Thrombosis

“ This operation rests on sound principles, for the ligature of the ovarian veins prevents the septic blood entering the circulation, thereby setting up, among other things, endocarditis and pulmonary embolism.
The great difficulty in dealing with this condition is the selection of suitable cases. Experience teaches that acute cases are unsuitable. The best results have been attained in the chronic forms of the disease where the thrombosis was limited. There is great uncertainty in a given case as to the extent of the thrombosis and the number of veins implicated. ”

“ Where direct injury to the sinus or in its immediate neighborhood gives rise to phlebitis and consequent thrombosis, we have a condition closely resembling that of the third class, where disease of an inflammatory character in the tissues of the skull, neck, or face sets up a phlebitis and thrombosis which are transmitted to the intracranial veins and sinuses. ”

“ If the patient has been very much run down, death may take place from thrombosis of some of the arteries. If the thrombosis takes place in the brain, consciousness will be lost, and the patient will often die without recovering it. Patients often develop tubercles in their brain as the result of a spread of the disease beyond the lungs, and then, as a rule, death will take place in the midst of a paralysis, which may be accompanied by loss of consciousness that lasts for several days or a week or more. ”

“ In the course of their growth they cause pressure symptoms upon the nervous system, and this leads to death. If patients become very much weakened, as is not infrequently the case, thrombosis occurs, and portions of the clots may be shot into the pulmonary veins, and cause death in this way. ”

“ Thrombosis—clotting in the vessel. Embolism, blocking of the vessel. Thrombus may form in any bloodvessel. Embolism occurs in arteries. Clot follows the blood current. Causes of clotting—fibrinogen, paraglobulin, fibrine ferment; foreign bodies; parasites; air; blood that has been exposed, transfusion; ærial germs; disease germs; chemical coagulants; high and low temperatures; breaches of endothelium; congestion or inflammation of the serosa; stasis of blood and extension of clot; ligature near a branch vessel: deoxidation and carbonization of blood, marasmus; neoplasms ”

“ Thrombosis of the femoral vein is best treated by elevating the affected leg and enveloping it with flannel cloths saturated with hot vinegar and water. Thrombosis of other veins is to be treated on the same general principles. When an artery becomes obliterated, whether from embolism or thrombosis, the part which it supplies should be surrounded with cotton wool and every effort made to favor the establishment of the collateral circulation. ”

“ In the young, apoplectic attacks are usually due to cerebral softening, thrombosis following acute disease or embolism resulting from endocarditis. Between the ages of twenty and forty apoplexies usually mean syphilitic thrombosis. In the later decades of life, either hemorrhage, thrombosis, embolism or softening may occur. ”

“ The most frequent source of this third form of inflammatory thrombosis [p. 985] is the chronic inflammation of the middle ear with the mastoid cells. The inflammation may be propagated through a carious or necrosed portion of the temporal bone to the petrosal and lateral sinuses, or may, without disease of the bone, be carried by the small veins which open into the sinuses from the petrous and mastoid portion of the temporal in this region. Abscesses in the neck may set up a phlebitis extending up the jugular to the lateral sinuses, to which a meningitis may possibly be added. ”

“ Thrombosis first occurs in that part of the sinus which is in closest relation to the primary cause of the infection, the clot rapidly increasing in size until the lumen of the sinus is entirely obliterated. In its early stages the thrombus is of a chocolate colour, softening at a later date and breaking down into a purulent material. Many varieties of bacteria may be present though the infection is mainly dependent on the presence of the streptococcus pyogenes. ”

“ Phlebitis and thrombosis are common sequelæ of varix, and may prove dangerous, either by spreading into the large venous trunks or by giving rise to emboli. The larger the varix the greater is the tendency for a thrombus to spread upwards and to involve the deep veins. Thrombi usually originate in venous cysts or pouches, and at acute bends on the vessel, especially when these are situated in the vicinity of the knee, and are subjected to repeated injuries—for example in riding. Phleboliths sometimes form in such pouches, and may be recognised in a radiogram. ”

“ Pieces of disintegrated coagula from the systemic veins, the contents of echinococcus cysts ruptured into the venous current, fragments of new growths, are carried to the heart and pass into the pulmonary artery, or large thrombi may be detached from their position in a vein and lodge in the trunk or main branches of the pulmonary artery.
Primary thrombosis of the pulmonary artery is very uncommon. In certain septic conditions, in parturient women, in typhoid fever, and in extreme anæmia thrombosis of the pulmonary artery may occur. ”

“ The most serious form of arterial thrombosis is that met with in the abdominal aorta, which is attended with violent pains in the lower limbs, rapidly followed by paralysis and arrest of the circulation. ”

“ As the portal vein is made up of many branches coming from the various organs of the abdominal cavity except the kidneys, and as it empties, so to speak, into the liver, it is obvious that various and complex derangements will ensue on the formation of thrombi.
CAUSES.—Thrombosis of the portal vein occurs under three general conditions: the blood is in a readily coagulable state; the action of the heart is weak and the blood-current sluggish; the circulation through the vein is impeded by external pressure. ”

“ PHLEBITIS AND PHLEBO-THROMBOSIS.—The formation of thrombi in the uterine and pelvic veins is sufficiently common during the puerperal period. The coagulation may result from compression or from enfeeblement of the circulation. A predisposition to its occurrence is created by relaxation of the uterine tissue. A normal thrombus is in itself harmless. In time it becomes organized, and the occluded vessel is converted into a connective-tissue cord, or a channel may form through it which permits the passage of the blood-stream. ”

“ Thrombosis is liable to occur when calcareous plates are exposed in the lumen of the vessel by destruction of the endothelium, and this predisposes to embolism. Arterio-sclerosis also interferes with the natural arrest of hæmorrhage, and by rendering the vessels brittle, makes it difficult to secure them by ligature. In advanced cases the accessible arteries—such as the radial, the temporal or the femoral—may be felt as firm, tortuous cords, which are sometimes so hard that they have been aptly compared to “pipe-stems.” ”

“ In many instances the inflammatory products escape by way of the parotid duct.
Septic parotitis is an unpleasant and painful complication of an abdominal operation, but it is rarely dangerous and has only had a fatal termination in very exceptional cases.
Thrombosis. After operations on the pelvic organs, thrombosis occasionally occurs in the iliac, femoral, and saphena veins, accompanied by fever, pain, especially in the course of the long saphenous vein, and œdema of the limb. It is noticed most frequently about the twelfth day after operation. ”

“ Arteritis and thrombosis of arteries are rare, and although lesions of atheroma have been discovered in certain chronic diseases, such as tuberculosis, chronic diarrhœa, etc., they are difficult to detect, even on examination per rectum of the bifurcation of the aorta. ”

“ At present there is very little evidence available as to the cause of the thrombosis, but it can scarcely be doubted that sepsis, it may be only of a mild type, is responsible for some of the cases.
A careful consideration of the matter reveals beyond any doubt that pulmonary embolism occurs much more frequently after hysterectomy or fibroids than after any other operation, and it is especially liable to happen in women who are profoundly anæmic from profuse and prolonged menorrhagia. ”

“ Percussion and auscultation may remain negative. The patient may have a succession of similar accidents, and yet finally recover. According to Ball, pulmonary embolism and pulmonary thrombosis cannot be distinguished during life. In one case which he reports where pulmonary embolism should have been present without question the autopsy showed the presence of a thrombus in the pulmonary artery. A succession of chills, general malaise, febrile excitement, the localized phenomena of pneumonia or gangrene of the lung, point indubitably to the existence of septic emboli. ”

“ The passive pulmonary hyperæmia which results from the obstructed pulmonary circulation may lead to those changes which collectively constitute brown induration of the lung. Another occasional occurrence, directly due to extensive mitral stenosis, is nodular hemorrhagic infarction. Hemorrhagic infarction of the lungs is in nearly every case preceded by thrombosis of the right side of the heart. ”

“ Where wasting disease has existed, the patient is much emaciated, and profuse discharges have diminished the fluidity of the blood, the rapid supervention of coma with slight spasms or general convulsions will render it highly probably that thrombosis is taking place. Unilateral symptoms would greatly increase this probability, and if any accessible veins about the head, neck, or face could be definitely distinguished as filled with firm coagula, the diagnosis would approach certainty. ”

“ As I was able to illustrate after my second lecture by a specimen from the Museum of Charing Cross Hospital, a branch of one of the coronary arteries that has been narrowed by atheroma for an indefinite length of time, with consequent cardiac weakness and discomfort, may any moment become thrombosed rapidly, apparently in consequence of some passing depression or other unfavourable influence, just as in thrombosis of degenerated cerebral vessels. ”

“ In cases of acute endocarditis we have no means usually to distinguish between the general symptoms of nervous shock and the physical signs occasioned by cardiac thrombosis on the one hand, and rupture of a valve or tendinous cord on the other. ”

“ We are justified in assuming the parenchymatous origin of cardiac hæmoptysis, because it rarely appears until chronic valvular disease has prepared the way for its occurrence by its well-known degenerative effects on the pulmonary circulation whereby thrombosis appears, and because at those advanced periods emboli are often injected into the pulmonary artery capable of producing hemorrhagic infarction and consequent hæmoptysis. This latter is accompanied by aggravation of symptoms already serious—increase of dyspnoea, cardiac perturbation, and probably cough. ”

“ The smaller vessels show an infiltration of lymphoid and plasma cells in their adventitia, as well as in the perivascular lymph spaces. The larger vessels show a great thickening of the intima which is consecutive, or, as Lambert described it, "girdling" in character. This is associated with a splitting of the membrana elastica. The proliferated intimal tissue is very susceptible to degenerative processes. Thrombosis and the formation of anemic infarctions may follow the obliteration of the vascular channels. The involvement of the larger vessels may lead to very distinctive focal symptoms. ”

“ A thrombus of the basilar artery may lead not only to rapid, but even to sudden, death. A phthisical patient died suddenly while eating his supper, and a thrombosis of the basilar artery, with softening of the pons, was found. Of course the lesion must have been of older date.50 Bright51 thought that when symptoms pointing to disease of the intracranial vessels were present the diagnosis was confirmed, and the location of the lesion in the vertebral arteries rendered highly probable, by a persistent occipital [p. 971] pain. ”

“ The patient should be placed in bed in a semi-recumbent position, properly supported, and arrangements must be made so that all fatigue of eating and drinking or attending to his excrementitial functions are provided against. Of course we should treat a case of cardiac thrombosis complicating a frank inflammatory condition, such as acute endocarditis, certain forms of pleurisy or pneumonia, very differently from a case in which the state is one of relative feebleness or adynamia, as in the advanced stages of diphtheria, or after profuse uterine hemorrhage during or after confinement. ”

“ On several occasions in which blood has been effused freely into the pelvic cavity, either as a consequence of tubal pregnancy, or as a sequel to an operation, such as an abdominal myomectomy, and the blood has been allowed to remain, or it has been inefficiently drained, the patients have died from septic pneumonia.
In cases of septic thrombosis the patients run a definite risk from pulmonary embolism. When the embolus is large the patient sometimes dies in a few minutes (see p. 101) ”

“ In air-embolism the pulmonary arteries contain a mixture of blood and air looking like a stiff-beaten white of egg of red color. Large emboli of liver-tissue or liver-cells may be found in the pulmonary arteries after traumatic rupture of the liver. Fat-emboli of the smaller arteries can be recognized by the naked-eye. Thrombosis of both pulmonary arteries and veins is very common in chronic valvular lesions, pneumonia, terminal infections, burns of the skin, poisoning with hemolytic agents, etc. ”