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.”
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”
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”
! Compression of the limb was required to cause pain
! Later, the patient developed edema of the legs, extending upwards
from the feet and “soon invading the thighs”
! 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”
! Eighteen days after initial commencement of symptoms, the left leg
and the foot had “notable lividity, where the slightest rubbing was
painful”
! This patient died after 22 days
! 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”
! 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”
! 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”
! 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
! 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
! 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 PULMONARY EMBOLISM
! Trousseau admitted a patient, aged 59 years, to his clinic ! Phlegmasia may be associated with “a most formidable accident –
! This patient was “seized with phlegmasia alba dolens” of the left leg the breaking up in fragments of the obliterating clots”
without any known cause ! In some cases, this clot may be “carried on by the current of
! The patient had “acute deep-seated pains in the calf, beginning blood to the heart, and thence to the pulmonary artery”
about the lower third of the leg and extending up to the ! Symptoms include “pain in the chest and great respiratory
hamstring” anxiety” and, frequently, death
! When consulted, Trousseau suggested that the patient had ! Trousseau notes that not all cases of pulmonary embolism are fatal;
deep seated, concealed cancer in these cases “it is probable that the clot was small, and capable of
! While the patient was living, no cancer was observed; however, being absorbed”
at autopsy, gastric cancer was found
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
! 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
! 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”
! 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.