Thrombosis and Emboli (1846-1856) (review)

Virchow’s Thrombose und Embolie was first published in two parts in 1910, but despite its great importance it has never until now been issued in English. In the foreword by Dr. Gert H. Brieger and the introduction by Drs. William R. Bell and Axel C. Matzdorff, the reader is made aware of the difficulties of the present enterprise and the magnitude of the attempt—for the most part, successful—to achieve clarity in the translations, the translators having gone so far as to consult portions of the original text that had been presented in various other languages. The translators state: “The major intent of our effort . . . was to provide to the reader the precise and exact thinking that existed in Prof. R. L. Virchow’s mind at the time he performed and recorded these studies, which . . . enabled him to be the first person to clearly delineate the process of intravascular thrombus formation and subsequent embolization of this thrombotic material to the pulmonary venous circulation” (p. 3).

The first item of the two that are included in the present volume is Virchow’s brief and extremely important fundamental article on obstruction of the pulmonary artery. It was published in January 1846 in Frorieps Neue Notizien when Virchow was twenty-four years and three months old, and was based on seventy-six “prosections” that were made in August 1845. (The huge number of autopsies is characteristic of major European institutions at that time; it makes us shudder to think of the American institutes that have thrown away their museums of gross specimens and do not blush at discharging their stained slides, having substituted photomicrographs in their stead.) The statements presented by Virchow in this essay are based on naked-eye observations, wide reading—part of which contains refutation of the extant literature—and acute original reasoning.

The brief and brilliant article in Frorieps Neue Notizien was followed within a few months by Virchow’s “Further Investigations about the Obstruction of the Pulmonary Artery and Its Consequences,” which appeared in Traubes Beitrage zur experimentellen Pathologie und Physiologie. This contribution occupies the remaining 212 pages of the present translation. It discusses the mechanism of vascular obstruction, the consequences of obstruction, and secondary disturbances—namely, acute respiratory disturbances due to major obstructions, small obstructions unaccompanied by generalized or localized obstructions, and local changes in the pulmonary parenchyma due to obstructions.

The text proper opens with an astoundingly courageous paragraph presenting the conclusions of the investigation, in advance of the evidence, which exemplifies the boldness that we often attribute to the young. Virchow’s detailed description of his experiments on animals is not always easy to understand. It is supported by references to his experiences with dissections of humans. His explanations are assisted (and clarified) occasionally by parenthetical insertions contributed by the translators. Virchow fortified his text at various places with a series of fourteen reports of autopsies, and with references to the literature in German, French, and English. Significantly, there are no references to the work by Americans, Virchow’s memorable encomium of the official American medical history of the Civil War being far in the future.

Virchow’s discussions are often accompanied by obiter dicta that are of great value. For example, he states that thrombi may break while the patient is alive and “the detached piece is only covered on that end which is directed toward the heart. . . . the ease with which such a piece breaks off has some practical implications, one of which is to be cautious when examining a patient who suffers from similar diseases in order not to induce such a detachment while he is alive” (p. 26).