|Year : 2019 | Volume
| Issue : 1 | Page : 42-43
Rudolf Virchow and venous thromboembolism: A recognition after 100 years
Department of Vascular and Endovascular Surgery, Yashoda Hospital, Hyderabad, Telangana, India
|Date of Web Publication||8-Mar-2019|
Dr. Devender Singh
Department of Vascular and Endovascular Surgery, Yashoda Hospital, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Singh D. Rudolf Virchow and venous thromboembolism: A recognition after 100 years. Indian J Vasc Endovasc Surg 2019;6:42-3
Venous thromboembolism is the result of hypercoagulability, stasis, and endothelial injury, which is now a well-established concept popularly known as Virchow's triad, after Rudolf Virchow. But to bring this concept to the medical world, it took him many years of his hard work and dedication in spite of massive resistance from the medical fraternity. Interestingly, Virchow only began to be routinely credited with this triad 100 years after publication of his work on venous thrombosis.
Rudolf Virchow, in full Rudolf Carl Virchow (born October 13, 1821, Schivelbein, Pomerania, Prussia [now Świdwin, Poland] – died September 5, 1902, Berlin, Germany), German pathologist and statesman, is one of the most prominent physicians of the 19th century. He pioneered the modern concept of pathological processes by his application of the cell theory to explain the effects of disease in the organs and tissues of the body. He emphasized that diseases arose, not in organs or tissues in general, but primarily in their individual cells. Moreover, he campaigned vigorously for social reforms and contributed to the development of anthropology as a modern science.
In 1839, Virchow began the study of medicine at the Friedrich Wilhelm Institute of the University of Berlin and was graduated as a doctor of medicine in 1843. As an intern at the Charité hospital, he studied pathological histology and in 1845 published a paper in which he described one of the two earliest reported cases of leukemia. This paper became a classic. Virchow was appointed as prosector at the Charité, and in 1847, he began, with his friend Benno Reinhardt, a new journal, Archiv für pathologische Anatomie und Physiologie, und für klinische Medizin (“Archives for Pathological Anatomy and Physiology, and for Clinical Medicine”). After Reinhardt's death in 1852, Virchow continued as sole editor of the journal, later known as Virchows Archiv, until his own death 50 years later.
Later in 1849, Virchow was appointed to the newly established chair of pathological anatomy at the University of Würzburg – the first chair of that subject in Germany. During his seven fruitful years in that post, the number of medical students in the university increased from 98 to 388. Many men who later attained fame in the medical field received training there from him. In 1850, he married Rose Mayer, with whom he had three sons and three daughters. At Würzburg, Virchow published many papers on pathological anatomy. He began there the publication of his six-volume Handbuch der speziellen Pathologie und Therapie (“Handbook of Special Pathology and Therapeutics”), most of the first volume of which he wrote himself. At Würzburg, he also began to formulate his theories on cellular pathology and venous thromboembolism.
In 1856, he published a collection of 10 years of work entitled “Gesammelte Abhandlungen zur Wissenschaftlichen Medicine” (Collective treatises on Scientific Medicine), which included his detailed studies of thrombosis, which were collated into a single work “Thrombosis und Embolie” in 1910 and eventually translated into English in 1998. This work probably resulted from a challenge laid down to Virchow during his very early career by his professor Robert Froriep to rebuke the claim made by the eminent French pathologist, Cruveilhier, that “La phlebite domine toute la pathologie” (Phlebitis dominates all pathology) (Cruveilhier, 1829–1842). Cruveilhier claimed that he had frequently seen thrombus in inflamed vessels, containing pus at its center. In turn, he deduced that it was the pus that had led to clot development, and therefore, coagulation was the main consequence of venous inflammation. It was a view held by many during the 19th century.
Virchow's personal experience of thrombosis had been through the numerous autopsies he had performed at the Charite´ hospital in Berlin. It was this work that first demonstrated to him that inflammation and infection occurred after the thrombus had formed and not before, as Cruveilhier proposed. To refute Cruveilhier's claims, he concentrated his efforts on investigating thrombosis development in the pulmonary vasculature. He had determined that this was a common condition through his own postmortem work, where he demonstrated the frequency of pulmonary thrombosis to be 8%–10% (Virchow, 1856).
It was his observations at autopsy that provided him with the first evidence that thrombosis in the lung might originate from alternative vessels in the circulation, in particular those in the leg. He discovered that thromboses in the lung and leg usually occurred concurrently, and in particular, these thrombi were so shaped that they could be neatly fitted together as though one had broken off the other. His theory was that part of the thrombus contained in the leg had broken off as a result of turbulent blood flow around its proximal tip and then traveled to the lungs.
Having made these initial discoveries, he proceeded to put forward a scientific hypothesis that pulmonary thrombi are transported from the veins of the leg and that the blood has the ability to carry such an object. He then proceeded to prove this hypothesis through well-designed experiments, repeated numerous times to consolidate evidence, and with meticulously detailed methodology. He inserted different types of foreign bodies into the jugular veins of dogs to represent a thrombus traveling from the leg. These included cadaveric venous thrombi, coagulated blood from living patients, and various seeds and berries. The dogs frequently developed symptoms of respiratory distress a few days following the procedure and then either died naturally or were euthanized. On every occasion, the foreign body in the jugular vein had traveled to the lung, proving that blood had the capacity to transport thrombi from the peripheral circulation to the lung vasculature and in turn demonstrating that peripheral venous thrombi were the likely source of thrombi in the lung. Two engravings he made clearly demonstrated this theory.
Crediting Virchow with a triad did not occur immediately following the publication and dissemination of his work on thrombosis. Extensive reviews of the literature by others have revealed that there is no mention of Virchow's triad in book or journal article titles until after the 1950s, nor in the contents of abstracts until the 1980s (Malone and Agutter, 2006). This was 100 years after Virchow's work on thrombosis.
Without doubt, Virchow deserves substantial recognition for his contribution to our understanding of venous thrombosis. His close association with the triad should therefore continue as acknowledgment of his pioneering work in the thrombotic process, particularly as the triad remains so clinically relevant today.
In recognition to his significant work on venous thromboembolism, we celebrate October 13 of every year as World Thrombosis Day.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kumar DR, Hanlin E, Glurich I, Mazza JJ, Yale SH. Virchow's contribution to the understanding of thrombosis and cellular biology. Clin Med Res 2010;8:168-72.
Huth EJ, Jock T, editors. Murray. Medicine in Quotations: Views of Health and Disease through the Ages. 2nd
ed. Philadelphia, US: American College of Physicians; 2006. p. 115.
Dalen JE. Venous Thromboembolism. New York: Marcel Decker, Inc.; 2003.