applications. On the 30th he was allowed to sit up ; a small abscess on bis scalp was opened. He sat up daily until October 7th, gaining in strength and improving in appearance. At this date the scalp was well and the bed sore was smaller. He now developed pain and swelling of both legs ; from the saphenous opening to the ankles the veins felt hard and were tender upon pressure. The symptoms having all subsided, a week later, October 15th, be was allowed to sit up tor a few In airs. The legs again become swollen and edematous ; be had prickling sensations in the feet, and there was also a sense of numbness. October 31st. He has been in bed since the last note. The bed sore is entirely well. As soon as he resumes the erect position the edema in the feet returns. The temperature is always normal. Since October 8th he has been taking the fluid extract of ergot, half a drachm, three times a day, and elevation of the, limbs has been practised, with hot fomentai ions daily. These as well as the elevation of the limbs have been, indeed, insisted upon since the swelling manifested itself. November 18th. He has steadily improved since the last note. Nitroglycerin, l-100tli of a grain, was substituted for the ergot. November 23d. The Widal test was again made, with positive results. November 30th. As be complained of headache, the nitroglycerin was discontinued. An oitment of belladonna and of camphor has been applied along the course of the veins. The legs now show no tendernesss above the lower third, the feet are still tender. There is no edema, and no cording of the veins. The patient is sitting up. In the case just shown the phlegmasia dolens was double, and so it was in this case : Case IL E. C. B., twenty-six years of age, was admitted to the ward October 26, 1898. He had been ill 1 Clinical lecture delivered at the Pennsylvania Hospital. since the 1st, but had not felt quite well for two months previously. The prominent symptoms were fever, frequent chills, diarrhea, headache, vomiting, and pain in the back and limbs, lie had no cough or nose bleed. The temperature on admission was 102°, the pulse 96, the respirations 20. The pulse was regular but dicrotic ; the mind was clear, the body emaciated. The tongue, tremulously protruded, was slightly coated. No symptoms referable to the heart and lungs were observable. The abdomen was scaphoid but soft, aud was covered with rosespots. The spleen was large and palpable, and pain was elicited by pressure. The liver was large, not tender ; gurgling was produced upon pressure in the right iliac fossa. The urine contained no albumin or casts, was acid in reaction, and the specific gravity 1.030. The Widal test gave a positive reaction. After a bath the temperature fell to 97°in the axilla. The case ran its course as one of typhoid fever of average severity. No new or remarkable symptoms were observed until the fortieth day of the disease, when the temperature went up to 101.6°. He had pains in the calf of both legs and along the course of the veins, but no tenderness in the thighs; the legs were tender and somewhat swollen. Treatment by elevation, hot applications, and rest in bed was pursued, and on the 15th of November the tenderness had nearly gone. There was no edema; lie felt well, and was very hungry. The Widal test, repeated on November 23d, again gave a positive reaction. The symptoms gradually disappeared, and the patient was discharged, cured, on December 1st. Gentlemen, phlegmasia dolens in typhoid fever is not a common occurrence. Murchison, in his classical treatise, estimates it at one per cent. The general proportion of cases presenting the complication iu this hospital is not more than one to two per cent. But among the 215 cases of typhoid fever in soldiers brought here we have had ¡50 cases in which it occurred, or almost 14 per cent., aud of 135 cases that were under my direct control or came under my observation after the febrile process had run its course there were 18 cases, making a proportion of üi-fc per cent. You may be interested to know that of these 18 cases, in three the left leg, and in two the right leg, alone was affected ; in thirteen the disorder showed itself in both legs, beginning, however, generally on the left Bide when not manifesting itself simultaneously in both. But, without going further into this point, it is certainly remarkable that for some cause which I cannot adequately explain these soldiers have shown a much greater tendency to the complication of phlegmasia alba dolens in typhoid fever than we usually meet with iu private or in ordinary hospital practice. Wo may, perhaps, attribute it to the fact that the venous system in the legs had become relaxed and distended by marching, and that this predisposed them to the disease. Yet, excepting some from Porto Rico, these soldiers came here from training camps, where marching, after all, was not excessive, though much more thau men just from civil life were accustomed to. We must also, 1 think, take into account the gravity of the blood infection, for nearly all the cases occurred iu those in whom the typhoid fever had been very severe. As regards the time of the appearance of this complication, let me state that it occurred mostly at the end of the fever or in early, sometimes in late, convalescence. This lias also been my experience in these wards for many years. 1 cannot recall a single instance in which milk leg occurred at the height of the fever. It is therefore a disease of the close of the fever, or of convalescence. In one of the cases which you saw, it came on at tho fortietli day ; iu another, not before The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at UNIVERSITY COLLEGE LONDON on June 28, 2016. For personal use only. No other uses without permission. From the NEJM Archive.