Phlegm Asia Trousseau Trousseau 2

Phlegmasia alba dolens Reported by: Trousseau A. Lectures on clinical medicine: Delivered at the Hotel-Dieu, Paris. Translated by Cormarck JR. The New Syndenham Society, London. 1872. ABSTRACT In this lecture, translated in 1872 by Cormarck, Trousseau reports for the first time the relationship between cancer and “phlegmasia alba dolens”, a condition later recognized as deep vein thrombosis (DVT). He is also the first to note that a strong relationship exists between the occurrence of DVT and occult cancer. Trousseau suggests that cancer is associated with “a special crisis of the blood, which, irrespective of inflammation, favors intra-venous coagulation.”

Case Study 1 ! He describes the case of a 33-year-old woman, admitted with “the signs and symptoms of the third stage of pulmonary pthisis” !

After 6 weeks in the clinic, Trousseau found that she had “white oedema” of both arms, involving the entire left arm but limited in the right arm to the region of the elbow”

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Compression of the limb was required to cause pain

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Later, the patient developed edema of the legs, extending upwards from the feet and “soon invading the thighs”

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Trousseau noted that the deep veins were affected first, followed by “a well-marked tendency for re-establishment of the circulation” with subcutaneous veins “taking over” until “they themselves became involved in the obliterative process”

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Eighteen days after initial commencement of symptoms, the left leg and the foot had “notable lividity, where the slightest rubbing was painful”

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This patient died after 22 days

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Autopsy of the patient revealed that the veins of the calf, the femoral, the internal saphenous, and external iliac veins were “obliterated by fibirinous clots”

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According to Trousseau, “the autopsy clearly showed that the continuance and extent of oedema of the lower extremities was explained by the continuance, extent, and structure of the clots”

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Trousseau noted that some of the fibirinous clots – particularly those in the upper extremities – had been spontaneously absorbed

Discussion ! Trousseau discussed the conditions under which “the blood presents a tendency to spontaneous coagulation” !

RELATIONSHIP BETWEEN CANCER AND PHLEGMASIA ALBA DOLENS ! In this lecture, Trousseau describes for the first time “phlegmasia alba dolens” – a condition which is later recognized as DVT !

According to Trousseau, phlegmasia alba dolens is caused by “a special alteration of the blood, an alteration which exists in pregnant women and in many cancers”

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In cachexiae generally, and in tuberculous and cancer cachexiae generally, the blood undergoes important changes ! These modifications consist chiefly in a change in the proportions of the constituents of the blood, with a diminution of “red globules” and an “augmentation of fibrin and the serum” ! These changes lead to “the blood having a great tendency to spontaneous coagulation” Trousseau notes that “he has long been struck with the frequency with which cancerous patients are affected with painful oedema of the superior and inferior extremities” regardless of the location of the cancer

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He suggests that the frequent occurrence of phlegmasia alba dolens with cancerous tumors suggests that “a relationship of cause and effect” exists between the two

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Notably, Trousseau observed that patients with painful oedema, but without apparent cancerous disease during life, were often found on autopsy to have visceral cancer

Case Study 2 ! Trousseau admitted a patient, aged 59 years, to his clinic !

This patient was “seized with phlegmasia alba dolens” of the left leg without any known cause ! The patient had “acute deep-seated pains in the calf, beginning about the lower third of the leg and extending up to the hamstring” ! When consulted, Trousseau suggested that the patient had deep seated, concealed cancer ! While the patient was living, no cancer was observed; however, at autopsy, gastric cancer was found

PULMONARY EMBOLISM ! Phlegmasia may be associated with “a most formidable accident – the breaking up in fragments of the obliterating clots” ! In some cases, this clot may be “carried on by the current of blood to the heart, and thence to the pulmonary artery” ! Symptoms include “pain in the chest and great respiratory anxiety” and, frequently, death !

Trousseau notes that not all cases of pulmonary embolism are fatal; in these cases “it is probable that the clot was small, and capable of being absorbed”

Case Study 3 ! A male patient had symptoms of a simple ulcer of the stomach, and subsequently developed phlegmasia !

Trousseau diagnosed rapidly advancing cancerous disease

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Soon after diagnosis, the patient died from gastric cancer

Case Study 4 ! A man, aged 40 years, consulted Trousseau with “pain and a feeling of weight in his left leg” !

Upon questioning, Trousseau found that the patient had experienced similar pain in the right leg and had been operated on for a tumor of the testicle

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Trousseau found deep-seated cancer in this patient

Discussion ! Trousseau suggests that “the painful oedema of the interior extremities in cases of cancer of the testicle, uterus, or rectum… arise from the inflammation of the veins of the primarily diseased parts being propagated to deep-seated veins, nor [is] oedema the mechanical consequence of pressure exerted on the abdominal veins by tumors or diseased glands” because even “cancers of the stomach or breast give risk to this kind of phlegmasia” !

According to Trousseau, “so great… is the semiotic value of phlegmasia in the cancerous cachexia, that I regard this phlegmasia as a sign of the cancerous diathesis as certain as sanguinolent effusion into the serous cavities”

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Trousseau suggests that cancer is associated with “a special crisis of the blood, which, irrespective of inflammation, favors intra-venous coagulation”

For educational purposes only. These were not prepared or reviewed by the primary author.