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Thrombosis of the veins of the lower extremity and pulmonary embolism as a complication of trauma
THROMBOSIS OF THE VEINS OF THE LOWER EXTREMITY AND PULMONARY EMBOLISM AS A COMPLICATION OF TRAUMA B. M. NEW
VANCE, YORK
0
a thrombus forms CCASIONALLY in one of the veins of the lower extremity and becomes an embolus which occIudes the puImonary artery. When this occurs death follows immediateIy from acute asphyxia. A great variety of medical and surgica1 patients die as a resuIt of this compIication. It is noted especiaIIy after abdomina1 operations, in the course of pregnancy, in many medica conditions, and as a seque1 to different types of injury. The Iast mentioned group forms a smaI1 but distinct proportion of the causes of death in any Iarge series of traumatic cases. It is my intention here to discuss the incidence of puImonary embolism in the traumatic cases coIIected from the OffIce of the Chief MedicaI Examiner of New York City and to discover, if possibIe, what factors tend to produce this compIication. It is advisabIe at the start to give a brief account of the process of thrombosis and the way in which the thrombus becomes an emboIus. First, thrombosis can be defined as the formation of a cIot in the bIood vesse1 during Iife from the constituents of the bIood. As described by MacCaIIum’ the process starts as a gray transIucent coIIection of bIood pIateIets on the vesse1 waI1, known as the head. On this as a foundation other pIateIets are deposited by the ffowing blood to form rows of Iaminae which run transverseIy to the Iong axis of the vesse1 and project into the Iumen. These Iaminae anastomose freeIy with one another and form a frame1MacCalIum, W. G. A Textbook 3, PhiIa., Saunders, 1926.
of PathoIogy.
M.D.
CITY
work to which adhere numbers of Ieucocytes from the circulating bIood. A thrombopIastic substance is produced and fibrin is formed between the Iaminae. In the fibrin meshwork Iarge numbers of red bIood ceIIs are imprisoned which give the thrombus a predominantIy red coIor. In the earIy stages of the process the Iaminae may project sIightIy above the surface of the growth as grayish corrugations known as the Iines of Zahn. When the thrombus has grown Iarge enough to occIude the vesse1, stasis occurs and the bIood coIIects around the proximal and distal ends of the obstruction, depending upon the distribution of the venous tributaries in these regions. The bIood in either event stagnates from the thrombus to the inflow of the next branch. This coIumn cIots en masse, Iike bIood cIots in a test tube, is dark red in coIor and may resembIe a postmortem cIot quite cIoseIy. This part of the thrombus is attached to the head and is known as the tai1. The growth of the tai1 may stop at the nearest point of inffow or the process may begin again with further pIateIet deposits. It may extend aIong the course of the vesse1 in a dista1 and in a proxima1 direction, continuaIIy growing by accretions to either end of the thrombus. In a vesse1 Iike the femora1 vein it may become as Iong as 13 to 25 cm. and it is usuaIIy as thick as the femora1 vein itseIf, which is about IO to 15 mm. in diameter. In some cases the thrombus in the from its femoraI vein may free itself attachments and traveI through the inferior vena cava and right side of the heart to bIockade the main branch of the
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Vance-Thrombosis
of Surgery
puImonary artery. This event happens in OccasionaIIy the entire various ways. thrombus, if it is coherent enough, may be
FIG.
OcroeEn,1934
In the vast majority of cases the emboIus in puImonary emboIism is composed of bIand, non-septic thrombotic materia1.
I. Long coherent pulmonary emboius.
transported en masse Iike a smaI1 piece of rope (Fig. I) and, because of the twists and turns in the right heart, may be bent, coiIed or even knotted when it reaches the puImonary artery. In other cases the cIot may not be as coherent and, in its journey through the right heart, it may be broken into a number of smaI1 pieces about 2 to 3 cm. in Iength (Fig. 2). In either event the emboIus impedes the flow of bIood through the Iungs and causes death suddenIy and without warning. In some cases the thrombus formed in the femora1 vein is not coherent at a11 and smaI1 pieces may detach themseIves from the vein to form an emboIus to a smaI1 branch of the puImonary artery in the Iung These smaI1 emboIi cause smaI1 tissue. hemorrhagic infarcts in the Iung tissue which may produce symptoms of pain in the chest, expectoration of bIood, etc. Premonitory signs thus are given that a cIot is forming in the femora1 vein so that the death a few days Iater by a Iarge emboIus is not unexpected.
Under the microscope, a section of the emboIus stained with hematoxyIin and eosin shows a homogeneous pink framework of bIood pIateIets with fibrin, red bIood ceIIs and a few Ieucocytes in between. The pIateIet framework is characteristic and if it can be demonstrated satisfactoriIy is proof enough that the structure is a rea1 thrombus. The different factors which contribute to the deveIopment of thrombosis and puImonary emboIism have been discussed at great Iength in the Iiterature. Mcan exceIIent summary Cartney2 gives of the subject in his articIe and Iists three which are considered the most important. (I) Injury to the vascuIar They are: endotheIium which may occur from actuaI infectious processes and toxic trauma, action in generaI. (2) SIowing of the bIood stream which may occur from a genera1 circuIatory disturbance or a IocaI condition Iike a phIeboscIerosis, pressure on a vein, 2 McCartney, 1927.
J. S. Jr. Arch. Pd.,
3: 921 (June)
NEW SERIES VOL.XXVI,
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Vance-Thrombosis
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etc. (3) Changes in the composition of the bIood induced by toxic or infectious conditions which renders the bIood more r - -.‘-
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that period; he considered suppurative and infectious diseases of Iess importance in the causation of thrombosis. As an
“.
FIG. 2. Fragmented
IiabIe to intravita1 cIotting. The injury to the endotheIia1 Iining of the bIood vesse1 generaIIy is considered the most important factor as it forms the nidus for the head of the thrombus. The sIowing of the bIood stream and the changes in the composition of the bIood are important contributory inffuences and aid in the future growth of the thrombus. PuImonary emboIism as a cause of death has received much attention in recent years. RosenthaI in his review has pointed out that there has been a steady increase in the incidence of puImonary emboIism in the cIinics of CentraI Europe from the years IgIg to 1928; after 1928 there was a sIight decrease. He attributes this phenomenon to the period of want and socia1 instabiIity which prevaiIed in these countries during the earIy nineteen twenties and especiaIIy to the rise in the proportion of cardiac and vascuIar diseases during 3 RosenthaI, S. R. Arch. Path., 14: 215 (August)
1932.
pulmonary
emboIus.
added confirmatory support of his point he mentions the fact that in Canada and the United States, where such socia1 conditions did not prevai1, there was not any increase in the incidence of puImonary emboIism during the same period. DESCRIPTION
OF THE
MATERIAL
The materia1 which I present here comprises go cases of thrombosis of the Iower extremity with death from puImonary emboIism due to a11 causes. AI1 of these cases are routine necropsies of the OffIce of the Chief MedicaI Examiner of New York City which were performed because of an obvious association of the death with a definite injury or because the deceased has died under suspicious or unusua1 circumstances. The majority of cases were coIIected between January I, I, 1934, but a smaI1 1924 and January number were added which had occurred in other years.
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This materia1 couId be divided into a number of different types on the basis of the probabIe cause of venous thrombosis and puImonary embolism. They are listed as foIIows : As a complication of a definite injury.. As a compIication of a phlebitis with a traumatic history but without a definite injury.. As a compIication of pregnancy.. . As a comphcation of an operation. . . As a complication of varicose veins. As a complication of other natural conditions. Total.....................................
60
.
6 3
4 7 . IO go
The reason for the preponderance of injury cases is because the OffIce of the Chief MedicaI Examiner is concerned mostIy with deaths which result from a11 sorts of vioIence. The other types mentioned wouId be incIuded in our materia1 at infrequent intervaIs and more or Iess fortuitousIy. Hence only the figures in connection with cases of trauma wouId have any significance in so far as statistics are concerned. Among the cases of puImonary emboIism associated with definite injury were 55 which occurred during the ten years between 1924 and 1934. When these were Iisted in the year in which they died the folIowing resuIts were obtained: Year 1924 1925
Cases 2 6
rgz6
2
1927
4
1928
2
1929 1930 ‘931 1932 1933
4 IO ; 8
In the years preceding the depression, the yearIy average was 3 to 4 cases, but after the depression it was over twice as much. An attempt is not made here to draw any conclusions from so smaI1 a series of cases, but it is suggestive that the cases of puImonary emboIism shouId increase during the years of depression, especiaIIy when viewed in the Iight of RosenthaI’s remark concerning the increase in the incidence of this condition in
OCTOBER, ,931
CentraI Europe from 1919 to 1928. A detailed examination of the 60 posttraumatic cases of puimonary emboIism discIosed the folIowing facts : The race incidence was not significant, as 55 were white and 5 were negroes. The sex ratio was: femaIes 37, maIes 23. In any Iarge series of cases of puImonary embolism, the femaIes outnumber the males. The age incidence onIy confirmed the prevaIent conception that puImonary emboIism is a condition which attacks middIe age for the most part. Taken by decades, the 60 cases were grouped as foIIows: Age in Years 30 40 50 60
to to to to
Cases
39 49 59 6g
4 IO 22
15 8
70 to 79 Over 80
I
The types of casuaIty which the trauma were as foIIows: AutomobiIe injury. .. FaIIs...................................... Hit by faIIing object.. . Blow from revoIving door. BIow during aIterca%on. ..................... Homicidal incised wounds. ................... Bullet wound.. Unknown injury..
produced Cases 36 16
2 I I I I
.
2
The injuries varied from the serious to the sIight; they were aIways definiteenough to persist unti1 the patient died of the puImonary emboIus, but were not severe enough to cause death before the emboIus had time to deveIop. The Iesions produced by the trauma were as foIIows : Cases Fractures of femur.. . Fractures of tibia and fibuIa. Fractures of tibia.. Fractures of Gbula.. . Fractures of pelvis.. . h4isceIIaneous injuries of Iower extremities. Injuries eIsewhere in body.. Total....................................
The injuries
14 fractures of varying
14 I I
2 7 5 I I IO
60
of the grades
femur were of severity.
NEW SERIES VOL. XXVI, No.
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Ten were intracapsuIar fractures of the neck, 2 were intertrochanteric fractures, and 2 were compound fractures of the shaft at the junction of the middIe and Iower third. Seven of these fractures were present in the right femur; in 6 of the cases a thrombus was present in the right femoraI vein or one of its tributaries, whiIe in one case a thrombus could not be found. The remaining fractures invoIved the Ieft femur; in 5 of these cases the Ieft femora1 vein was thrombosed, and in 2 cases no thrombus was present. The I I fractures of the tibia and fibuIa combined showed simpIe fractures present in 8 cases, and in 3 cases compound fractures with a sIight infection around the broken bones. A simple fracture of the tibia was present in 2 cases and simpIe fractures of the fIbuIa were present in 7 cases. In this Iist of 20 cases, the right Ieg was invoIved 4 times; in 3 cases there was a thrombus of one of the veins of the right Iower extremity, and in one case a thrombus couId not be found. The bones of the Ieft Ieg were fractured in 16instances; in I I cases a thrombus was found in one of the veins of the Ieft Iower extremity, whiIe in 5 cases a thrombus couId not be Iocated. Fractures of the peIvis were present in 5 cases. In one there was an acetabuIar fracture on the Ieft side and a thrombus was present in the Ieft interna iIiac vein. In 2 of the other cases a left femora1 thrombosis was found, but it was not located on the side of the injury. In the remaining 2 cases a thrombus was not found. EIeven cases of misceIIaneous injuries of the Iower extremities were described which were Iisted as foIIows:
Ca.W Bullet wound of the right knee. Traumatic arthritis of right knee. Sprained ankle.. . . Lacerated wound of leg.. .. Contusions and abrasions of legs..
. .
I .
..... .. . . . ... ...
I
5 5
A right femora1 vein thrombosis was found in 6 cases corresponding to injuries on the
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right Lower extremity, whiIe in 5 cases a thrombus couId not be Iocated. Injuries eIsewhere in the body were recorded in IO cases. They were Iisted as foIIows :
Cases Fracture of skuI1.. Fracture of skull and ribs.. Fracture of Iumbar spine.. Injuries of chest.. . Fractures of ribs.. . Injuriesofhead............................. Fracture of right humerus., Incised wounds of chest and abdomen.
z I I 2
I I
I I
The Ieft femora1 vein was thrombosed in 3 cases, the right femora1 vein in 4 cases, and the inferior vena cava in one case. In 2 cases a thrombus couId not be Iocated in any of the veins. In this group the site of the thrombus was not reIated to the site of the injury. These facts can be summarized by noting that in cases of trauma to the bones and soft parts of one of the Iower extremities, a thrombus was found in the veins of that extremity in 32 instances. Of these 32 cases, the right Ieg was invoIved 16 times and the Ieft Ieg 16 times. In 14 injuries of the Iower extremities, a thrombus couId not be located. Injuries which did not invoIve one of the Iower extremities were described in IO cases; the thromboses which were found in the veins of the Iower extremities did not correspond with the site of the traumatic Iesion. The Iength of time which eIapsed between the onset of the trauma and death from puImonary emboIism was quite variabIe. The minimum interval was four days and the maximum interva1 was The majority of cases fifty-four days. showed an average which varied between ten and twenty-four days. The significance of this fact is not cIear and can be discussed more advantageousIy Iater. The cIinica1, anatomic and microscopic features of this condition were studied in 21 cases taken from the Iarger group of 60. On these 21 cases I had performed the necropsy and had done a microscopic
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examination on the femora1 vessels and the other organs. The cIinica1 histories tended to faII into different patterns. In aI1, the patient had been in some type of accident and had been incapacitated for a shorter or Ionger time by the injuries received. At the time of their death the patients had recovered from the immediate effects of the trauma or their condition was improving. Sixteen of them died suddenIy in the hospitat ward, 9 were stiI1 confined to bed on account of the injury, whiIe 7 were convaIescing and were up and around the ward. OnIy one of these cases is mentioned as having given premonitory signs; about twenty days after the injury this patient suddenIy deveIoped a friction rub and a pain in the right chest which, at necropsy, was found to be due to a recent pulmonary infarct caused by a smaI1 emboIus. Five of the patients had received injuries which had not incapacitated them unduIy and they died suddenIy at their residences. The individuaIs in this series varied from earIy middIe age to seniIity and a11 types of physica conformation were represented, from the poorIy nourished to the ffeshy type tending towards obesity. In 12 of the 21 cases the emboIus in the puImonary artery consisted of smaI1 cIots measuring about 9 to 13 mm. in diameter and 2 to 5 cm. in Iength. In other instances the emboIi were Ionger and fewer in number. Some were either bent or coiIed or knotted, and often had branches corresponding to the tributaries of the femora1 vein. Microscopic examination of some of these cIots usuaIIy discIosed the charac- p teristic pIateIet framework. In 5 instances recent hemorrhagic infarcts were found in the Iungs, indicating that smaI1 emboIi had preceded the Iarge fata one. Associated morbid conditions of greater or Iesser severity were found in 17 of the 2 I cases. They were: CU.%3 G’eneralrzed artermsclerosrs. .’ Luetic meningitis and aortitis. Thrombosis of a cerebra1 artery ” mfarct...................................
g
2 and cerebral I
OCTOBER. 1934 Cases
Carcinoma of uterus.. Uterine poIyp. PuruIent pericarditis. Subacute infection at point of injury.
I I I 2
The veins of the Iower extremities, however, showed the most significant Iesions. OnIy 5 cases of the 21 discIosed varicose veins on external examination. In the remaining 16 there was no external evidence that the venous circuIation was abnorma1 in any way, even when the main femora1 vein was occIuded by a thrombus. Microscopic examination generaIIy discIosed, however, that some type of inflammation was present in the vein waI1 or in the tissues immediately adjacent. In those cases in which thrombosis was found, the thrombus was confined to the veins of one extremity. The veins of the other Ieg were not thrombosed and did not show any inflammation on section, though the vein waI1 might show a sIight phIeboscIerosis. A cIoser consideration of the veins which were thrombosed showed the thrombus as a red or dark reddish brown clot distending the vein or simply attached to the waI1 as a smaI1 mura1 growth. The Iarger veins in about 80 per cent of the cases showed a definite phIeboscIerosis, that is, there was fibrous thickening of the waII and fibrous pIaques on the intima. In most cases there was an inff ammatory infiItration of Iymphocytes and in a few instances of pIasma ceIIs and of eosinophiIes in the vein waI1 or in the perivascuIar tissues. This infiItration varied from smaI1 ceIIuIar coIIections around the vasa vasorum to marked diffuse infiItration of the waI1 of the vein. The thrombus was frequentIy incIuded in the section and in many instances the platelet Iaminae were demonstrated. In a few cases a process of organization was present which started from the intima and invaded the margin of the thrombus. The foIIowing case, which was taken from the smaI1 series of 2 I cases, iIIustrates quite we11 some of the pathoIogic Iesions T In the vems.
NEW SERIES VOL. XXVI, No. I
Vance-Thrombosis
A white woman, thirty-seven years of age, was struck by an automobiIe about three weeks prior to death. Her right knee was injured, but
vein (upper Ieft). Throminflamed right femora1 vein
FIG. 3. Norma1 Ieft femoraI
bosed thickened (Iower right).
and
aside from a moderateIy severe traumatic arthritis she suffered no III effects from the accident. Two weeks later she began to bIeed freeIy from the uterus and soon suffered from Ioss of blood. She was admitted to a hospita1 for her uterine condition. On the fourth day of her stay she died suddenIy in an attack of acute asphyxia. As far as couId be ascertained, the patient had been perfectIy heaIthy prior to the accident. The necropsy discIosed a woman of about the age stated, of good muscuIar deveIopment and nutrition. There was a sweIIing of the right knee and, on section into the joint, about an ounce of rusty brown fluid was removed. The bones were not fractured, though the joint tissues were swoIIen. The diagnosis was traumatic arthritis of the right knee. The right femora1 vein was fiIIed with a thrombus and its waI1 was thickened, scIerotic and congested. Microscopic section showed the vein waI1 permeated by vasa vasorum which were surrounded by a perivascuIar i&Itration of round ceIIs and Ieucocytes. The Ieft femora1 vein was thin waIIed and normaI. Figure 3 shows the contrast between the right and Ieft femora1 veins in this case. The puImonary artery was effectuaIIy bIocked by a number of smaI1 thrombotic emboIi which were the cause of death. Figure 4 discIoses an emboIus fiIIing a Iarge branch of the pulmonary artery. Figures 3 and 4 were
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Journal
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photographed at the same magnification. The uterus showed a papiIIoma about I cm. in diameter which projected into the cervicaI
FIG. 4. EmboIus
in pulmonary
artery.
cana and evidentIy caused the uterine hemorrhage. The other organs of the body were normaI. In this case the deceased in a11 probabiIity had a miIdIy scIerotic femora1 vein on the right side which antedated the accident. When her right knee was injured the trauma and the enforced inactivity caused an exacerbation of the phIebitis and the formation of a thrombus. The hemorrhage from the uterus because of the poIyp doubtIess aItered the composition of the bIood and encouraged the growth of the thrombus. Three weeks after the injury, parts of the thrombus detached themseIves from the right femora1 vein and produced a fata puImonary emboIism.
embolism The 30 cases of purmonary which were not associated with a definite traumatic Iesion wiII not be discussed here in detaiI. It is suffkient to note that, whiIe there was no trauma present, the pathoIogic Iesions in the veins were not different essentiaIIy from those just described in the traumatic cases. SUMMARY
A summary of the important points brought out by the study of the cases associated with a definite traumatic Iesion is as foIIows: I. The sex incidence showed that 37 of the cases were women and 23 men.
I
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2. The age incidence indicated that 50 per cent of the cases occurred between the ages of forty and sixty years. 3. The types of trauma which injured the patients were the ordinary casuaIties encountered in any Iarge city. Of the injuries, 72 per cent were produced by automobiIe accidents. The Iesions varied in severity from severe fractures of the peIvis or of the shaft of the femur to mere contusions and abrasions of the extremities. 4. The interva1 which eIapsed between the onset of the trauma and the sudden death by puImonary emboIism varied between four days for the minimum and fifty-four days for the maximum. The average interva1 occurred between ten days and twenty-four days. This indicates that the influence of the trauma on the production of the thrombosis and the emboIism was not simiIar in every case. 5. Where the trauma invoIved the bones and soft parts of one of the Iower extremities, thrombosis was found in the veins of the corresponding Iower extremity in 32 instances. In 14 exampIes of this type a thrombus couId not be found. There were 14 cases of injury in which some other part of the body besides the Iower extremities were invoIved; in g of these cases femora1 vein thromboses were found. These figures suggest that a traumatic Iesion near the femora1 vein or its tributaries undoubtedIy has an influence on the production of thrombosis in that vein. On the other hand, a simiIar thrombosis occurred in the femora1 veins in injuries which did not affect the Iower extremities and in such instances the inffuence of the trauma must have been more remote. In addition, femora1 vein thromboses and fata puImonary embolism occurred in non-traumatic cases of a11 sorts, so that the basic etiology of this condition is some factor besides physical injury. 6. Microscopic investrgation of the thrombosed veins of the Iower extremity, both in the traumatic and the nontraumatic cases, discIosed that in aImost a11 instances there was a phIeboscIerosis, a subacute phIebitis or a periphIebitis of greater or Iess degree present. In
many cases these Iesions probabIy antedated the trauma. In others the effects of the trauma, whether genera1 or Iocal, probabIy precipitated the inflammation and produced a non-septic thrombosis which eventuaIIy resuIted in a fata puImonary emboIism. In our series it is impossibIe to interpret the course of events more exactIy or to teI1 just how the three factors mentioned by McCartney operate in any one given case. 7. It is interesting to note that in 17 of the 21 cases which I examined personaIIy, various acute and chronic disease conditions were present, which may have contributed to the formation of the thrombosis in the veins of the Iower extremity. COMMENT It is evident that thrombosis of the veins of the Iower extremity foIIowed by puImonary emboIism is a condition which must be considered by the surgeon as a possibIe complication of fractures and other traumatic Iesions, especiaIIy in individuaIs who have reached middIe age. The deveIopment of the thrombosis is insidious and the patient seems to be on the road to recovery; then without warning the puImonary embolism deveIops and the patient dies suddenIy in an attack of acute asphyxia. Deaths by puImonary emboIism raise many interesting medicoIega1 tangIes, especiaIIy in accident cases. There is aIways room for a difference of opinion concerning the part which the trauma has pIayed in producing this complication. ObviousIy a bruise of the Ieg is not as serious an injury as a fracture of the Iower third of the shaft of the femur, but both types may deveIop a puImonary emboIism. Perhaps the soundest view to take is to regard the trauma as the factor which precipitates the process. The basic causative factor is a vein of the Iower extremity which is either diseased or a Iocus resistentis minorae and so is prone to deveIop a thrombophIebitis readiIy under sIight provocation.
The author wishes to thank Dr. CharIes Norris for the cases reported in this paper and Mr. W. J. O’NeiII
for the photographs.
VANCE, YORK
0
a thrombus forms CCASIONALLY in one of the veins of the lower extremity and becomes an embolus which occIudes the puImonary artery. When this occurs death follows immediateIy from acute asphyxia. A great variety of medical and surgica1 patients die as a resuIt of this compIication. It is noted especiaIIy after abdomina1 operations, in the course of pregnancy, in many medica conditions, and as a seque1 to different types of injury. The Iast mentioned group forms a smaI1 but distinct proportion of the causes of death in any Iarge series of traumatic cases. It is my intention here to discuss the incidence of puImonary embolism in the traumatic cases coIIected from the OffIce of the Chief MedicaI Examiner of New York City and to discover, if possibIe, what factors tend to produce this compIication. It is advisabIe at the start to give a brief account of the process of thrombosis and the way in which the thrombus becomes an emboIus. First, thrombosis can be defined as the formation of a cIot in the bIood vesse1 during Iife from the constituents of the bIood. As described by MacCaIIum’ the process starts as a gray transIucent coIIection of bIood pIateIets on the vesse1 waI1, known as the head. On this as a foundation other pIateIets are deposited by the ffowing blood to form rows of Iaminae which run transverseIy to the Iong axis of the vesse1 and project into the Iumen. These Iaminae anastomose freeIy with one another and form a frame1MacCalIum, W. G. A Textbook 3, PhiIa., Saunders, 1926.
of PathoIogy.
M.D.
CITY
work to which adhere numbers of Ieucocytes from the circulating bIood. A thrombopIastic substance is produced and fibrin is formed between the Iaminae. In the fibrin meshwork Iarge numbers of red bIood ceIIs are imprisoned which give the thrombus a predominantIy red coIor. In the earIy stages of the process the Iaminae may project sIightIy above the surface of the growth as grayish corrugations known as the Iines of Zahn. When the thrombus has grown Iarge enough to occIude the vesse1, stasis occurs and the bIood coIIects around the proximal and distal ends of the obstruction, depending upon the distribution of the venous tributaries in these regions. The bIood in either event stagnates from the thrombus to the inflow of the next branch. This coIumn cIots en masse, Iike bIood cIots in a test tube, is dark red in coIor and may resembIe a postmortem cIot quite cIoseIy. This part of the thrombus is attached to the head and is known as the tai1. The growth of the tai1 may stop at the nearest point of inffow or the process may begin again with further pIateIet deposits. It may extend aIong the course of the vesse1 in a dista1 and in a proxima1 direction, continuaIIy growing by accretions to either end of the thrombus. In a vesse1 Iike the femora1 vein it may become as Iong as 13 to 25 cm. and it is usuaIIy as thick as the femora1 vein itseIf, which is about IO to 15 mm. in diameter. In some cases the thrombus in the from its femoraI vein may free itself attachments and traveI through the inferior vena cava and right side of the heart to bIockade the main branch of the
Ed.
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Vance-Thrombosis
of Surgery
puImonary artery. This event happens in OccasionaIIy the entire various ways. thrombus, if it is coherent enough, may be
FIG.
OcroeEn,1934
In the vast majority of cases the emboIus in puImonary emboIism is composed of bIand, non-septic thrombotic materia1.
I. Long coherent pulmonary emboius.
transported en masse Iike a smaI1 piece of rope (Fig. I) and, because of the twists and turns in the right heart, may be bent, coiIed or even knotted when it reaches the puImonary artery. In other cases the cIot may not be as coherent and, in its journey through the right heart, it may be broken into a number of smaI1 pieces about 2 to 3 cm. in Iength (Fig. 2). In either event the emboIus impedes the flow of bIood through the Iungs and causes death suddenIy and without warning. In some cases the thrombus formed in the femora1 vein is not coherent at a11 and smaI1 pieces may detach themseIves from the vein to form an emboIus to a smaI1 branch of the puImonary artery in the Iung These smaI1 emboIi cause smaI1 tissue. hemorrhagic infarcts in the Iung tissue which may produce symptoms of pain in the chest, expectoration of bIood, etc. Premonitory signs thus are given that a cIot is forming in the femora1 vein so that the death a few days Iater by a Iarge emboIus is not unexpected.
Under the microscope, a section of the emboIus stained with hematoxyIin and eosin shows a homogeneous pink framework of bIood pIateIets with fibrin, red bIood ceIIs and a few Ieucocytes in between. The pIateIet framework is characteristic and if it can be demonstrated satisfactoriIy is proof enough that the structure is a rea1 thrombus. The different factors which contribute to the deveIopment of thrombosis and puImonary emboIism have been discussed at great Iength in the Iiterature. Mcan exceIIent summary Cartney2 gives of the subject in his articIe and Iists three which are considered the most important. (I) Injury to the vascuIar They are: endotheIium which may occur from actuaI infectious processes and toxic trauma, action in generaI. (2) SIowing of the bIood stream which may occur from a genera1 circuIatory disturbance or a IocaI condition Iike a phIeboscIerosis, pressure on a vein, 2 McCartney, 1927.
J. S. Jr. Arch. Pd.,
3: 921 (June)
NEW SERIES VOL.XXVI,
No.
Vance-Thrombosis
I
etc. (3) Changes in the composition of the bIood induced by toxic or infectious conditions which renders the bIood more r - -.‘-
American Journal of Surgery
21
that period; he considered suppurative and infectious diseases of Iess importance in the causation of thrombosis. As an
“.
FIG. 2. Fragmented
IiabIe to intravita1 cIotting. The injury to the endotheIia1 Iining of the bIood vesse1 generaIIy is considered the most important factor as it forms the nidus for the head of the thrombus. The sIowing of the bIood stream and the changes in the composition of the bIood are important contributory inffuences and aid in the future growth of the thrombus. PuImonary emboIism as a cause of death has received much attention in recent years. RosenthaI in his review has pointed out that there has been a steady increase in the incidence of puImonary emboIism in the cIinics of CentraI Europe from the years IgIg to 1928; after 1928 there was a sIight decrease. He attributes this phenomenon to the period of want and socia1 instabiIity which prevaiIed in these countries during the earIy nineteen twenties and especiaIIy to the rise in the proportion of cardiac and vascuIar diseases during 3 RosenthaI, S. R. Arch. Path., 14: 215 (August)
1932.
pulmonary
emboIus.
added confirmatory support of his point he mentions the fact that in Canada and the United States, where such socia1 conditions did not prevai1, there was not any increase in the incidence of puImonary emboIism during the same period. DESCRIPTION
OF THE
MATERIAL
The materia1 which I present here comprises go cases of thrombosis of the Iower extremity with death from puImonary emboIism due to a11 causes. AI1 of these cases are routine necropsies of the OffIce of the Chief MedicaI Examiner of New York City which were performed because of an obvious association of the death with a definite injury or because the deceased has died under suspicious or unusua1 circumstances. The majority of cases were coIIected between January I, I, 1934, but a smaI1 1924 and January number were added which had occurred in other years.
22
American
Journal
Vance-Thrombosis
of Surgery
This materia1 couId be divided into a number of different types on the basis of the probabIe cause of venous thrombosis and puImonary embolism. They are listed as foIIows : As a complication of a definite injury.. As a compIication of a phlebitis with a traumatic history but without a definite injury.. As a compIication of pregnancy.. . As a comphcation of an operation. . . As a complication of varicose veins. As a complication of other natural conditions. Total.....................................
60
.
6 3
4 7 . IO go
The reason for the preponderance of injury cases is because the OffIce of the Chief MedicaI Examiner is concerned mostIy with deaths which result from a11 sorts of vioIence. The other types mentioned wouId be incIuded in our materia1 at infrequent intervaIs and more or Iess fortuitousIy. Hence only the figures in connection with cases of trauma wouId have any significance in so far as statistics are concerned. Among the cases of puImonary emboIism associated with definite injury were 55 which occurred during the ten years between 1924 and 1934. When these were Iisted in the year in which they died the folIowing resuIts were obtained: Year 1924 1925
Cases 2 6
rgz6
2
1927
4
1928
2
1929 1930 ‘931 1932 1933
4 IO ; 8
In the years preceding the depression, the yearIy average was 3 to 4 cases, but after the depression it was over twice as much. An attempt is not made here to draw any conclusions from so smaI1 a series of cases, but it is suggestive that the cases of puImonary emboIism shouId increase during the years of depression, especiaIIy when viewed in the Iight of RosenthaI’s remark concerning the increase in the incidence of this condition in
OCTOBER, ,931
CentraI Europe from 1919 to 1928. A detailed examination of the 60 posttraumatic cases of puimonary emboIism discIosed the folIowing facts : The race incidence was not significant, as 55 were white and 5 were negroes. The sex ratio was: femaIes 37, maIes 23. In any Iarge series of cases of puImonary embolism, the femaIes outnumber the males. The age incidence onIy confirmed the prevaIent conception that puImonary emboIism is a condition which attacks middIe age for the most part. Taken by decades, the 60 cases were grouped as foIIows: Age in Years 30 40 50 60
to to to to
Cases
39 49 59 6g
4 IO 22
15 8
70 to 79 Over 80
I
The types of casuaIty which the trauma were as foIIows: AutomobiIe injury. .. FaIIs...................................... Hit by faIIing object.. . Blow from revoIving door. BIow during aIterca%on. ..................... Homicidal incised wounds. ................... Bullet wound.. Unknown injury..
produced Cases 36 16
2 I I I I
.
2
The injuries varied from the serious to the sIight; they were aIways definiteenough to persist unti1 the patient died of the puImonary emboIus, but were not severe enough to cause death before the emboIus had time to deveIop. The Iesions produced by the trauma were as foIIows : Cases Fractures of femur.. . Fractures of tibia and fibuIa. Fractures of tibia.. Fractures of Gbula.. . Fractures of pelvis.. . h4isceIIaneous injuries of Iower extremities. Injuries eIsewhere in body.. Total....................................
The injuries
14 fractures of varying
14 I I
2 7 5 I I IO
60
of the grades
femur were of severity.
NEW SERIES VOL. XXVI, No.
Vance-Thrombosis
I
Ten were intracapsuIar fractures of the neck, 2 were intertrochanteric fractures, and 2 were compound fractures of the shaft at the junction of the middIe and Iower third. Seven of these fractures were present in the right femur; in 6 of the cases a thrombus was present in the right femoraI vein or one of its tributaries, whiIe in one case a thrombus could not be found. The remaining fractures invoIved the Ieft femur; in 5 of these cases the Ieft femora1 vein was thrombosed, and in 2 cases no thrombus was present. The I I fractures of the tibia and fibuIa combined showed simpIe fractures present in 8 cases, and in 3 cases compound fractures with a sIight infection around the broken bones. A simple fracture of the tibia was present in 2 cases and simpIe fractures of the fIbuIa were present in 7 cases. In this Iist of 20 cases, the right Ieg was invoIved 4 times; in 3 cases there was a thrombus of one of the veins of the right Iower extremity, and in one case a thrombus couId not be found. The bones of the Ieft Ieg were fractured in 16instances; in I I cases a thrombus was found in one of the veins of the Ieft Iower extremity, whiIe in 5 cases a thrombus couId not be Iocated. Fractures of the peIvis were present in 5 cases. In one there was an acetabuIar fracture on the Ieft side and a thrombus was present in the Ieft interna iIiac vein. In 2 of the other cases a left femora1 thrombosis was found, but it was not located on the side of the injury. In the remaining 2 cases a thrombus was not found. EIeven cases of misceIIaneous injuries of the Iower extremities were described which were Iisted as foIIows:
Ca.W Bullet wound of the right knee. Traumatic arthritis of right knee. Sprained ankle.. . . Lacerated wound of leg.. .. Contusions and abrasions of legs..
. .
I .
..... .. . . . ... ...
I
5 5
A right femora1 vein thrombosis was found in 6 cases corresponding to injuries on the
American Journal of Surgery
23
right Lower extremity, whiIe in 5 cases a thrombus couId not be Iocated. Injuries eIsewhere in the body were recorded in IO cases. They were Iisted as foIIows :
Cases Fracture of skuI1.. Fracture of skull and ribs.. Fracture of Iumbar spine.. Injuries of chest.. . Fractures of ribs.. . Injuriesofhead............................. Fracture of right humerus., Incised wounds of chest and abdomen.
z I I 2
I I
I I
The Ieft femora1 vein was thrombosed in 3 cases, the right femora1 vein in 4 cases, and the inferior vena cava in one case. In 2 cases a thrombus couId not be Iocated in any of the veins. In this group the site of the thrombus was not reIated to the site of the injury. These facts can be summarized by noting that in cases of trauma to the bones and soft parts of one of the Iower extremities, a thrombus was found in the veins of that extremity in 32 instances. Of these 32 cases, the right Ieg was invoIved 16 times and the Ieft Ieg 16 times. In 14 injuries of the Iower extremities, a thrombus couId not be located. Injuries which did not invoIve one of the Iower extremities were described in IO cases; the thromboses which were found in the veins of the Iower extremities did not correspond with the site of the traumatic Iesion. The Iength of time which eIapsed between the onset of the trauma and death from puImonary emboIism was quite variabIe. The minimum interval was four days and the maximum interva1 was The majority of cases fifty-four days. showed an average which varied between ten and twenty-four days. The significance of this fact is not cIear and can be discussed more advantageousIy Iater. The cIinica1, anatomic and microscopic features of this condition were studied in 21 cases taken from the Iarger group of 60. On these 21 cases I had performed the necropsy and had done a microscopic
24
American
Journd
of Surgery
Vance--Thrombosis
examination on the femora1 vessels and the other organs. The cIinica1 histories tended to faII into different patterns. In aI1, the patient had been in some type of accident and had been incapacitated for a shorter or Ionger time by the injuries received. At the time of their death the patients had recovered from the immediate effects of the trauma or their condition was improving. Sixteen of them died suddenIy in the hospitat ward, 9 were stiI1 confined to bed on account of the injury, whiIe 7 were convaIescing and were up and around the ward. OnIy one of these cases is mentioned as having given premonitory signs; about twenty days after the injury this patient suddenIy deveIoped a friction rub and a pain in the right chest which, at necropsy, was found to be due to a recent pulmonary infarct caused by a smaI1 emboIus. Five of the patients had received injuries which had not incapacitated them unduIy and they died suddenIy at their residences. The individuaIs in this series varied from earIy middIe age to seniIity and a11 types of physica conformation were represented, from the poorIy nourished to the ffeshy type tending towards obesity. In 12 of the 21 cases the emboIus in the puImonary artery consisted of smaI1 cIots measuring about 9 to 13 mm. in diameter and 2 to 5 cm. in Iength. In other instances the emboIi were Ionger and fewer in number. Some were either bent or coiIed or knotted, and often had branches corresponding to the tributaries of the femora1 vein. Microscopic examination of some of these cIots usuaIIy discIosed the charac- p teristic pIateIet framework. In 5 instances recent hemorrhagic infarcts were found in the Iungs, indicating that smaI1 emboIi had preceded the Iarge fata one. Associated morbid conditions of greater or Iesser severity were found in 17 of the 2 I cases. They were: CU.%3 G’eneralrzed artermsclerosrs. .’ Luetic meningitis and aortitis. Thrombosis of a cerebra1 artery ” mfarct...................................
g
2 and cerebral I
OCTOBER. 1934 Cases
Carcinoma of uterus.. Uterine poIyp. PuruIent pericarditis. Subacute infection at point of injury.
I I I 2
The veins of the Iower extremities, however, showed the most significant Iesions. OnIy 5 cases of the 21 discIosed varicose veins on external examination. In the remaining 16 there was no external evidence that the venous circuIation was abnorma1 in any way, even when the main femora1 vein was occIuded by a thrombus. Microscopic examination generaIIy discIosed, however, that some type of inflammation was present in the vein waI1 or in the tissues immediately adjacent. In those cases in which thrombosis was found, the thrombus was confined to the veins of one extremity. The veins of the other Ieg were not thrombosed and did not show any inflammation on section, though the vein waI1 might show a sIight phIeboscIerosis. A cIoser consideration of the veins which were thrombosed showed the thrombus as a red or dark reddish brown clot distending the vein or simply attached to the waI1 as a smaI1 mura1 growth. The Iarger veins in about 80 per cent of the cases showed a definite phIeboscIerosis, that is, there was fibrous thickening of the waII and fibrous pIaques on the intima. In most cases there was an inff ammatory infiItration of Iymphocytes and in a few instances of pIasma ceIIs and of eosinophiIes in the vein waI1 or in the perivascuIar tissues. This infiItration varied from smaI1 ceIIuIar coIIections around the vasa vasorum to marked diffuse infiItration of the waI1 of the vein. The thrombus was frequentIy incIuded in the section and in many instances the platelet Iaminae were demonstrated. In a few cases a process of organization was present which started from the intima and invaded the margin of the thrombus. The foIIowing case, which was taken from the smaI1 series of 2 I cases, iIIustrates quite we11 some of the pathoIogic Iesions T In the vems.
NEW SERIES VOL. XXVI, No. I
Vance-Thrombosis
A white woman, thirty-seven years of age, was struck by an automobiIe about three weeks prior to death. Her right knee was injured, but
vein (upper Ieft). Throminflamed right femora1 vein
FIG. 3. Norma1 Ieft femoraI
bosed thickened (Iower right).
and
aside from a moderateIy severe traumatic arthritis she suffered no III effects from the accident. Two weeks later she began to bIeed freeIy from the uterus and soon suffered from Ioss of blood. She was admitted to a hospita1 for her uterine condition. On the fourth day of her stay she died suddenIy in an attack of acute asphyxia. As far as couId be ascertained, the patient had been perfectIy heaIthy prior to the accident. The necropsy discIosed a woman of about the age stated, of good muscuIar deveIopment and nutrition. There was a sweIIing of the right knee and, on section into the joint, about an ounce of rusty brown fluid was removed. The bones were not fractured, though the joint tissues were swoIIen. The diagnosis was traumatic arthritis of the right knee. The right femora1 vein was fiIIed with a thrombus and its waI1 was thickened, scIerotic and congested. Microscopic section showed the vein waI1 permeated by vasa vasorum which were surrounded by a perivascuIar i&Itration of round ceIIs and Ieucocytes. The Ieft femora1 vein was thin waIIed and normaI. Figure 3 shows the contrast between the right and Ieft femora1 veins in this case. The puImonary artery was effectuaIIy bIocked by a number of smaI1 thrombotic emboIi which were the cause of death. Figure 4 discIoses an emboIus fiIIing a Iarge branch of the pulmonary artery. Figures 3 and 4 were
American
Journal
of Surgery
25
photographed at the same magnification. The uterus showed a papiIIoma about I cm. in diameter which projected into the cervicaI
FIG. 4. EmboIus
in pulmonary
artery.
cana and evidentIy caused the uterine hemorrhage. The other organs of the body were normaI. In this case the deceased in a11 probabiIity had a miIdIy scIerotic femora1 vein on the right side which antedated the accident. When her right knee was injured the trauma and the enforced inactivity caused an exacerbation of the phIebitis and the formation of a thrombus. The hemorrhage from the uterus because of the poIyp doubtIess aItered the composition of the bIood and encouraged the growth of the thrombus. Three weeks after the injury, parts of the thrombus detached themseIves from the right femora1 vein and produced a fata puImonary emboIism.
embolism The 30 cases of purmonary which were not associated with a definite traumatic Iesion wiII not be discussed here in detaiI. It is suffkient to note that, whiIe there was no trauma present, the pathoIogic Iesions in the veins were not different essentiaIIy from those just described in the traumatic cases. SUMMARY
A summary of the important points brought out by the study of the cases associated with a definite traumatic Iesion is as foIIows: I. The sex incidence showed that 37 of the cases were women and 23 men.
I
26
American
Journd
of Surgery
Vance-Thrombosis
2. The age incidence indicated that 50 per cent of the cases occurred between the ages of forty and sixty years. 3. The types of trauma which injured the patients were the ordinary casuaIties encountered in any Iarge city. Of the injuries, 72 per cent were produced by automobiIe accidents. The Iesions varied in severity from severe fractures of the peIvis or of the shaft of the femur to mere contusions and abrasions of the extremities. 4. The interva1 which eIapsed between the onset of the trauma and the sudden death by puImonary emboIism varied between four days for the minimum and fifty-four days for the maximum. The average interva1 occurred between ten days and twenty-four days. This indicates that the influence of the trauma on the production of the thrombosis and the emboIism was not simiIar in every case. 5. Where the trauma invoIved the bones and soft parts of one of the Iower extremities, thrombosis was found in the veins of the corresponding Iower extremity in 32 instances. In 14 exampIes of this type a thrombus couId not be found. There were 14 cases of injury in which some other part of the body besides the Iower extremities were invoIved; in g of these cases femora1 vein thromboses were found. These figures suggest that a traumatic Iesion near the femora1 vein or its tributaries undoubtedIy has an influence on the production of thrombosis in that vein. On the other hand, a simiIar thrombosis occurred in the femora1 veins in injuries which did not affect the Iower extremities and in such instances the inffuence of the trauma must have been more remote. In addition, femora1 vein thromboses and fata puImonary embolism occurred in non-traumatic cases of a11 sorts, so that the basic etiology of this condition is some factor besides physical injury. 6. Microscopic investrgation of the thrombosed veins of the Iower extremity, both in the traumatic and the nontraumatic cases, discIosed that in aImost a11 instances there was a phIeboscIerosis, a subacute phIebitis or a periphIebitis of greater or Iess degree present. In
many cases these Iesions probabIy antedated the trauma. In others the effects of the trauma, whether genera1 or Iocal, probabIy precipitated the inflammation and produced a non-septic thrombosis which eventuaIIy resuIted in a fata puImonary emboIism. In our series it is impossibIe to interpret the course of events more exactIy or to teI1 just how the three factors mentioned by McCartney operate in any one given case. 7. It is interesting to note that in 17 of the 21 cases which I examined personaIIy, various acute and chronic disease conditions were present, which may have contributed to the formation of the thrombosis in the veins of the Iower extremity. COMMENT It is evident that thrombosis of the veins of the Iower extremity foIIowed by puImonary emboIism is a condition which must be considered by the surgeon as a possibIe complication of fractures and other traumatic Iesions, especiaIIy in individuaIs who have reached middIe age. The deveIopment of the thrombosis is insidious and the patient seems to be on the road to recovery; then without warning the puImonary embolism deveIops and the patient dies suddenIy in an attack of acute asphyxia. Deaths by puImonary emboIism raise many interesting medicoIega1 tangIes, especiaIIy in accident cases. There is aIways room for a difference of opinion concerning the part which the trauma has pIayed in producing this complication. ObviousIy a bruise of the Ieg is not as serious an injury as a fracture of the Iower third of the shaft of the femur, but both types may deveIop a puImonary emboIism. Perhaps the soundest view to take is to regard the trauma as the factor which precipitates the process. The basic causative factor is a vein of the Iower extremity which is either diseased or a Iocus resistentis minorae and so is prone to deveIop a thrombophIebitis readiIy under sIight provocation.
The author wishes to thank Dr. CharIes Norris for the cases reported in this paper and Mr. W. J. O’NeiII
for the photographs.