Between bleeding and thrombosis is a precarious state of fluidity wherein blood cells zip about, suspended and contained in plasma, a complex elixir of proteins.
Under circumstances both normal and pathologic, the blood is called upon to clot. In such a case, plasma interacts with it’s cellular milieu, triggering a cascading waterfall of serial enzymatic changes that activate clotting factors, terminating in a mesh of fibrin gel and platelets.
The resultant clot can be a life saving response to a penetrating injury, a nuisance if small and in a leg vein, or quickly deadly if lodged in the lung vasculature. In any case, the deep vain thrombosis (DVT) is common and we would expect there to be some record of historical observations. And so there is.
Some would date the earliest description of DVT to the Sushruta Samhita, a Sanskrit text of ancient Indian Ayurvedic medicine, written some 2500 hundred years ago.
And Avicenna (see earlier post) most certainly was dealing with DVT when he discussed ‘particle migration’ during vein surgery, suggesting the process of embolization.
The Miracle of St. Louis
However, a more colorful description comes from Europe in the Middle Ages. This story concerns a 20-year old Norman cobbler and was described in The Life and Miracles of Saint Louis by Guillaume de Saint Pathus. In 1271, the cobbler, Raoul, sought out the surgeon Henri de Perche. He had pain and swelling from calf to thigh. Advised to wait, he got worse. The leg had ulcered by the time Raoul visited the shrine of St. Eloi, where he received no benefit.
He next went to the tomb of King Saint Louis, prayed, and collected dust to apply to his ulcer. Healing ensued and a miracle proclaimed. This story and a exhaustive history of DVT by Galanaud et al. They note that the signs and symptoms of DVT are not identifiable in the works or Hippocrates nor Galen.
Jesus on the Cross
The Galanaud paper also gives a nod to the historical speculations concerning the death of Jesus. A recent eruption of medical controversy was played out in the pages of the Journal of Thrombosis and Haemostasis. Brenner, the director of an academic thrombosis and hemostasis unit in Israel asked “Did Jesus Christ die of pulmonary embolism?” He suggests “yes”, based on a review of the secondary sources in the New Testament concerning the crucifixion of Christ in particular and what is known more reliably about the Roman methods of torture.
He accumulates all the factors that suggest a fatal pulmonary embolism as cause of death: a non-lethal amount of blood loss expected from whipping, dehydration from the forced walk and sun exposure, release of procoagulant tissue factor from nailing of hands and feet, stasis from immobilization, and a plausible possibility that Jesus had one of the thrombophilic mutations prevalent around Galilee (factor V Leiden and prothrombin mutation).
The spear thrust to the chest was delivered after death. An additional gruesome contributory factor, delivered to the two thieves but not to Jesus, was the Roman practice of fracturing the legs of the victims, which the knew to precipitate death. They did not know that thrombus and fat embolization mediated the desired effect. The ensuing letters speculate further about rhabdomyolysis, hemothorax.
This brings us to the Rudolph Ludwig Carl Virchow (1821-1902): the “Father of Modern Pathology”, the “Pope of Medicine”. His interests in medicine and anthropology made him a leader in science and politics. Given the scope and magnitude of his achievements we can overlook the fact that he did not embrace Darwinism nor the germ theory of disease.
As to the topic at hand, Virchow proceeded from autopsy observations that suggested an association between lower extremity thrombus and lung clots to conducting experiments designed to deduce the conditions that lead to thrombus and embolism (both terms coined by him). Hence we now have the famous Virchow’s Triad: Stasis, Endothelial Injury, and Hypercoagulability.
In politics he was no less active or important. He was a nemesis of none other then Chancellor of Germany Otto von Bismarck and challenged by him to a duel (not carried out). He had concrete social views (like opposing Bismarck’s military budget) and sweeping social concepts, proclaiming the “Medicine is a social science, and politics nothing but medicine at a larger scale.”
This notion was no more aptly applied that when John Dean said to Richard Nixon in 1973, discussing the corruption in the White House: “We have a cancer--within, close to the Presidency, that's growing. It's growing daily. It's compounding, it grows geometrically…“ And so it is, forty four years later, cancer still afflicts bodies, both corporeal and politic.