i * a? i 1 - iil flHI k^:"; && i At ) M ^SMf *^ ^ Cornell University Library RC 691.S63 Venous thrombosis during myocardial insu 3 1924 000 273 361 DATE DUE GAYLORD PRINTED IN U.S.A. The original of this book is in the Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924000273361 CONTENTS. PAGE Introduction 1 Relation to (Edema 1 Relation to Outcome of Primary Disease 1 Frequency 1 Localization 2 Type of Cardiac Lesion 2 Etiology 2 Case Report 3 Analysis of the Literature 6 Report of Cases 9 Cases from the Literature 9 New Cases 14 Analysis of Cases 33 Number of Cases 33 Age 34 Sex 35 Etiology 35 Cardiac Lesion 36 Localization of Thrombi 37 Clinical Evidence of Infection at Time of Thrombosis 38 Clinical Symptoms, Signs of Thrombosis 38 Result 39 Bibliography 40 VENOUS THOMBOSIS DUKING MYOCARDIAL INSUFFICIENCY. By F. J. SLADEN, M. D., Late Resident Physicion, The Johns Hopkins Hospital, AND M. C. WiNTERNITZ, M. D., Associate Pathologist, The Johns Hopkins Hospital. (From the Medical Clinic and the Pathological Laboratory of The Johns Hopkins Hospital.) Extensive thromboses of venous trunks during a state of insufficiency of the heart muscle, dependent upon valvular disease of the heart or primary myocardial degeneration, have been recognized and reported in a few excellent monographs abroad and in this country. The cases reported, however, are few in number, in fact so few that the condition may be regarded by some as a medical curiosity and as one not deserving careful analysis or attention. This conception should be corrected. It immediately suggests itself that these thromboses may be readily overlooked, when one bears in mind that they are invariably associated with an extensive cardiac oedema, and that this oedema may not only effectually mask the local circulatory disturbance, i. e., the oedema re- sulting from thrombosis of a large venous trunk, but also make it impos- sible to see or palpate the occluded vessel. It is a relatively frequent clinical experience to see an asymmetrical oedema in cases of myocardial insufficiency, and it will be shown that this is not an effect of gravity, as is usually accepted, but much more frequently than supposed is dependent upon an actual venous thrombosis. The relation of the thrombosis to the outcome of the primary disease is also of importance. The thrombosis itself adds another insult to a constitution already weakened by disease and often though not always leads to death. The outcome is usually directly dependent upon the seriousness of the primary condition. The veins in some cases become canalized, or a sufficient collateral circulation is established to alleviate the mechanical effects of the venous occlusion. The frequency and importance of the condition have not only been overlooked clinically but very few observations are recorded from the 2 F. J. Sladen and M. C. Winternitz. post-mortem table. This may be partly accounted for by the fact that many of the thromboses occurring during myocardial insufficiency are situated in vessels not exposed in the routine autopsy on account of the necessity to avoid mutilation of the body. Many others, located in the large veins, may be very easily dislodged in removal of the heart and then overlooked entirely. This is attested to by the well-known fact that pulmonary emboli are not infrequently missed, unless the oper- ator's attention is especially directed to them by the clinical history, and with this lead the pulmonary vessels are opened in situ. It is not par- ticularly uncommon to have one's attention first directed to the pos- sibility of a large pulmonary embolus by finding smaller ones projecting from the larger arterial trunks on section of the lung. The localization of the thromboses occurring in cases of myocardial insufficiency appears, from the literature, to be mtfst frequently in the veins of the upper extremities. This is of especial interest because it is exceptionally rare to encounter venous thrombi in these vessels in other conditions than the one under consideration. Further, it has been stated repeatedly that the venous trunks of the left side of the body are much more frequently affected than those of the right. This finding has led previous writers to many theories concerning the localization of the thrombosis. Most important among these is the greater length of the left subclavian vein and the possibility that it may be compressed by a dilated auricle. This theory we shall show to be fallacious, since in the analysis of the total number of cases, including those collected from the literature and our own relatively large series, there is practically no dif- ference in the frequency of the thrombosis on the right and the left side. The type of cardiac lesion with which the accident is reported to occur with greatest frequency is mitral stenosis. It is not unnatural to expect this, since mitral stenosis is, as is well known, one of the most severe of the cardiac affections, leading early in its course to chronic congestion of the systemic vessels. But this is not the only cardiopathy in which extensive venous thrombosis occurs. As will be shown, almost any lesion of the heart resulting in myocardial insufficiency may be asso- ciated with thrombosis of the veins of the upper extremities particularly and, more rarely in our experience, of those of the lower, though here too the condition is more frequent than at present imagined. In the etiology of venous thrombosis the mechanical factor of venous slowing has been emphasized by almost all writers. This slowing is a natural result of the insufficiency of the heart muscle. However, it can- Venous Thrombosis During Myocardial Insufficiency. 3 not be the only factor, since it does not account for the relatively greater frequency of the thrombosis in the veins of the upper extremities. To explain this most authors resort to the above mentioned possibility, namely, pressure on the large veins of the left arm by the dilated left atrium. But, as has been pointed out, this cannot be the cause, since thrombosis is no more frequent on the left side than on the right. The abnormal dilatation of the veins themselves has been mentioned by Cohnheim, and it seems reasonable to suppose that their engorgement and dilatation, associated with the slowing of the blood stream, may be of importance in producing retrogressive changes in the vessel walls, which might render them more prone to thrombotic involvement. The most acceptable suggestion concerning the etiology of the thrombosis is that it results from infection. This seems very reasonable and, while still a theoretical possibility, is certainly to be considered. With these etiological factors, slowing of the blood stream, dilatation and engorge- ment of the venous trunks and infection, all the necessary conditions for thrombosis are present. The localization alone remains unexplained. Our attention was directed to this subject by the occurrence of what was then thought to be an exceptionally marked instance of venous thrombosis involving all the veins of the right upper extremity together with all of the branches draining into the right innominate vein, even to its finest ramifications. This was associated with a myocardial insuf- ficiency resulting from a severe primary myocarditis. The following is a brief account of the case with photographs : J. H. H. Serial No. 59. — R. F. W., male, white, aged 49 years. Clinical diagnosis: Myocardial insufficiency; thrombosis of right innominate, jugu- lar and subclavian veins and their branches; pulmonary infarction. Death. Autopsy. The past history was unimportant. The onset of the terminal illness was four months before admission with cough and dyspnoea. For three weeks patient remained in a state of myocardial insufficiency with cyanosis, dyspnoea, oedema of the lungs, rapid and irregular pulse, an enlarged heart without murmurs and an enlarged and tender liver. Two days before death swelling of the right arm was noticed and regarded as a mechanical effect of gravity in the general anasarca. It increased the next day, and thick, firm whip-cords could be traced from elbow to axilla in the course of the brachial vein. The right external jugular stood out prominently. Before death small thrombosed veins were apparent in the right pectoral region and in the region of the thyroid gland. Blood cul- tures and cultures from the thrombosed veins intra vitam remained sterile. Fever and leucocytosis were present. 4 F. J. Slaclen and M. G. Winternitz. Anatomical diagnosis: Chronic fibrous myocarditis; dilatation and hypertrophy of the heart; cardiac insufficiency; chronic passive conges- tion of the viscera; multiple mural puriform thrombi of right and left ventricle; healed and healing anaemic infarcts of spleen and kidneys; thrombosis of right superior vena cava; propagated thrombus extending into the large veins of the neck and right arm; oedema of right arm; multi- ple pulmonary emboli with multiple haemorrhagic infarcts of the lungs; acute pleuritis (right); hemorrhagic exudate; chronic splenic tumor; 3fc^ Photogkaph on Second Day of Thrombosis Showing Prominent Jugular Veins and (Edema of the Right Arm. chronic perisplenitis; fatty degeneration of liver; chronic fibrous epidi- dymitis; thrombi in the spermatic and prostatic veins. The right portion of the thorax and the right arm are very oedematous. The arm measures half again the circumference of the left arm. In the upper portion of the anterior mediastinum the veins stand out as large firm cords. The right innominate vein and all of its neck and arm branches are similarly involved. Along the course of the veins bulbous nodules protrude, which show the situation of the valves within. The entire sub- cutaneous tissue in the region where these veins are thrombosed is very markedly (Edematous, and on section one sees that this oedema is partly Venous Thrombosis During Myocardial Insufficiency. 5 interstitial, but partly due to a tremendous dilatation of the lymphatics, some of which in the region of the lymphatic duct and along the course of the subclavian vein and in the axilla are almost 1 cm. in diameter. They contain a clear, yellowish fluid. V'l'-' &.*fll\ The accompanying illustration made by Mr. Max Broclel, is an excel- lent reproduction of the condition found at autopsy. During the year 1913, while reviewing the 49 cases in the literature, five examples of venous throm-bosis during myocardial insufficiency 6 F. J. Sladen and M. C. Winternitz. were observed in this clinic. This suggests strongly that it occurs much more frequently than has been supposed. In the following paper the literature will first be reviewed, and then the 48 reported cases, with our own 17 cases, will be presented. We shall attempt to correlate the clinical and pathological pictures and the cases will be analyzed with this point in view. Literature. In 1845 Bouchet reported the first case in the literature of venous thrombosis during myocardial insufficiency. He, like many subsequent writers, failed to appreciate the importance of their simultaneous occurrence. Peter (1873), one of the first to become interested in the etiology of thrombosis in this condition, believed the cachexia of cardiopathies was the essential factor in producing thrombosis; it was a popular theory that the blood was changed to a hyperinotic condition and the tendency to coagulation thereby increased. The anatomical peculiarities of the venous trunks of the upper ex- tremities impressed Hanot. In 1874, he pointed out that the left bra- chiocephalic trunk was longer and more oblique than the right, making the return of the blood from the left side more difficult than from the right, even in a normal person. This he thought to be supported by the fact that cardiac oedema appears earlier and persists longer in the left upper extremity. Parmentier (1889) further emphasized what Hanot had pointed out. He believed that while ordinarily the stream would be slower in the longer, more oblique veins from the left side, a condition of insuf- ficient heart muscle would accentuate the relative venous stagnation. More extensive consideration of the subject is found in Hirschlaff' s Inaugural Dissertation (1893) " Upon the Causes of Thrombosis in the "Upper Extremities." In a series of 20 cases he contrasted two that had occurred during myocardial insufficiency with 18 complicating aneurysm, malignant disease, tuberculosis, pneumonia and acute infec- tions. Hirschlaff explains the localization of the thrombosis in myocar- dial insufficiency as follows: He believed that unusual dilatation of the venous trunks and consequent slowing of venous flow were not the only factors, although conspicuous ones. The endothelial defects of the ressel wall or areas of endophlebitis, emphasized by Cohnheim, Hirsch- laff considered to be small and difficult to locate. Venous Thrombosis During Myocardial Insufficiency. 7 He pointed out that the valves on the left side at the junction of the subclavian and internal jugular veins are more often insufficient than those on the right. This led him to conclude that there was a relation between the thrombosis and the insufficiency of the venous bulb valves accounting for the more frequent occurrence of the thromboses on the left side. He believed also in the importance of the greater length of the veins on this side and that they emptied themselves with greater difficulty. This he thought manifested itself clinically in the earlier occurrence of oedema in the left arm in developing anasarca. The localization of the thrombosis at the junction of the subclavian and jugular veins, Hirschlaff thought might be due to many causes. First, platelets tend to accumulate at places where veins meet (Ebert and Schimmelbusch) and here, where the large valves of the veins are located and where two large veins meet at a sharp angle, the eddy (Wirbelbewegung of v. Eecklinghausen) is marked and may promote clotting. Further, he ingeniously suggests the emptying of infectious material from the thoracic duct into the subclavian vein at this location as a possible factor in the localization of the thrombosis. The first communication in the English literature was by Baldwin (1897), who collected 34 cases of jugular thrombosis. Only one of these, however, developed during myocardial insufficiency. To Baldwin the etiological factors were : (1) The sluggish or arrested circulation; (2) an infectious process in the vein, that is, an injury due to bacterial invasion of the blood; (3) a morbid condition of the blood rendering it more coagulable. Poynton (1898) stated that the process occurred where the vertical jugular current meets the cross current from the subclavian vein. The frequency of active carditis suggested to him that the thrombosis might be associated with a similar infectious process in the veins. Gallavardin reviewed the cases in the literature up to 1900. He noted the frequent association of the thrombosis with mitral stenosis and the fact that it occurred most frequently in the veins of the upper extremity, especially in those of the the left side. He emphasized the occurrence of the thrombosis during cardiac decompensation and the constant fatality of the affection. Cachexia and stasis appealed to him as causative fac- tors of the thrombosis, and he considered that bacteria must be accepted as the cause of the clotting. He says in conclusion: "This venous thrombosis in heart cases forms a distinct group, possessing etiological, 8 F. J. Sladen and M. G. Winternitz. anatomical and clinical individuality, unique especially in their causa- tion, localization and fate." This brings us to the best and most comprehensive consideration of the subject, the monograph by Welch * in 1900. He reported five cases of his own .and 23 from the literature. Welch states : " In the great majority of cases the thrombosis ap- peared during a condition of failure, generally extreme failure, of com- pensation of advanced mitral disease." In 24 of the 28 cases the thrombi were found in the veins of the neck and arms and so constitute a special group of thromboses of the upper extremity. This group of thromboses was associated almost exclusively with mitral disease, stenosis leading. This suggested to Welch that a dilated left auricle or dilated pulmonary vessels may press upon the left subclavian vein, and play a part in determining the localization of the thrombi. Additional factors he believed to be the valves of the veins, the bulbous jugular base, the attachment of the veins to the fascia, the coming together at oblique or right angles of venous currents at different speeds, and the systolic reflux in tricuspid insuffiency. In conclusion, he emphasized as the cause of the thrombosis and its localization: (1) The particular disturbance of the circulation ; (2) the anatomical structure and dis- position of the veins; (3) infection as the most probable etiological factor. Huchard collected 50 cases in 1905 and gave the subject very com- plete consideration. He, too, emphasized the role of infection and cited the concurrent presence of fever, bronchitis, pleurisy, pneumonia, etc., as further evidence of this point. He pointed out that, clinically, jugu- lar-subclavian thrombosis has an onset with pain followed by swelling of the face, neck and upper extremity. The oedema becomes hard and cyanotic. In the neck it resembles parotitis (Cheadle and Lees). It spreads over the thoracic wall and involves the mammary gland (Hanot). There is pain in the course of the vein. Hard cords are palpable and visible. Finally, Blumer noted that canalization or collateral circulation, suf- ficient to carry off the blood, may occur, but may be entirely insufficient under the stress of the serious decompensation. * Welch's paper " Venous Thrombosis as a Complication of Cardiac Dis- ease " includes cases not necessarily in a state of myocardial insufficiency, the criterion of the writers. Some of these, therefore, have been excluded from our series. Venous Thrombosis During Myocardial Insufficiency. 9 Repoet op Cases. The following is a very brief digest of the cases found in the literature, arranged in chronological order. No mention is made of the dyspnoea, cyanosis, cough and bloody expectoration, abdominal pain and such manifestations of the varying degrees and combinations of pulmonary oedema, passive congestion of the liver and viscera, ascites and effusions in other serous sacs, and oadema, indicative of myocardial insufficiency. Every case supplies this picture to a greater or lesser extent. Where possible the sex, age, etiology of the cardiac affection, the cardiac lesion, symptoms and signs of thrombosis, localization of thrombosis, result, duration of observa- tion, autopsy, conformation and additional important autopsy findings will be given. No. 1. — Bouchet (Gaz. m6d. de Par., 1845, xiii, 2»»e s. 245): Male, age (?). Myocardial insufficiency. Cyanosis, oedema of face, neck and arms. Palpable painful, firm veins. Collateral circulation over chest. Thrombo- sis of superior vena cava, jugulars and axillaries of both sides and their branches. Recovery in five months. No. 2. — Cohn (Klinik der embolischen Gefasskrankheiten, Berl., 1860, S. 118) : Female, aged 61 years. Marked arteriosclerosis and hemiplegia four years before present illness. Aortic stenosis and insufficiency. CEdema of left foot and leg. Fourteen weeks later oedema of right leg. Thrombosis of both iliac veins. Death in 14 weeks. Autopsy. No. 3. — Ramirez (Gaz. m6d. de Par., 1867, xii, 716) : Male, aged 12 years. History of acute rheumatic fever one year before present illness. Aortic and mitral insufficiency. Painful oedema of right and left arms during general anasarca. Thrombosis of right jugular, axillary, subclavian veins and branches. Death in 24 hours. No autopsy. No. 4. — Ramirez (Gaz. med. de Par., 1867, xii, 716) : Male, aged 50 years. Aortic and mitral insufficiency. Aortic stenosis. Painful, hard oedema of left neck and arm. Palpable cords. Thrombosis of left jugular and sub- clavian veins and branches. Death in two days. Autopsy. No. 5.— Diuguet (These de Par., 1872) : Sex (?) Age(?) Mitral steno- sis and insufficiency, rheumatic in origin. Painful hard oedema of left arm with palpable axillary veins. Thrombosis of left subclavian, axillary and brachial veins. Autopsy: Pulmonary infarcts. No. 6.— Audral (Bull. Soc. anat. de Par., 1873, xlviii, 328) : Old woman. History of two attacks of acute rheumatic fever at nine. Mitral stenosis and insufficiency. Painful oedema of left neck and arm. Evidence of collateral circulation. Thrombosis of left subclavian, jugular and axillary veins. Death. Autopsy: Pulmonary infarcts. 10 F. J. Sladen and M. C. Wintemitz. No. 7. — Peter (Legons de clinique meU, 1873, i, 209) : Woman. Age (?) Mitral stenosis and insufficiency. Painful oedema of left arm. Later oedema and tenderness in left neck. Hard, palpable veins. Recovery in three weeks. No. 8. — Hanot (Compt. rend. Soc. de biol., 1874, i, 80): Female, aged 58 years. Mitral stenosis and insufficiency. GEdema of left arm. One month later, oedema of right arm. Thrombosis of left and right subclavian veins. Death in six months. No autopsy. No. 9. — Hanot (Compt. rend. Soc. de biol., 1874, i, 80) : Female, aged 40 years. Endocarditis of aortic and mitral valves. CBdema of left arm. Thrombosis of left subclavian vein. Death in three months. No autopsy. No. 10. — Hanot (Compt. rend. Soc. de biol., 1874, i, 80) : Female, aged 57 years. Aortic insufficiency and stenosis. CBdema of left arm. Thrombosis of left subclavian vein. Death in four weeks. No autopsy. No. 11. — Hanot (Compt. rend. Soc. de biol., 1874, i, 80) : Male, aged 73 years. Mitral insufficiency. CBdema of left arm. Thrombosis of left sub- clavian vein. Death in one month. No autopsy. No. 12. — Dreyfus (Bull. Soc. anat. de Par., 1875, 1, 599) : Female, aged 37 years. History of acute rheumatic fever at 20. Mitral stenosis and insufficiency, and aortic insufficiency. Painless oedema of left arm. Throm- bosis of left subclavian vein. Jaundice. Acute endocarditis. Renal in- farction. Death in one month. Autopsy: Pulmonary infarcts. No. 13. — Robert (Bull. Soc. anat. de Par., 1880, lv, 314) : Female, aged 30 years. History of cardiac symptoms following pneumonia eight years before present illness. Mitral stenosis. CEdema of left arm and left face. Palpable veins in left neck. Collateral circulation. Thrombosis of left innominate, subclavian, and jugular veins. Death in one month. Autopsy: Pulmonary infarcts. No. 14.— Malibran (Bull. Soc. anat. de Par., 1884, lix, 104): Female, aged 49 years. Mitral stenosis and insufficiency. Pain in left groin and popliteal space. Hard, firm cord. Painful oedema of left leg. Throm- bosis of left femoral and popliteal veins. Death in 47 days. Autopsy. No. 15. — Potherat (Bull. Soc. anat. de Par., 1889, lxii, 620) : Male, aged 40 years. Aortic insufficiency, not recognized clinically. General oedema including face and arms. Thrombosis of right subclavian and jugular veins. Death in two days. Autopsy: Pulmonary infarction. No. 16. — Parmentier (Arch. gen. de m§d., 1889, ii, 91) : Female, aged 40 years. Mitral insufficiency, probably following puerperal infection four years before present illness. Painful oedema of left arm and breast. Thrombosis of left subclavian vein. Jaundice and fever. Death in four days. Autopsy. Venous Thrombosis During Myocardial Insufficiency. 11 No. 17. — Ormerod (Trans. Path. Soc. Lond., 1889, xl, 75): Sex ? Age ? Mitral stenosis. CEdema of right arm, later of left arm. Thrombosis of both innominate, jugular and subclavian veins. Death. Autopsy. No. 18. — Hirschlaff (Inaug. Diss., Berl., 1893) : Femalvs, aged 53 years. History of acute rheumatic fever at 12, 15, 18, 20 and 22. Mitral insuffi- ciency and stenosis, and aortic insufficiency. CEdema of both hands, left half of thorax, left supraclavicular fossa and left face. Disappearance of pulse in left external jugular vein. Painful hard jugular cord. Throm- bosis of left innominate subclavian, and jugular veins. Jaundice. Death in six days. Autopsy. No. 19. — Hirschlaff (Inaug. Diss., Berl., 1893) : Female, aged 51 years. History of acute rheumatic fever at 20. Mitral stenosis, aortic insuffi- ciency, tricuspid stenosis. Painful swelling of left neck and arm. Three weeks later swelling of right neck and face and over right thorax. Throm- bosis of superior vena cava, left innominate vein and branches. Jaundice. Death in one month. Autopsy: Pulmonary infarcts and fresh endocarditis. No. 20.— Huchard (Le Bull. med., 1894, viii, 423): Female, aged 24 years. History of two attacks of acute rheumatic fever seven years before last illness. Mitral stenosis. Painful oedema of left arm. Thrombosis of left brachial vein. Death in 10 days. Autopsy: Pulmonary infarction. No. 21. — Gatoy (These, de Par., 1895) : Female, aged 25 years. History of acute rheumatic fever 20 years before last illness. Mitral stenosis and insufficiency. Hard oedema of left arm and hard brachial cord. Thrombosis of left brachial vein. Chills. Death. Autopsy: Pulmonary infarcts. No. 22.— Meslay (Rev. mens. d. mal. de 1' ent, 1895, xiii, 559) : Female, aged 13 years. History of two attacks of acute rheumatic fever one year before final illness. Mitral stenosis and insufficiency. Adherent pericar- dium. Pain and swelling in right arm involving neck next day. Palpable cords. Thrombosis of right innominate, subclavian and jugular veins. Fever. Enlarged axillary and cervical glands. Death in 16 days. Autopsy: Pulmonary infarcts. No. 23. — Mader (Jahrb. d. Wien. K. K. Krankenanst, 1895, iv, 252) : Female, aged 45 years. History of acute rheumatic fever. Mitral stenosis and insufficiency. Pain and swelling of arms, neck and upper chest. Collateral circulation to epigastric veins. Thrombosis of both innominate veins. Recovery. No. 24.— Kahn (Arch. gen. de med., 1896, vi, 469) : Female, aged 52 years. Mitral insufficiency. Painless oedema of right hand, arm and breast. Thrombosis of right subclavian vein. Fever. Chronic lymphadenitis about subclavian vein. Death in 20 days. Autopsy: Pulmonary infarcts; pneumococcus isolated from the thrombus. No. 25.— Baldwin (J. Am. M. Asso., 1897, xxix, 371) : Female, aged 19 years. History of five attacks of acute rheumatic fever seven years before 2 12 F. J. Sladen and M. C. Winternitz. present illness. Aortic, mitral and tricuspid stenosis and insufficiency. Pain and swelling of left axilla and neck. Tender tortuous cords. Throm- bosis of left innominate, jugular and subclavian veins. Death in nine days. Autopsy: Pulmonary infarcts. No. 26.— Nicolle et Robineau (La Normandie med., 1897, xii, 68): Female, aged 16 years. History of repeated attacks of acute rheumatic fever four years before final illness. Mitral stenosis and insufficiency. Pain and oedema of left neck and head. Painful palpable jugular cord, followed in 10 days by oedema of left arm. Thrombosis of left innominate, jugular and subclavian veins. Jaundice. Death in 23 days. Autopsy: Pulmonary in- farcts ; chronic lymphadenitis about subclavian vein. No. 27. — Poynton (Lancet, Lond., 1898, ii, 206) : Female, aged 19 years. History of acute rheumatic fever nine months before final illness. Aortic and mitral insufficiency and adherent pericardium. Swelling of left arm, face, right arm and chest. Thrombosis of superior vena cava, both innomi- nate veins and branches. Jaundice. Death in two weeks. Autopsy. No. 28. — Poynton (Lancet, Lond., 1898, ii, 206) : Female, aged 21 years. History of acute rheumatic fever as a child and also two years before final illness. Mitral insufficiency. (Edema of left face. Thrombosis of left jugular vein to angle of jaw. Fever, sweats and jaundice. Death in three days. Autopsy: Pulmonary infarcts; fresh endocarditis. No. 29. — Poynton (Lancet, Lond., 1898, ii, 206) : Female, aged 9 years. Mitral insufficiency. (Edema of face, neck, arms and chest. Palpable jugular cords. Thrombosis of superior vena cava, both innominate veins and branches. Death in eight days. Autopsy: Fresh endocarditis; nega- tive cultures from blood. No. 30. — Gallavardin (Province mSd., 1899, xxxv, 409) : Female, aged 16. History of chorea at seven. Mitral insufficiency and stenosis. Firm, painful swelling of left arm and neck. Palpable cords. Thrombosis of left subclavian and jugular veins. Death in two days. Autopsy: Pul- monary infarcts. No. 31. — Gallavardin (Province med., 1899, xxxv, 409) : Female, aged 30 years. Mitral stenosis. Swelling in neck above right clavicle. Pain along right jugular veins. Jugular cord. Thrombosis of right jugular vein. Recovery in one month. No. 32.— Hanot '(Arch. gen. de m6d., 1899, 91) : Female, aged 40 years. Mitral insufficiency. (Edema of left arm and breast. Thrombosis of left subclavian vein. Death. Autopsy. No. 33. — Gallavardin (Lyon mgd., 1900, xci, 10): Female, aged 53 years. History of heart trouble for two years. Mitral insufficiency and stenosis. Pain below left clavicle. Swelling of left hand and arm. Collateral circu- lation. Red, painful swelling of right leg for two months. Thrombosis of left subclavian, jugular and right femoral veins. Recovery. Venous Thrombosis During Myocardial Insufficiency. 13 No. 34. — Klnnicutt (Trans. Assn. Am. Phys., 1900, xv, 469) : Male, aged 58 years. Mitral stenosis and insufficiency. Pain and oedema of left arm, neck and face. Collateral circulation. Thrombosis of left jugular and subclavian veins. Recovery. No. 35. — Biggs (Trans. Assn. Am. Phys., 1900, xv, 469): Female, aged 20 years. Mitral insufficiency. Pain and oedema of left arm, neck and chest. Thrombosis of left innominate, jugular and subclavian veins. Death in four weeks. Autopsy: Enlarged glands about jugular vein. No. 36.— Ford (Phila. M. J., 1900, vi, 960) : Male, aged 56 years. His- tory of acute rheumatic fever as a child. Mitral insufficiency and stenosis. Tender, hard mass in right groin and popliteal space. Thrombosis of right common iliac vein. Death in one month. Autopsy. No. 37. — Macgregor (Amer. Med., 1901, i, 353) : Male, aged 46 years. Mitral stenosis. Cyanotic, painful swelling of left arm and neck. Col- lateral circulation. Thrombosis of left jugular and subclavian veins. Death in six weeks. No autopsy. No. 38.— White (Clin. J., 1902, xx, 297) : Female, aged 24 years. History of acute rheumatic fever and tonsillitis. Mitral and aortic insufficiency and stenosis. Tender swelling of left neck, shoulder and arm. Jugular cords on both sides. Thrombosis of left subclavian and jugular veins and right jugular vein. Recovery in three and one-half months. No. 39.— White (Clin. J., 1902, xx, 297) : Male, aged 26 years. Mitral insufficiency. Hard, palpable jugular veins. Thrombosis of right and left jugular veins. Recovery. No. 40. — Favier (These de Lyon, 1903) : Female, aged 60 years. Myo- cardial degeneration. Painful, swollen left jugular vein. Jugular cord. Exophthalmos. Right hand swollen. Collateral circulation. Thrombosis of left jugular and right brachial veins. Death. No autopsy. No. 41. — Favier (These de Lyon, 1903) : Female, aged 36 years. His- tory of acute rheumatic fever at 20. Myocarditis. Cyanotic, painful swelling of right arm. Palpable axillary and jugular cords. Axillary adenitis. Torticollis. Collateral circulation. Thrombosis of right sub- clavian and jugular veins. Death in two and one-fourth months. Autopsy. No. 42. — Favier (These de Lyon, 1903) : Female, aged 66 years. Mitral insufficiency. Painful swelling in left neck. Collateral circulation. Skin red. Recrudescence after two and one-half months. Thrombosis of left jugular veins. Death in three months. No autopsy. No. 43. — Desquiens (Bull. Soc. anat. de Par., 1904, lxxix, 429) : Female, aged 22 years. Myocarditis. Painful oedema of right arm and neck. Pal- pable jugular cord. Collateral circulation. Thrombosis of right subclavian and jugular veins. Death in 19 days. Autopsy: Pulmonary infarcts. 14 F. J. Sladen and M. C. Winternitz. No. 44. — Lacombe (J. d. Practiciens, 1904, 359) : Female, aged 70 years. Mitral insufficiency. Painful swelling of right arm and neck. Palpable axillary cord. Thrombosis of right subclavian and jugular veins. Death in 32 hours. Autopsy. No. 45. — Desquiens (These de Par., 1906) : Female, aged 43 years. Mitral insufficiency and adherent pericardium. CEdema of right arm and neck. Jugular cord. Fever. Thrombosis of right jugular and subclavian veins. Death. Autopsy. No. 46. — Peters (Proc. N. Y. Pathol. Soc, 1909, ix, 149) : Female, aged 38 years. History of several attacks of acute rheumatic fever during 20 years. Mitral insufficiency and stenosis. Painful swelling in left neck and axilla. Palpable jugular and axillary cords. Leucocytosis, 14,000. Fever. Thrombosis of superior vena cava, left innominate, jugular and subclavian veins. Death in three weeks. Autopsy. No. 47.— Collet and Curtil (La Clinique, 1909, iv, 228) : Female, aged 63 years. Fibrous myocarditis. Swelling of left arm, shoulder, breast and neck. Palpable jugular cord. Thrombosis of left subclavian and jugular veins. Death in six days. Autopsy. No. 48. — Blumer (Yale'M. J., 1908-09, xv, 296): Male, aged 12 years. History of acute rheumatic fever. Mitral insufficiency. Pain in left neck. Swelling of left neck and arm. Tender veins. Fever. Thrombosis of left subclavian and jugular veins. Death. No autopsy. The following 17 eases have not been reported before, most of them occurring in the medical and pathological services of The Johns Hopkins Hospital. No. 49. — (J. H. H. Medical No. 708) : Male, black, aged 50 years. Aortic insufficiency, possibly of syphilitic origin. Thrombosis of right femoral vein. Death in one month. Autopsy: Pulmonary infarction. Past History. — The patient had gonorrhoea and lues as a young man, and rheumatic pains from time to time in knees and elbows. The joints were never swollen. Present Illness. — Onset was seven weeks before admission with shortness of breath on exertion, cough and expectoration. Three weeks before admis- sion swelling of legs appeared, which increased during the last week. There was a diminished amount of urine. The abdomen was swollen and much distress was felt in the region of the heart. Physical Examination. — On admission there was general anasarca, ascites, enlarged heart with signs of aortic insufficiency and gallop rhythm. The oedema diminished rapidly during the following week. One month after admission there was a recurrence of moderate oedema of the ex- tremities and ascites. Two weeks later there was no very definite impulse on inspection or palpation of vessels of neck. Ten days later tenderness on motion of the calf and thigh muscles of the right leg developed. CEdema Venous Thrombosis During Myocardial Insufficiency. 15 of the right leg appeared though there was none of the left. No difference was noted in the temperature of the two extremities. Sensation was nor- mal. During the following month there was more or less persistent myo- cardial insufficiency. There was no fever. The patient died suddenly three months after admission. Autopsy No. 149 — Anatomical Diagnosis. — Acute and chronic endocarditis of the aortic valves; cardiac hypertrophy and dilatation, with relative mitral and tricuspid insufficiency; hydrothorax (right) ; chronic passive congestion of viscera; thrombi in right ventricle; femoral thrombosis (right) ; infarction of lung; gangrenous abscesses in lung. Body. — The lower extremities, especially the right, are (Edematous. There is a slight excess of fluid in the abdominal cavity, and 1400 cc. of fluid blood in the right pleural cavity. There are several firm, red infarcts in the left lung. In the branches of the pulmonary artery leading to these are firm, adherent, thrombotic masses. The surface of the right lung is covered by a fresh, fibrinous exudate, and there is a large area of infarction in the lower border. In removing the lung this was broken into, revealing a gangrenous cavity with ragged walls and foul contents. The heart is very much enlarged and both sides are filled with clots and fluid blood. In the left ventricle near the aortic orifice there is a firmly adherent thrombus mass which is white and measures 5x3 cm. The aortic valves are much thickened. The heart muscle is firm, and of a dark red color. There are several small, fresh vegetations on the aortic valves. The other valves are normal. The length of the left ventricle is 9 cm., of the right TVz cm. Thickness of the wall of the left ventricle is 18 mm. and of the right 6 mm. Weight, 530 gm. The femoral {right) vein is occluded by a firm thrombus. No. 50.— (J. H. H. Med. No. 1231) : Male, black, aged 37 years. Myo- cardial degeneration. General anasarca. Fever. Thrombosis of right and left femoral veins. Condition not recognized clinically. Death. Au- topsy. Past History. — The patient had measles as a child. He has never been well since an attack of grip two years before admission. He has com- plained of cough and shortness of breath, especially during the previous six months, and of orthopncea at night. He has had oedema of legs and ascites for the last three months, and fever. Autopsy No. 196 — Anatomical Diagnosis. — General pulmonary substan- tive emphysema; hypertrophy and dilatation of the right ventricle and auricle; fatty degeneration of left ventricle; chronic passive congestion of liver and spleen; ascites; anasarca; large ulceration of thigh and scrotum; thrombus of femoral veins. Body. — There is marked oedema of both lower extremities. At the middle of the inner side of the left thigh is a very large, irregular, deep ulcer, 10 cm. in length and 9 cm. in breadth, extending down to the fascia covering the muscles. It is covered with a sloughing tissue and a red, (Edematous granulation. There is a similar ulcer on the anterior surface 16 F. J. Sladen and M. C. Wintemitz. of the scrotum, measuring 4 cm. in diameter. There is some oedema of the scrotum. The abdominal cavity contains 500 cc. of turbid, brownish- red, fluid. There are 100 cc. of yellow fluid in each pleural sac. The pericardium covering the right auricle is much thickened. The cavities of the right side of the heart are much distended and filled with a soft, cruor coagulum. The wall of the right ventricle measures 6-8 mm. in thickness, that of the left, 11-12 mm. The tissue has a pale, yellow-brown color, mottled with dark red dots and streaks. The heart weighs 360 gm. The coronaries are free of sclerosis. The lungs are bound down by old adhesions. There is marked emphy- sema. On section the lung has a salmon color. The other organs show chronic passive congestion. There is no further note on the thrombus in the femoral vein. No. 51.— (J. H. H. Med. No. 9282) : Female, black, aged 17 years. His- tory of two attacks of acute rheumatic fever six months before admission. Mitral insufficiency and adherent pericardium. Thrombosis of left innomi- nate, subclavian, axillary and jugular veins. Fever. Death in two days. Autopsy. Past History. — Measles, whooping-cough, chicken-pox, pneumonia one year before admission and a severe attack of inflammatory rheumatism. Nearly all joints were affected (swollen and tender). There was a second attack six months later with swollen, red, painful elbows and fever for one week. Present Illness. — Onset, 11 months before admission, with shortness of breath on exertion and palpitation of the heart. Three months before admission pains over the heart, slight cough and expectoration. No swelling of the feet at that time. Physical Examination. — On admission there was oedema of bases of lungs, enlarged heart, signs of mitral insufficiency and adherent pericardium. The heart's action was irregular. No oedema was present. Later notes showed that the condition of the heart was considered serious. Then ensued an attack of acute rheumatic fever involving both elbows and knees. There were definite signs of aortic insufficiency. Seven weeks after admission and two days before death the left arm became oedematous, the face and legs puffy. On the day of death the feet and left arm were somewhat puffy as well as the face. The patient com- plained of severe headache. The exitus was very sudden. Moderate, irreg- ular fever was present throughout stay in hospital. Autopsy No. 1245 — Anatomical Diagnosis. — Chronic aortic and mitral endocarditis; chronic adhesive pericarditis; cardiac hypertrophy and dila- tion; chronic passive congestion of the viscera; thrombosis of left innomi- nate, internal and external jugular, subclavian and axillary veins. No. 52.— (J. H. H. Med. No. 9423) : Female, white, aged 35 years. His- tory of eight attacks of acute rheumatic fever. Mitral and tricuspid steno- sis and insufficiency and aortic stenosis. Thrombosis of left subclavian and jugular veins and both common iliac veins. Fever. Death. Autopsy. Venous Thrombosis During Myocardial Insufficiency. 17 Past History. — Diphtheria at 10; chorea at 11, associated with paralysis of right side and eight attacks of acute rheumatic fever. Present Illness. — The patient was admitted two and one-half weeks after the onset with general nervous symptoms. Physical Examination. — On admission there were profuse crackles throughout the lungs, an enlarged heart, a presystolic murmur terminating in an accentuated first sound. The pulse was rapid and irregular. No oedema was noted, except for the crackles in the lungs. The cardiac condi- tion improved. Bight days after admission an attack of arthritis in the left ankle occurred. Eighteen days after admission uniform distension of the abdomen was noted. The liver dulness extended 5% cm. below the costal margin in the right mammillary line. The liver was tender and showed intrinsic pulsation. The oedema of the lung increased. Twenty-two days after admission the patient complained of swelling of the left arm from the shoulder to the wrist, without tenderness. By the next day the swelling had involved the left side of the neck, pectoral and shoulder regions and extended down the left arm as far as the left elbow in front and nearly to the wrist on the dorsal surface. There was pitting on pressure, disten- tion of the superficial veins and some tenderness. Twenty-seven days after admission the swelling in the arm had nearly disappeared, but the indurated swelling of the neck persisted. Thirty-six days after admission Dr. Osier made the following note : " Still a good deal of swelling over the shoulder and neck. Marked swelling along the jugular as high as the angle of the jaw. Foetal heart rhythm at base of heart." Then followed a period during which the general condition improved very much. The oedema of the left arm came and went. Pain in the right half of the abdomen and tenderness over the course of the external iliac vein developed, as well as distension of the abdomen and oedema of the legs. At times there was more or less myocardial insufficiency. Eleven months after admission sudden pain and cyanosis developed in the left leg and foot. A diagnosis of embolism was made by Dr. Osier. No pulsation was made out in the left popliteal and posterior tibial arteries. Three and three-quarter years after admission a similar attack of pain in the right leg occurred. Follow- ing this no pulsation was obtained from either femoral or popliteal arteries, and great discoloration of both legs developed. Sudden death intervened three years and nine months after admission. Autopsy No. 2458 (Dr. MacCallum) — Anatomical Diagnosis. — Chronic endocarditis; stenosis and insufficiency of the tricuspid and mitral valves; contraction of the aortic valves; hypertrophy of the heart; occlusion of the left jugular and subclavian veins with subsequent canalization; throm- bosis of aorta and common iliac artery; infarctions of spleen and kidneys; chronic passive congestion of viscera; obesity. Body. — There is a marked lividity of the legs — a bluish color extending over the thighs and even on the abdomen. Thorax. — On dissecting out the superior vena cava, it is found that the branches that form the left jugular are much thickened and contracted. 18 F. J. Sladen and M. C. Winternitz. On being followed up they are found to form a definite fibrous cord, which on section is seen to contain several small lumina full of fluid blood. The original lumen of the vein has entirely disappeared. On an attempt to open the vein the scissors pass into several small channels. Similarly in the subclavian vein there has been the same production of fibrous cords and canalization. The heart is somewhat enlarged. The epicardial surfaces are every- where smooth. The right side of the heart is especially enlarged. On opening the auricle it is found that the tricuspid orifice is narrowed to a diameter of 2 cm. and forms a slit-like orifice, 1 cm. in length. The chord* tendineae about this orifice are thickened and shortened. The pul- monary valves are normal. The endocardium" on the right side is clear. The pulmonary veins are free from thrombi. The left auricular appendage contains a definite thrombus. The mitral orifice is narrowed by a thick contracted edge to a slit of about 2x4 mm. Here, too, the chordae tendinese are shortened and thickened. The aortic valves are extraordinarily scarred and contracted. The right auricular appendage is almost enveloped in the fat of the epicardium. The posterior coronary artery opens here at the . sinus of Valsalva. The coronaries show no very marked sclerotic changes. The posterior and anterior coronary segments are especially contracted. The posterior coronary segment of the aortic valve is reduced in length to 4 mm. The edge is deeply eroded. All the valves are greatly thickened and bound together. In spite of all these alterations there is no great insufficiency apparent. The wall of the left ventricle measures about 12 mm. in thickness, that of the right ventricle about 5 mm. The right ventricle measures 8 cm. in length. The left ventricle measures about 6.5 cm. The muscle is cloudy and flecked with patches of gray opacity. There are no definite areas of fibrous myocarditis. The lungs on section are moist, tough and rubbery, everywhere air-con- taining and deeply congested. The arteries are very sclerotic. The spleen is enlarged and firm. On section several irregular red infarcts surrounded by a hemorrhagic zone are found. The liver is slightly enlarged. The surface is mottled with yellowish and dark red markings. On section the lobules are distinctly marked out. They are yellowish in color, separated by a dark red tissue. The kidneys are congested, and the left kidney shows several firm yellow- ish infarcts. The inferior vena cava is clear throughout. The aorta, on the other hand, at the level of the inferior mesenteric artery is completely occluded by a thrombus. Below this at the level of Poupart's ligament on the left side the common iliac artery forms a large mass which is quite firm to the touch. Below Poupart's ligament the arteries again contract and are empty. On section of the inferior mesenteric artery it is found to be closed at its root. The obliterated jugular vein shows microscopically the muscular wall of the vein, inside of which there is no thrombus but a firm connective tissue distending the original wall. The connective tissue is perforated with Venous Thrombosis During Myocardial Insufficiency. 19 very numerous, irregular cavities lined with endothelium. There are also small, narrow vessels apparently both venous and arterial in character. No. 53.— (J. H. H. Med. No. 9738) : Female, black, aged 70 years. His- tory of arthritis six months before admission. Myocardial degeneration. Thrombosis of femoral vein. Death. Autopsy: Thrombosis of right pul- monary artery. Present Illness. — The patient had rheumatism six months previous to admission lasting one month, involving the right knee which was swollen and painful. She has been short of breath and has had occasional cough with expectoration. Seven weeks before admission, after exposure to cold, she noticed, in addition to intensification of the above symptoms, swelling of the abdomen, left leg and left arm. The swelling of the arm was less at night, that of the leg remained the same. Physical Examination. — On admission there were scattered crackles throughout the lungs; the area of cardiac dulness was increased, and a soft, poorly transmitted, systolic murmur was heard. The pulse was rapid and irregular in force and rhythm. In addition there were ascites, oedema of the back of the abdominal wall, and of both legs, especially of the left. The course of the disease was afebrile. The patient died four days after admission and seven and one-half weeks after the onset of the present illness. Autopsy No. 1329— Anatomical Diagnosis. — Arteriosclerosis; chronic diffuse nephritis; cardiac hypertrophy; chronic passive congestion of the liver and intestines; thrombi in the right auricular appendage; throm- bosis of the left femoral vein. The body shows general oedema, especially of the subcutaneous tissues of the trunk. There are numerous varicose ulcers with scars over the left tibia. The peritoneal cavity contains two liters of clear fluid. Heart. — The pericardium contains 200 cc. of clear straw-colored fluid. The epicardium shows numerous milky patches and occasional supra- arterial fibroid nodules of a rather diffuse nature. The heart weighs 470 gm. The heart muscle is firm and of a brownish color. The valves, aside from slight thickening, show no abnormality. The coronaries are slightly sclerosed. The right auricular appendage is firmly distended by an ante-mortem thrombus. There are many thrombosed arteries in the lungs, which arise from a large mass just at the bifurcation of the main pulmonary artery. There is no infarction. The liver, spleen and kidneys as well as the lung show chronic passive congestion. The right femoral vein is patent. The left femoral vein is completely thrombosed, the thrombus distending the varicose dilatations that exist in the lower part of the vein. The thrombus extends up to just above Poupart's ligament. All the tissues of the legs are very cedematous. A small vein perforating the second left intercostal space near the sternal margin is much dilated and plugged with a thrombus mass. Streptococcus pyogenes was isolated from the heart's blood, from the thrombi in the intercostal and femoral veins, as well as from the auricular appendage, pulmonary artery and femoral gland. 20 F. J. Sladen and M. C. Winternitz. No. 54. — (J. H. H. Med. No. 10951) : Male, white, aged 16 years. History of pneumonia at seven. Aortic and mitral insufficiency. Thrombosis of the left subclavian, axillary and brachial veins. Fever, leucocytosis and purpura. Death in 19 days. No autopsy. Present Illness. — Two months before admission swelling of the feet, legs and abdomen developed, with constant shortness of breath, followed one week before admission by swelling of the face and hands. Physical Examination. — On admission there was orthopnoea, Cheyne- Stokes respiration, cyanosis, and general anasarca involving the eyelids, face, arms, trunk and legs. In addition, the left hand and wrist were very markedly (Edematous. There was oedema of the lungs, a wide area of cardiac dulness, a systolic murmur well transmitted through the axilla, a presystolic rumble, an aortic diastolic murmur and gallop rhythm. The day after admission the following note was made: " The left arm is very much more swollen than the right. The condition suggests venous throm- bosis. The brachial vein is distinctly indurated and cord-like and rolls beneath the fingers." By the eighth day after admission the swelling of the left forearm and hand had increased and the axillary and brachial veins felt like firm, thickened rods. Fever, leucocytosis, jaundice, purpura, and pleural friction rub developed nine days after admission with pain and an increase in the swelling of the left hand, forearm and lower half of the upper arm. On the day of death, 12 days after admission — 19 days after the onset of the thrombosis, and two months and one week after the onset of present illness — the oedema of the left arm was sufficient to cause a splitting of the corium. The patient died in a condition of myocardial insufficiency. No autopsy was obtained. No. 55. — (J. H. H. Med. No. 13023) : Female, white, aged 57 years. His- tory of arthritis seven years before admission. Mitral insufficiency. Fever. Death in six days. Autopsy: Condition not recognized clinically. Thrombosis of right and left femoral veins. Pulmonary infarcts. Past History. — Patient has had measles, whooping cough, chicken-pox, typhoid fever, pneumonia, small-pox and scrofula. She was. confined to bed for 10 weeks with rheumatism in the ankles and knees seven years before the present illness. Present Illness. — The onset was five months before admission with swelling of the feet and legs, hacking cough with expectoration, shortness of breath on exertion and scanty micturition. Physical Examination. — On admission there was cyanosis, dyspnoea, oedema of the lungs and fluid in the right pleural cavity. The cardiac dulness was not increased. The sounds were faint and a systolic murmur was present. There were marked arteriosclerosis, ascites and oedema of the lungs. Death occurred six days after admission with the patient in a state of myocardial insufficiency. Autopsy No. 175% — Anatomical Diagnosis. — Chronic nephritis; arterio- sclerosis; hypertrophy and dilatation of heart; general anasarca; thrombus Venous Thrombosis During Myocardial Insufficiency. 21 of femoral veins; mural thrombi (right and left ventricle and auricular appendage) ; thrombotic occlusion of the branches of the pulmonary arteries; multiple pulmonary infarcts; hydrothorax with slight fibrinous exudate; atelectasis of lung; chronic passive congestion of viscera; healing infarcts in spleen and kidneys; mitral and tricuspid vegetative endo- carditis. Body. — The dependent portions are very oedematous. (Edema of the legs is especially marked. The peritoneal cavity contains a small quantity of somewhat bile-stained fluid. The right pleural cavity contains about two liters of a turbid fluid of a brownish color. The pleural layers are bound together by old adhesions, overlying which is a layer of fresh fibrin. The left pleural cavity is obliterated by old adhesions. Over the apex the pericardial layers are bound together by adhesions. Heart. — The right auricular appendage is found filled with thrombus masses. The tricuspid valves are slightly thickened. Along the mitral valves corresponding to the line of closure there is a series of minute, ragged vegetations. The mitral valves are markedly shortened and thick- ened. The aortic valves are somewhat thickened but not deformed. Near the margin of the left coronary segment and the posterior segment are small verrucose vegetations. In the apical portion of the left ventricle is a small, globular thrombus projecting from the trabecule. A similar one is found in the right ventricle in the region of the conus. The heart muscle is rather mottled, grayish and opaque, and moderately soft. There are no definite areas of fibrous myocarditis. The coronary arteries are markedly sclerosed showing yellow patches on the intima. The heart weighs 520 gm. Lungs. — The pulmonary artery contains a large thrombus mass which is well rounded towards the hilum. It extends into the branches of the pul- monary artery, to the wall of which it is adherent. These branches of the artery, however, are for the most part incompletely filled by the thrombus. The viscera show chronic passive congestion. There are one or two thrombi in the veins of the broad ligament. There is marked sclerosis of the femoral vessels. The femoral veins contain a fresh thrombus. No. 56. — (J. H. H. Med. No. 15741) : Male, white, aged 40 years. Myo- carditis. Thrombosis of right jugular vein not recognized clinically. Death in two and one-half weeks. Autopsy: Pulmonary infarction. Past History. — First admission: Patient had had measles as a child. Present Illness. — The illness began six days before admission when the patient noticed that his feet, legs and thighs were swollen, and he had some shortness of breath. He has had a cough for the past six months with expectoration. Physical Examination. — On admission there were cyanosis, (Edema of lungs, enlarged heart, gallop rhythm, arterial hypertension, ascites and general oedema. Improvement was rapid with the disappearance of myo- cardial insufficiency. The attack was afebrile. Second admission, No. 15973. Two months later a similar condition of myocardial insufficiency was present for about six days. 22 F. J. Sladen and M. C. Wintemitz. Physical Examination. — There was oedema of the lungs, enlarged heart, gallop rhythm, enlarged liver, but no ascites or oedema. The patient improved rapidly. He began to work five weeks after the second discharge and continued for one year. For the last month he had shortness of breath, pain in the chest and swelling of the feet. Physical Examination. — On the third admission there were oedema of the lungs, enlarged heart, gallop rhythm, arteriosclerosis, enlarged liver, ascites, oedema of legs. The patient did not improve. Two weeks after admission he had an attack in which he became very cyanotic, restless and had pain in the legs. The legs up to the knees and the hands were extremely blue. By the following day the oedema of the legs was markedly increased. There were jaundice, suppression of breath sounds and crackles at the bases of the lungs, with pleural friction in the right back, pulsating liver, and extreme myocardial insufficiency. Death occurred two and one-half weeks after admission. There was a good deal of fever during the two weeks he was in the hospital. Bacteriological examination at autopsy: Heart: Streptococcus pyogenes. Thrombus: B. lactis wrogenes; B. proteus vulgaris, M. alius. Peritoneal cavity sterile. Autopsy No. 2458 (Dr. MacOallum) — Anatomical Diagnosis. — Arterio- sclerosis of the coronary arteries; degeneration of the myocardium; hyper- trophy and dilation of the heart; thrombus formation in the auricular appendage and left ventricle; chronic passive congestion of viscera; em- bolism of pulmonary and other arteries; hemorrhagic infarction of lungs; anaemic infarctions of spleen and kidneys; thrombosis of jugular vein (right). Body. — The abdominal cavity contains a large amount of turbid fluid. The liver extends 15 cm. below the ensiform cartilage. The right pleural cavity contains about 800 cc. of fluid. The heart is very much enlarged and weighs 530 gm. The right auricle is distended with a soft, post-mortem clot. The right ventricle is some- what enlarged. Its wall measures 7 mm. in thickness. The tricuspid and pulmonary valves are delicate and competent. The right auricular appendage contains a post-mortem clot and also a softened ante-mortem clot. This is a typical thrombus composed of friable, grayish material with irregular superficial lines. On incision it shows a central cavity filled with a grayish-red, turbid material. The left auricle is normal in appearance. The left auricular appendage contains mostly post-mortem clots, but also another one of these softened thrombi. The left ventricle is dilated; its wall measures about 16 mm. in thickness. The mitral valves are normal throughout. At the apex of the ventricle is a mass about 22 mm. in diameter, which is rounded and projects from between the trabecule. This has a superficial network of projecting ridges which alternate in color from dark red to grayish-red. On section it is found to be softened in the center, so that the surface forms merely the capsule for a quantity of reddish-gray, thick, semi-fluid material underlying this thrombus. The Venous Thrombosis During Myocardial Insufficiency. 23 heart muscle is rather opaque and yellowish. The aortic valves are deli- cate. The coronary arteries show sclerotic changes. The myocardium is rather soft and opaque. On tangential section it looks very cloudy and shows alteration of red or gray or even yellowish-gray patches. Lungs. — On opening the arteries extending to the lower branch of the lower lobe of the right lung, numerous plugs of thrombus material with softened centers similar to those seen in the heart are found. These are continued by propagated thrombi into the smaller vessels. On the edges of the lower lobe are several areas which project somewhat and are dark red and covered with fibrinous exudate. These do not contain air and are of a deep red color on section. They are directly continuous with the occluded vessels; otherwise, the lungs are moist and contain air. The spleen is enlarged, very firm in consistence. The connective tissue is increased. On section the pulp is dark red and cuts smoothly. The liver is large. On section it has a typical nutmeg appearance. The kidneys are enlarged, very firm in consistence, and show numerous infarcts which vary considerably in size. The right internal jugular vein is completely occluded by a thrombus. No. 57. — (J. H. H. Med. No. 19287) : Male, black, aged 46 years. Myo- carditis, probably of syphilitic origin. Thrombosis of left subclavian and jugular veins. Discharged against advice. Past History. — The patient has had six previous admissions with a diagnosis of arteriosclerosis and myocarditis. He had syphilis at 20. Present Illness. — He was admitted with shortness of breath, swelling of the feet, legs, abdomen and left upper arm, which had developed gradually during the previous nine days. Physical Examination. — On admission there were scattered crackles through the lungs; a wide area of cardiac dulness; a blowing systolic murmur, not well transmitted; a pulse irregular in force and rhythm, and general anasarca. The left supra-clavicular fossa was obliterated by a swelling which extended down to the left arm, and was most marked from the middle of the upper arm to the middle of the forearm. The superficial veins were markedly distended, especially the cephalic. The patient com- plained of pain and tenderness in the region of the left sterno-clavicular articulation, and in supra-clavicular fossa. Comparative measurements of the right and left arm were: R. L. Wrist 16 cm. 18 cm. Elbow -. 27.5 " 33.5 " Upper arm 27 " 34 After three days the swelling in the left arm still persisted, although the general anasarca had diminished. The heart's action remained irregu- lar, and a blowing diastolic murmur had developed. The oedema of the lungs persisted. The following day the whole left shoulder and chest became fuller, the axillary folds were obliterated, the left external jugular stood out, the arm was much enlarged from the shoulder down. Just above 24 F. J. Sladen and M. 0. Wintemitz. the left clavicle, at the junction of its middle and inner thirds there was a firm mass, about the size of a pignut (2.5x2 cm.), suggesting strongly a thrombus. The patient was discharged, against advice, 10 days after admission in the condition above described. He had had no fever. No. 58.— (J. H. H. Med. No. 27065) : Male, white, aged 49 years. Myo- carditis. Thrombosis of the right innominate, jugular, subclavian, axil- lary and brachial veins. Fever and leucocytosis. Death in 48 hours. Autopsy. Pulmonary infarction. Present Illness. — Onset was four months before admission with cough and dyspnoea. The latter was worse at night and accompanied by orthop- ncea. On admission there were cyanosis and dyspnoea, scattered crackles through the lungs, rapid, irregular pulse, enlarged heart (no murmurs) and enlarged liver. The next day Dr. Barker noted marked dilatation of the left ventricle, gallop rhythm over the whole heart, enlarged and tender liver, oedema at the bases of both lungs and Cheyne-Stokes respiration. The patient's condition gradually became worse for the next three weeks. Then the temperature rose, leucocytosis developed and fluid collected at the right base. This was aspirated and had the character of a transfusion. Two days before death a swelling of the whole right arm was noticed. The next day it had increased and the firm, thrombosed, brachial vein could be traced into the axilla. The right external jugular stood out prominently as a thick cord. There was no tenderness in the course of these throm- bosed vessels. Later small thrombosed veins were palpable over the right pectoral region and toward the thyroid gland. The thrombosis developed during extreme myocardial insufficiency and during an afebrile period. Blood cultures and cultures from the thrombosed veins intra vitam were sterile. Autopsy No. 3524 (Dr. Wintemitz) — Anatomical Diagnosis. — Chronic fibrous myocarditis; dilatation and hypertrophy of the heart; cardiac insufficiency; chronic passive congestion of viscera; multiple mural puri- form thrombi of right and left ventricles; healed and healing anaemic infarcts of spleen and kidneys; thrombosis of right superior vena cava; propagated thrombus extending into the large veins of the neck and right arm; oedema of arm; multiple pulmonary emboli with multiple hemor- rhagic infarcts of the lungs; acute pleuritis (right); hemorrhagic exu- date; chronic splenic tumor; chronic perisplenitis; fatty degeneration of liver; chronic fibrous epididymitis; thrombi in the spermatic and prostatic veins. The right portion of the thorax and right arm are very oedematous. Its circumference is half as large again as that of the left. The liver extends a hand's breadth below the costal margin in the mammillary line. On incision, a large amount of blood escapes. The right pleural cavity contains about 1 liter of blood-stained, brownish fluid in which definite flakes of fibrin are to be seen. In the upper portion of the anterior mediastinum the large veins stand out as dilated, firm masses. These Venous Thrombosis During Myocardial Insufficiency. 25 dilated, firm cords involve the right innominate vein and all of its neck and arm branches. Along the course of the veins bulbous nodules pro- trude, which show definitely the valves within. The entire subcutaneous tissue in the region where these veins are thrombosed is very markedly (Edematous, and on section one sees that this cedema is partly interstitial and partly due to a tremendous dilatation of the lymphatics, some of which in the region of the lymphatic duct and along the course of the subclavian vein and in the axilla are almost 1 cm. in diameter. They contain a clear, yellowish fluid. The pericardial sac contains only a slight amount of clear, straw-colored fluid. The parietal pericardium is normal in appear- ance. The visceral pericardium shows numerous, small ecchymoses over the right ventricle. The heart is tremendously enlarged, and a few milky patches are found over the right ventricle. The right auricle is markedly dilated, and its wall thickened. The tricuspid ring is greatly dilated measuring 14.5 cm. in circumference. The valves are normal. The ventricle is likewise dilated. The columnar carne* are greatly hypertrophied and leave large pockets in which, especially at the apex, small, grayish, polypoid thrombi are found attached to the heart muscle. These contain, on incision, a small amount of reddish, softened material. The wall of the ventricle is otherwise smooth. The musculature is pale brown in color. The wall is thicker than normal, despite the great dilatation. The pulmonary valves are normal. No thrombus is found in the main branch of the pulmonary artery. The left auricle is not dilated; its wall is slightly thickened. The foramen ovale is closed. The mitral valves are large and show only slight sclerosis. The mitral ring is dilated. The left ventricle is greatly dilated; its wall varies much in thickness. Here again one finds large pockets between the columnar earner, and in these are large masses of ante-mortem clot, which are of two general types; the one gray on the surface, the other softer and of a reddish color. On incision, many of them contain a turbid, reddish-brown fluid. The thickest part of the wall of the ventricle is the upper portion near the aortic orifice where it measures 15 mm., while down at the apex it measures only about 4 mm. The aortic valves are large and normally attached and show no marked abnormality. The base of the aorta likewise is not very abnormal. On incising the heart muscle at the apex one finds that it is studded with large, scar-like, translucent, gray masses which take the place of the muscle. The descending branch of the posterior coronary artery shows a few atheromatous scars on its surface, but these are not sufficient to interfere much with the size of the lumen. The other coronaries are similar. Lungs. — In the anterior margin of the upper lobe there is a small, black, consolidated wedge-shaped area. The rest of this lobe contains air. In the lower lobe the surface becomes much more congested toward the base, and here one finds another consolidated area involving one-third of this lobe. On section through the lung, it is pale, grayish in color, except in the consolidated areas above described. 26 F. J. Sladen and M. C. Wintemitz. The right lung is very much more voluminous than the left. The upper lobe is bound down by a few adhesions; it is pale, and resembles the upper lobe of the left lung. The middle lobe is more voluminous than the upper and in the middle portion there is a large, black area standing out sharply from the surrounding, pale, grayish-pink lung tissue. The lower third of the lower lobe is entirely consolidated. Over the surface there is a granular, dry exudate which dulls the surface. On section through the right lung the middle lobe in the consolidated area is reddish-black, dry and stands up from the surface. Joining this definite area of infarction is an area of congestion, extending for some distance in the neighborhood. In this area thrombosed veins are visible, but no definite infarction has occurred. The lower half of the lobe is almost entirely involved by the infarct. Extending from the base of the lower lobe is a deep, reddish-black, dry mass with a rather sharp line of demarcation. Above this the lung tissue is firm, atelectatic and congested. On opening the vessels one finds that running to all of these consolidated areas in either lung are thrombi which are fresh and friable and entirely occlude the vessel. The lung tissue aside from these consolidated areas is dry, grayish-pink in color, with a definite increase in consistence and a rusty shimmer. The spleen is enlarged and shows a small healing infarct, which appears as a depressed, yellowish zone, and on section is pyramidal in shape, sur- rounded by an area of congestion. At its base is a tiny occluded vessel. The spleen is deep purple in color, very firm, cuts with considerable resistance and shows an excess of fibrous tissue. The liver collapses as soon as the great vessels are cut. It is deep reddish-purple in color. On section the lobules are distinct and are much smaller than normal. The zones about the hepatic veins are reddish-black and depressed, while around the portal veins they are yellowish and elevated. There is a considerable variation in the size of these two zones throughout the liver. The kidneys show numerous infarcts and are markedly congested. The veins around the prostate are thrombosed. The spermatic vein likewise contains a large thrombus mass which dilates the vein greatly, particularly at the region of the valves, where bulbous prominences are formed. No. 59. — (J. H. H. Med. No. 27402) : Male, white, aged, 54 years. Myo- cardial degeneration. Thrombosis of left subclavian and jugular veins and of left femoral vein. Fever and leucocytosis. Recovery in one month. Pulmonary infarction. Present Illness. — Patient was admitted to the surgical service with swelling of the left arm of 6 days' duration. Physical Examination. — Firm, knotted cords were felt in the course of the axillary and brachial veins and their branches. The superficial veins over the shoulder were dilated. The external jugular vein was engorged and a prominent, firm cord was found at the base of the neck. Seventeen days later the left leg became swollen. There were fever, leucocytosis, Venous Thrombosis During Myocardial Insufficiency. 27 cyanosis and dyspnoea. The heart's action was rapid and irregular. During the course of the illness the patient had an attack of pain in the left chest and expectoration of much bright red blood. Dulness on per- cussion and crackles at angle of left scapula were associated with this attack. The cardiac condition improved but the oedema of the leg was still present on discharge one month after admission. No. 60.— (J. H. H. Med. No. ? ) : Female, white, aged 43 years. His- tory of acute rheumatic fever at 20. Mitral insufficiency and stenosis. Thrombosis of right innominate, jugulars, subclavian, axillary and brachial veins. Fever and leucocytosis. Death in 22 days. Autopsy: Pulmonary infarction. Past History. — There was a possible attack of acute rheumatic fever at 20. Present Illness. — Onset was six weeks before admission with shortness of breath, orthopnoea, especially at night, swelling of ankles, cough and blood-stained expectoration. Physical Examination. — On admission there were cyanosis, dyspnoea, an enlarged heart, irregular and rapid in action, a slightly enlarged liver, ascites, and oedema of the extremities. There were also signs of mitral insufficiency and stenosis. Six days after admission patient had three attacks, at 7.45 a. m., 9.15 a. m., and 9.55 a. m., of dyspnoea, cyanosis, cold sweating, irregular and weak pulse, dizziness, pain in the epigastrium and left axilla. At this time measurements showed the right lower leg to be slightly larger than the left, and two very small, nodular areas were felt in the right external jugular vein. Twelve days after admission, the right arm and leg were more swollen than the left, pitting on pressure. The right external jugular vein was prominent and hard. The patient expectorated an abundance of frothy blood. The leucocytes were 24,000 and there was fever. For a period of five days she was critically ill. The right chest, breast, arm and hand were oedematous and cyanotic. Thrombosis of the right external jugular vein was visible as a distinct thickening, palpable 5 cm. above the clavicle. Sixteen days after admission there developed extensive oedema of the right cervical and pectoral regions, including the mammary gland, and of the entire right upper extremity, it being twice the size of the left. A definite thrombus was palpable in the right external jugular vein, extend- ing 5 cm. above the clavicle. The superficial veins over the right pectoral region, right breast and upper half of the right upper arm were dilated and conspicuous. Blood cultures were negative. Autopsy No. 3793 (Dr. Kline) — Anatomical Diagnosis. — Subacute endo- carditis affecting the tricuspid, aortic and mitral valves, producing insuffi- ciency and stenosis; pulmonary and splenic infarctions (organizing); moderate chronic passive congestion of viscera; central necrosis of liver; chronic atrophic endometritis and salpingitis; chronic adhesive peritonitis and pericarditis; moderate ascites; moderate pericardial and pleural effu- 3 28 F. J. Sladen and M. C. Winternitz. sion; diffuse tracheitis and bronchitis; oedema of lungs; thrombosis of transverse, scapular, external jugular and subclavian veins on right. Body. — There is considerable general oedema. Fifteen centimeters above the olecranon the circumference of the right arm is 33 cm., and that of the left is 26 cm.; 15 cm. above the patella the circumference of the right leg is 53 cm., and that of the left is 49 cm. On opening the abdominal cavity a moderately increased amount of clear, yellow fluid is found. There is about 200 cc. of similar fluid in the left pleural sac. The pericardial sac contains about 80 cc. of clear, yellow fluid. There are localized fibrous adhesions covering an area of a few square centimeters over the left ventricle, binding the apex to the parietal pericardium. The heart weighs 525 gm. The right auricle is considerably dilated and somewhat hypertrophied. In the tip af the auricle there is a fairly fresh, small thrombus. The tricuspid ring measures 10.5 cm. in circumference. The cusps are thin and delicate. At the junction of two of the cusps, however, there seems to be some shortening of the chordae tendinese, draw- ing the cusps to the ventricular wall, and the edge of each cusp is rolled up and thickened. The right ventricle is considerably dilated and hyper- trophied. The papillary muscles are large. The left auricle is consider- ably dilated and somewhat hypertrophied. The mitral ring measures 8 cm. The valves and chordae tendineae are remarkably thickened and shortened. Along the line of closure of two of the cusps are several small, fresh, wart- like growths. The left ventricle is dilated and considerably hypertrophied. The papillary muscles are markedly enlarged and thickened. On section the cardiac muscle presents nothing strikingly abnormal. The aortic ring measures 7 cm. The cusps are thickened for about half of their extent and show along the line of closure of the three cusps a row of small, fresh, wart-like growths. The coronary arteries present no abnormalities. Lungs. — Left lung. On section of the left upper lobe there is some con- gestion and marked oedema. Frothy fluid exudes on slight pressure leaving a residual rusty color. In the left lower lobe there is a large, consolidated patch, measuring 4 x 3.5 cm. This patch is sharply circumscribed and does not contain air. It is granular and of a purple color. In the right upper lobe there is a consolidated patch of similar character as that in the left lower lobe, the cut surface measuring 10 x 4.5 cm. This mass involves fully one-third of the lobe. In the lower lobe there is another patch 4 x 3.5 cm. Spleen. — On the surface several yellow, opaque areas are visible. On section the organ is much firmer in consistence than normal. It presents a garnet-red color. There is a marked increase in the connective tissue and numerous, dry, yellow, wedge-shaped, opaque areas may be seen. Liver. — On section the organ presents an irregular lobulation; the central veins are black and the parenchyma yellow. The amount of con- gestion varies in different portions of the gland. The transverse scapular, external jugular and subclavian veins on the right are completely thrombosed, the subclavian and transverse scapular Venous Thrombosis During Myocardial Insufficiency. 29 veins through their entire length and the external jugular for a distance of about 7 cm. No. 61.— (J. H. H. Med. No. ? ) : Female, black, aged 23 years. His- tory of acute rheumatic fever during the past two years. Mitral insuffi- ciency. Thrombosis of both innominate veins, right jugular and sub- clavian, left external jugular veins and central vein of left retina. Fever and leucocytosis. Death in 28 days. Autopsy. Past History. — The patient has had repeated attacks of tonsillitis, and arthritis during the past two years, involving both upper and lower extremities. Physical Examination. — The patient was admitted in a state of myo- cardial insufficiency with orthopnoea, cyanosis, enlarged heart, tachycardia, oedema of the lungs, enlarged pulsating liver, ascites and oedema of the lower extremities. There were signs of organic mitral insufficiency and of relative aortic and tricuspid insufficiency. An irregular fever suggested a smoldering endocarditis, though repeated blood cultures were negative. The patient was never free from myocardial insufficiency. Twenty-eight days before death the right forearm and lower third of the upper arm became swollen. The superficial veins of the right shoulder and chest were dilated. There was oedema of both legs. Both external jugular veins were con- spicuous, firm, and could be rolled under the fingers. The right face became swollen, especially the lower eyelid and cheek. There was a puffy swelling in the right supra-clavicular fossa, and whip-cords were palpable later in the right bicipital fossa. The left optic disc 11 days before death was obscured in outline with an oedematous retina about it. Scattered red and white areas of hemorrhage and exudate could be seen. The veins, especially that leading from the upper temporal retina, were large, blue-black vessels without light streaks. Before death the right brachial and axillary veins, and the right jugular vein as far as the angle of the jaw became palpable. Autopsy No. 3787 (Dr. Davis) — Anatomical Diagnosis. — Acute and chronic fibrous myocarditis; acute mitral vegetative endocarditis; thrombus forma- tion involving the superior vena cava, innominate, axillaries and jugular veins; multiple emboli in spleen and kidneys with infarcts; arteriosclero- sis; chronic passive congestion of viscera; healed foci at lung apices; chronic pleural adhesions; aneurysm of splenic artery; chronic fibrous perisplenitis; ascites; double hydrothorax; relative valvular insufficiency of heart; general oedema; bronchopneumonia. Body. — There is marked pitting on pressure over the ankles. The face and upper thorax are cyanotic. The pupils are not equal. The left is dilated and much larger than the right. On opening the abdomen one finds a moderate amount of free fluid in the peritoneal cavity, which is clear and yellow. Both pleural cavities contain a large excess of straw colored fluid — about 500 cc. The left lung is much compressed. The heart is enlarged, weighs 320 gm. The epicardium is smooth and glistening. The right auricle contains only a post-mortem clot. The tricuspid orifice admits five finger-tips and measures 13 cm. The tricuspid 30 F.J. Sladen and M. C. Winternitz. valve is delicate and appears normal. The pulmonary orifice measures 7 cm. The left auricle contains a few rather firm thrombi, but none of them are very adherent. The mitral ring also admits five finger-tips and measures 11.5 cm. The mitral valve is considerably shrunken and thick- ened along the edge. There are also to be seen a number of small, granular masses along the line of closure, which can be scraped off with some difficulty, leaving small ulcerated areas. There are also a number of similar vegetations attached to the chordae tendinese. The wall of the left ventricle is considerably hypertrophied and its cavity is larger than normal. The aortic ring measures 6 cm. The aortic valves are delicate and seem competent. The heart muscle on tangential section shows an extreme grade of fibrous change; the grayish looking fibrous tissue seems to occupy about one-half of the tissue. In some places it has a decidedly yellowish tinge. The coronary arteries are not occluded by emboli, but show a few fine yellow patches throughout their extent. The pulmonary arteries show no emboli after a careful search. The pulmonary veins appear normal and contain no thrombi. The tail of the pancreas reaches to the hilum of the spleen, where it is adherent to a smooth, firm, round nodule measuring about 4 cm. in diameter. This nodule is closely attached to the spleen, and on section is seen to consist of a thin wall surrounding a cavity which is almost filled with laminated, blood-clot; the space which is not filled by blood-clot measures 1 cm. across. No connection is to be made out with what remains of the splenic artery. On incision of the lower branch of the splenic artery, it is found to be occluded outside of the spleen tissue for a distance of 2 cm. by a thrombus mass. This branch of the artery on being traced down from the thrombus to the spleen is seen to lead directly to the apex of the discolored area at the lower pole. On section that portion of the splenic tissue which lies under the discolored area at the pole is seen to be quite pale and yellowish looking, and has a distinct line of demarcation from the rest of the splenic tissue. Left Kidney. — At the upper pole there is an area which is only slightly depressed, but which is of a bright yellow color, surrounded by an area of hyperemia. This area, on section, shows beneath it a triangular yellow mass extending down to the medulla, and surrounded on all sides by an intensely hyperaemic zone. In this yellow area the striations and glomeruli are still to be faintly made out. On opening the superior vena cava there is seen a firm, rather light colored thrombus mass, extending almost to the opening of the right auricle. This thrombus mass, by palpation outside of the, veins, is seen to extend into the innominate veins, the left external jugular and the axillary vein as far as it can be followed without cutting the skin over the arm. On the right it extends into the internal and external jugular veins and the axillary as far as it can be followed, and all the other small veins arising from this. (Permission was not obtained to open the neck.) The jugular bulb is removed for a distance of 2 cm. Beyond this point it can be felt as a firm cord extending up, as far as can Venous Thrombosis During Myocardial Insufficiency. 31 be made out, into the upper triangle of the neck. The vena cava, innomi- nates, axillaries and jugulars are removed en masse. Microscopically the thrombosed veins show evidence of organization; but not of infection. No. 62.— (J. H. H. Med. No. 29319) : Female, white, aged 23 years. Mitral stenosis and insufficiency, possibly following puerperal infection, Thrombosis of left subclavian and jugular veins. Fever and leucocytosis. Death in 12 days. No autopsy. Present Illness. — The cardiac condition became apparent during preg- nancy. Two months before death, the patient was delivered of an 8-month child because of myocardial insufficiency. She showed cyanosis, dyspnoea, oedema of the lower half of the body, enlarged heart and gallop rhythm, signs of mitral stenosis and insufficiency, oedema of the lungs and ascites. Twelve days before death the left arm became oedematous, the hand puffy. The oedema extended under the clavicle to the supraclavicular fossa. There was some pain and tenderness in the arm, and the left breast became swollen. Leucocytosis and fever developed. In five days the thrombosed left jugular veins were palpable. The superficial veins over the left breast and shoulder were dilated. There was no evidence of embolism or infarc- tion. No. 63 (Blumer). — This is an unreported case occurring in the service of Dr. Daggett and we are indebted for the record to Dr. Geo. Blumer of Yale University who saw the patient. Female, white, aged 50 years. Mitral insufficiency. Thrombosis of right subclavian and jugular veins. Fever. Recovery in two months. Present Illness. — Patient noticed swelling of ankles 10 months before admission. Sudden dyspnoea, orthopncea, cough, frothy expectoration, swelling of limbs, body and face, developed. Physical Examination. — On admission there was an irergular, rapid pulse, enlarged heart, signs of mitral insufficiency and an enlarged tender liver. Later a right hydrothorax occurred. While the patient was in this condition soreness in the right neck and painful swelling of the right hand and arm developed. The right jugular vein was palpable as a tender cord. The oedema cleared slowly and was gone in two months. Fever was associated with the thrombosis. No. 64 (Ellis). — For the records of this unpublished case we are indebted to Dr. A. W. Ellis, now of the Rockefeller Hospital, New York City. Male, white, aged 46 years. Myocarditis. Thrombosis of right innomi- nate, jugular and subclavian veins. Fever, jaundice and leucocytosis. Death in 10 days. Autopsy: Pulmonary infarction. Present Illness. — Two months before admission the patient noted short- ness of breath and palpitation, swelling of feet and occasional bloody expectoration. Two days before admission the right hand became swollen. On admission, the right hand and arm were oedematous as far as the shoulder. There was no pulse in the veins of the right neck. The right jugular vein was prominent, hard, and very tender. The heart was en- 32 F. J. Sladen and M. C. Winternitz. larged, but there were no murmurs, though the sounds were feeble and the action irregular. The arm continued to swell and became cold and cyanotic. The liver was enlarged and tender. ■ Jaundice, leucocytosis and fever were noted. Blood cultures were negative. Autopsy (Dr. Ellis) — Anatomical Diagnosis. — Chronic fibrous myocar- ditis; dilatation and hypertrophy of heart; chronic passive congestion of viscera; mural thrombus of right ventricle; extensive venous thrombosis beginning in the bulbus venosus and involving all of the distal veins; extensive embolism into the pulmonary arteries with massive infarction of the lungs; acute fibrinous pleurisy. The body shows a general icterus. The lips are cyanotic. The right hand and arm are markedly (Edematous and swollen, measuring about three times the diameter of the left, and pit on pressure. The right leg, foot and thigh are swollen and (Edematous, pitting on pressure. There is a firm, hard swelling above the clavicle on the right side which is appar- ently the thrombosed bulbus venosus. The peritoneal cavity contains no excess of fluid. The liver extends 3 cm. below the costal margin in the nipple line. The left pleural cavity contains a few ounces of bloody fluid, and there are a few fine adhesions over both lungs. The heart is enlarged and acutely dilated. It weighs 435 gm. All the cavities are markedly dilated and filled with post-mortem clot. The right ventricle contains a grayish-brown, friable, mural thrombus, covering almost its entire posterior surface for a thickness of about half an inch. The center of the clot shows puriform softening. The endocardium throughout shows marked bile staining. The tricuspid ring measures 13.5, the pulmonary 8, the mitral 12, the aortic 9 cm. in circumference, respectively. The mitral valve shows very slight thickening along the edge of its aortic segment. The aorta shows no arterial changes macro- scopically, nor could anything be made out in the other great arterial trunks of the body. Venous System. — The tibial, femoral and iliac veins show nothing abnor- mal. The inferior vena cava, portal, renal and superior cava are all free from thrombi. The right bulbus venosus, external and internal jugulars, axillary and brachial and radial veins are distended and filled with throm- bus. The axillary and brachials show a marked irregular distension, firm nodules where the vein is half as large again occurring at fairly regular intervals throughout its length. These swellings occur at the situation of the valves. By far the larger portion of this thrombus is dark and soft, showing absolutely no sign of organization. It is only in the bulbus venosus that any sign of organization is seen. Here the clot is firm, pale in color, and firmly adherent to the vessel wall. The walls of the veins do not appear thickened. Lungs. — The surface of the left lung is dulled, with occasional flakes of fibrin over it. A large portion of the lung, especially the lower part of the lower lobe, is consolidated. On section the whole lung shows a condi- tion of massive infarction. The lower lobe is absolutely solid, dark red in color and does not contain air. The upper lobe shows large areas of Venous Thrombosis During Myocardial Insufficiency. 33 complete hemorrhagic consolidation, but between them are small areas of lung tissue which contain some air. The pulmonary artery and its main branches show no sclerosis or thrombosis, only the small, terminal branches being filled with soft, dark thrombi. The middle lobe of the right lung shows a similar consolidation, while in the lower lobe a few small areas of air-containing tissue still remain. The upper lobe contains air. Here again the vessels are filled with thrombi. No. 65. — (J. H. H. Outside case) : No clinical notes. Male, white, aged 70 years. Aortic insufficiency and adherent pericar- dium. Thromboses of right iliac and right brachial veins. Death. Pul- monary infarction. Autopsy No. 3274 (Dr. Thomas) — Anatomical Diagnosis. — General arteriosclerosis; chronic diffuse nephritis; chronic aortic endocarditis with insufficiency; coronary sclerosis; chronic adhesive pericarditis; chronic passive congestion of viscera; ascites; hydrothorax; atelectasis and general anasarca; acute vegetative endocarditis (aortic and mitral valves) ; mural thrombi; pulmonary embolism; thrombus of the right iliac and right brachial veins; healing infarcts of lung; bronchopneumonia. Body. — The skin over the body is very (Edematous. The abdominal cavity contains an excess (500 cc.) of clear fluid. The right pleural cavity is filled with a clear amber colored fluid. The lung is compressed. Heart. — The right auricle is dilated. The wall is thickened. The mus- cle bundles are quite plump. In the auricular appendage is a small, grayish-white body measuring about 4-8 mm., which is adherent to the wall and quite friable. The tricuspid ring measures 13 cm. The cusps are quite thin and delicate. There is no roughening seen at any place. The right ventricle is free from thrombi. The musculature is apparently normal. The pulmonary valves are delicate. The left auricle is dilated. The wall is thickened. The mitral ring measures 10 cm. On the aortic cusp is a small, grayish, translucent, nodular mass. The cusps of the valve are to a slight extent thickened. The left ventricle is free from thrombi. The aortic ring measures 8 cm. The valve leaflets are decidedly thickened. On the free margin of all three cusps are seen tiny, translucent bodies not more than 1 mm. in diameter. The heart muscle on tangential section is brownish-red in color. The muscle fibers are rather coarse. Lungs. — In the right lung several thrombi in the pulmonary arteries lead to areas of hemorrhagic infarction. The right iliac and brachial veins contain large thrombus masses which are grayish-yellow in color and friable. Analysis of Cases. Number of Gases.— There are 65 cases reported in the literature by 41 different authors. In many instances the details of the cases are meager, but in most the conditions are satisfied, which are necessary for includ- ing the cases in the series of venous thrombosis during myocardial 34 F. J. Sladen and M. C Winternitz. insufficiency. Out of the possible 65 cases we have selected 48 which seem to fall in this group. The other 18 were excluded, because it could not be ascertained from the reports whether the thrombosis was associ- ated with myocardial insufficiency or with some other condition such as tuberculosis, malignant disease, arteriosclerosis, aneurysm, or other more common cause. The conditions which have been more or less arbitrarily chosen as requirements for including cases in this series are two : (1) That there was a definite myocardial insufficiency present at the time the throm- bosis occurred; (2) That in all cases in which an autopsy was not per- formed, the diagnosis of the presence of a thrombosis was based upon unquestionable clinical observation. In addition to these 48 cases in the literature there have been 17 cases observed in the clinics of the Johns Hopkins Hospital during the 24 years to date. Five of these cases were reported by Dr. Welch in 1900. One of the patients subsequently died and the pathological findings are here included. One other instance included by Dr. Welch has been excluded from this series, because the thrombosis was not associated with myocardial insufficiency. The series contains two other cases which we are allowed to report through the kindness of Dr. George Blumer, of Yale University, and of Dr. A. H. Ellis, now of the Kocke- f eller Hospital for Medical Kesearch. It is of interest to note that of the 17 cases from this clinic five were observed since our attention was drawn to the subject by one of the recent cases (No. 58) described above. Twelve of these cases have been observed, both clinically and pathologically; in one only the autopsy records were accessible. ANALYSIS OF 65 CASES. Age Decades No. of Cases. 1-10 1 11-20 10 21-30 9 31-40 11 41-50 10 51-60 12 61-70 7 71-80 1 Not given 4 This table shows the unimportance of age in this relation. The earliest age is nine years; the oldest, 73 years. The condition may Venous Thrombosis During Myocardial Insufficiency. 35 occur at both extremes of life. Between 10 and 70 the cases are equally divided as to decades. Sex. — Forty-six of the patients were females, compared to 19 males. This is possibly partly explained by the frequency of association with mitral disease, a cardiac lesion notoriously more common in females than in males. Etiology. — It is essential to attempt to determine the etiology of the underlying cardiopathy. How far it may have a bearing upon the cause of the associated venous thrombosis can only be conjectured but, as will be shown, the relation may be important. Of the 65 patients, 26 had developed valvular lesions during or after attacks of acute rheu- matic fever, or at least gave histories permitting them to be classified as belonging to the rheumatic group. In two cases, the valvular lesions had followed an influenza; in one, a previous endocarditis; in two, puerperal infection ; in one, scarlet fever ; in two, syphilis, and in four, pneumonia. In many instances these infectious diseases dated several years before the thrombosis. In those with acute rheumatic fever, as this table shows, the limits were from six months to 40 years, with variation in the number of attacks. Time Interval between Acute Rheumatic Fever and Thrombosis. Number of Attacks of Acute Rheumatic Fever. 6 mos. 1 attack 9 " 7 10 it 2 attacks 1 yr. ? 1 " 2 attacks 14 yrs. 2 << 2 Cf 2 " 2 " 1 attack 4 " 7 7 " 1 attack 7 it ? 7 a 3 attacks 9 tt 7 16 it 7 17 t( 7 20 it 7 23 it 1 attack 24 " 8 attacks 31 tt 5 <( 31 it 7 40 " 7 40 tt 2 attacks 36 F.J. Sladen and M. C. Winternitz. In four cases the time interval and numbers of attacks were not stated. In the other 12 instances of infectious diseases the time interval ranged from two to eight years. While these intervals are long, still our knowledge concerning the chronicity of the infection associated with endocarditis and its tendency to recur in repeated acute exacerbations points to a persistence of the primary focus of infection and indicates that in many such diseases the infection does persist, however mild in virulence. In fact the milder the infection, the more likely it is to persist. This may be of great importance in determining the infectious agent responsible for the thrombosis. It seems noteworthy that so many of the cases were asso- ciated with some infection and in such a large number it was acute rheu- matic fever. Cardiac Lesion. — The cardiopathy underlying the state of myocar- dial insufficiency was as follows : Cases. Mitral insufficiency 14 Mitral stenosis 6 Aortic insufficiency 4 Mitral insufficiency and stenosis 12 Aortic insufficiency and stenosis 2 Mitral and aortic insufficiency 3 Mitral and aortic stenosis 1 Mitral and tricuspid insufficiency and stenosis and aortic stenosis 1 Tricuspid stenosis and mitral and aortic insufficiency. . 1 Mitral insufficiency and aortic insufficiency and stenosis 1 Mitral insufficiency and stenosis, and aortic insuffi- ciency and stenosis 3 Myocarditis 13 Not given 4 The mitral valve was affected in the largest number of cases. Cases. Mitral valves alone 30 Mitral valves in combination 12 Aortic valves alone 6 Aortic valves in combination 10 Mitral stenosis alone and in combination 24 Mitral insufficiency alone and in combination 35 It is interesting to note that the preponderance of the cases are asso- ciated with valvular disease and relatively few with myocarditis. The Venous Thrombosis During Myocardial Insufficiency. 37 valvular lesions occur in the relative frequency with which they are usually met, unaccompanied by any complications. This would lead one to believe that they do not have any important bearing upon the specific condition under discussion. Localization of the Thrombi.— These may be briefly tabulated as follows. Superior vena cava or both innominate veins and branches, 6 cases s - V. C 3 cases. R. and L. 1 3 « Left arm and neck veins, 29 cases. *-*• 1 6 cases. L. Subcl. and J 14 L. Subcl 8 " L - J 1 case. Right arm and neck veins, 17 cases. R- I 5 cases. R. Subcl. and J 8 " R. Subcl 2 " R. J 2 " Combination of the two sides, 5 cases. L. Subcl. and J. and R. Subcl 1 case. L. Subcl. and R. Subcl 1 " L. Subcl. and L. F 1 " L. Subcl. and J. and L. P l " L. Subcl. and J. and L. and R. Fern 1 " Iliac or femoral veins, 7 cases. Both sides 4 cases. Leftside 2 Right side 1 case. Not given 3 cases. The most interesting facts derived from the above analysis are the relative number of cases in which the thrombosis involved the veins of the upper extremities as opposed to those of the lower. Of the 65 cases, in only seven did it occur in the lower extremities alone. In three other eases the veins of both upper and lower extremities were thrombosed. Secondly, of the 57 cases in which the veins of the upper extremity were involved, both were affected in eight cases. In the remaining 49, the right side was affected in 17, and the left in 32 cases. While these figures give a predominance to the localization of the thrombosis in the veins of the left upper half of the body, still it is believed this is due to insufficient statistics. In our own cases the right upper extremity was involved to a greater extent than the left. This is 38 F. J. Sladen and M. G. Winternitz. of importance, since the process has frequently been attributed to a mechanical condition present only on the left side. For the above figures such an explanation is, of course, quite inadequate. Clinical Evidence of Infection at the Time of Thrombosis. — Data concerning infection at the time of the thrombosis were lacking in most of the case reports. Cases. Fever alone 12 Fever and leucocytosis 5 Fever and jaundice 1 Fever, jaundice and sweats 1 Fever, leucocytosis and purpura 1 Chills 1 Fever, leucocytosis and pleurisy 4 Acute fibrinous pericarditis and pleurisy 1 Even though these cases have no absolute value as evidence of the infectious nature of the thrombosis, still they form the only clinical evi- dence of infection present at the time of the thrombosis, which may be gathered from the reported cases. Infection seems to be of so much importance in our knowledge of thrombosis in general, that these data are worthy of emphasis here. In only two cases were organisms recovered by culture: in one, streptococci from the heart's blood ; in the other, streptococci from the thrombus. Such really positive evidence is difficult to obtain. In four of the recent five eases blood cultures intra vitam and cultures at autopsy proved sterile. In one, cultures made before death from a puncture of the thrombosed veins gave no growth. Clinical Symptoms and Signs of Thrombosis. — (Edema is by far the most common and not infrequently the only manifestation of the venous thrombosis. Local pain and tenderness over the veins and palpable whip-cords in the course of the vessels were the next most frequent indi- cation of the condition. Cyanosis and local coolness to the palpating hand, evidences of collateral circulation, loss of the jugular pulse, unilateral exophthalmos and torticollis were among the other symptoms noted. Three cases were not recognized clinically. In two of these the veins of the lower extremity were involved, in the other the jugular. General anasarca was marked in all three. It is our impression that it is quite impossible to recognize this condition when the veins of the legs are involved and the general oedema marked. An aid to diagnosis was Venous Thrombosis During Myocardial Insufficiency. 39 emphasized in one case. The anasarca disappeared during the night and returned during the day in the entire body, except in the left leg where the swelling remained constantly the same. An interesting fact from the above analysis is that the oedema may frequently be the only sign of the condition. This supports the idea that the condition may readily be overlooked and the distribution of the oedema considered only a mechanical effect of gravity resulting from the insufficiency of the heart muscle. Careful observation of such cases, however, will show that the oedema resulting from the thrombosis is a persistent phenomenon, and usually a residue, when the oedema else- where in the body, the pure effect of the myocardial insufficiency, is dis- appearing. Result. — -As far as the records reveal, the mortality in the 65 cases was 83 per cent (54 cases). One patient was discharged against advice and lost track of. The remaining 9 patients were considered recovered. However, in six of these cases the period of observation was only from three weeks to three and a half months. In the other four no statement is made aside from the fact that they "recovered." The condition then is an extremely fatal one. In 44 cases the interval between the onset of the thrombosis and death is known. In 1 case death followed In 1 day 6 cases IC " 2 days 1 case ' " " 3 " 1 " 11 « 4 ■■ 3 cases ' l( " 6 " 3 " (( " 1 week 1 case (( " 10 days 5 cases ' It " 2 weeks 15 " " " 3 to 4 weeks 1 case ' " " 6 weeks 5 cases " " 2 to 5 months 1 case ' 11 " 6 months 1 " " " 3| years Except for this last case, which remained under constant observation for three and one-half years, the interval was fairly short. Thirty-six of the 45 patients died within a month after the onset of the throm- bosis. Pulmonary embolism and infarction are the most serious complica- tions, making the complication a particularly serious one. Pulmonary infarction occurred in 27 cases and every one of these was fatal. It is striking that no patient that recovered gave evidence of pulmonary 40 F. J. Sladen and M. G. Wmternitz. infarction at any time. If infarction does not occur, then the determin- ing factor in the outcome is the underlying cardiac condition or the associated infection. Keferences. Bouchut : Gaz. med. de Paris, 1845, xiii, 2 me s., 245. Pbtee: Legons de clinique med., 1873, i, 209. Hanot: Compt. rend. Soc. de biol., 1874, i, 6 me s., 80. Paementieb : Arch. gen. de mM., 1889, ii, 91. Hieschlafp : Inaugural Diss., Berlin, 1893. Baldwin: J. Am. M. Ass. 1897, xxix, 371. Poynton : Lancet, 1898, ii, 206. Gallavaedin : Province med., 1899, xiii, 409. Lyon med., 1900, xcv, 10. Welch : Trans. Ass. Am. Phys., 1900, xv, 448. Jacobi's Festschrift, 1900, p. 463. Huchaed : Traite des maladies du coeur 3 me 6d., 1905, iii, 581. Blumee: Yale M. J., 1908-09, xv, 296. THE JOHNS HOPKINS HOSPITAL REPORTS. PLATE I. Chronic Passive Congestion. Embolus and Hemorrhagic Infarct op the Lung. mm*-