Virchow's triad?

To the Editor: Your journal recently published an interesting letter offering a unique perspective on the intent of Virchow's triad. (1) Brotman et al successfully demonstrated that Rudolf Virchow postulated a triad as an explanation for the adverse consequences observed in the pulmonary vasculature following pulmonary embolism, and more specifically, as it pertained to the reaction elicited following experiments in which he introduced various foreign bodies into the venous circulation of dogs. (2)

As evidenced by the information reported by Brotman et al, Virchow probably never published a triad elucidating the pathogenesis of venous thrombosis. (3,4) It may further interest your readers to know that Virchow's triad--if we are to assume that Virchow's dissertation on the consequences of a pulmonary embolism forms the actual basis for today's paradigm--was not a novel observation attributable to Virchow. (4) Many of his predecessors described in modest detail how three categories contribute to venous thrombosis: alterations in blood flow, vascular endothelial injury, or alterations in the constitution of the blood. (4) For example, Wiseman (1686) (5) and Andral (1830) (6,7) both predated Virchow by identifying the contributors to venous thrombosis in recognizing two and three of the triad's categories, respectively.

Curiously, the initial appearance of the term "Virchow's triad" remains nebulous. A review of the English and French literature using the Index Medicus, Surgeon General's Catalogue, and period texts, suggests that the eponym first appeared around the 1950s, and somewhat later in most major pathology texts. Of course, a comprehensive review of the German literature might be expected to advance the date of the term's appearance in the medical literature. (4) More surprising, however, is the fact that a consensus on each of the three categories contributing to venous thrombosis does not readily appear until the 1930s, decades after Virchow's death. (4)

Remarkably, this paradigm has endured despite marked advancements during the last century in our appreciation of the factors contributing to venous thrombosis. (1,4) Consequently, despite its tenuous origins, Virchow's triad remains relevant to pathologists and clinicians alike.

References

1. Brotman DJ, Deitcher SR, Lip GY, et al. Virchow's triad revisited. South Med J 2004;97:213-214.

2. Virchow RLK. Gesammelte Abhandlungen zur Wissenschaftlichen Medicin [Frankfurt, Meidinger Sohn & Co., 1856], in Virchow RLK: Thrombosis and Emboli (1846-1856). Matzdorff AC, Bell WR (transl). Canton, Science History Publications, 1998, pp 5-11, 110.

3. Owen CA. A History of Blood Coagulation. Rochester, Mayo Foundation for Medical Education and Research, 2001, pp. 169-180.

4. Dickson BC. Venous thrombosis: on the history of Virchow's triad. UTMJ 2004;81:166-171.

5. Wiseman R. Several Chirurgical Treatises. 2nd ed. London, Norton and Macock, 1686, pp. 64-66.

6. Owre A. Studies of the clinic and etiology of post-operative thrombosis. Acta Chir Scand 1929;65:1-111.

7. Hellsten WO. Phlebographic studies and heparin treatment. Acta Chir Scand 1942;87:1-296.

Brendan C. Dickson, BA, BSC, MSC, MD

Department of Laboratory Medicine and Pathology

University of Toronto 

Toronto, ON