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Analysis of results following sympathectomy for peripheral vascular disease
ANALYSIS OF RESULTS FOLLOWING SYMPATHECTOMY FOR PERIPHERAL VASCULAR DISEASE* G&A
DE TAKATS,
M.D.
Associate Professor of Surgery, University CHICAGO, MATERIAL
T
TABLE OF
I
SYMPATHECTOMY VASCULAR
FOR
PERIPHERAL
DISEASE
lgz8--1g36 SeIection of Cases /Lack of marked structura1 changes Raynaud’s phenomena. Absence of scIerodactvIia (Stages I and 2 ” Absence of acute infiammatory stage Buerger’s disease.. . . . Below 40 years of age with definite colIateraI reserve Poor response to consert vative treatment Moderate paraIysis limited to one extremity; evidence PoIiomyeIitis. . . ! of vasospastic phenomena Age preferabIy between 6 1 and IO years Reflex dystrophy (cau- Severe cases producing disabiIity, resistant to physiosalgia, traumatic vesse1 spasm, Sudeck’s therapy, exhibiting abnoratrophy). 1 ma1 vasomotor phenomena Rapid onset of digita thrombosis with impending UncIassified.. . . . . . . , . 1 gangrene MostIy upper extremities \ invoIved Diagnosis
In the group diagnosed as Raynaud’s disease (TabIe I), a number of patients exhibiting Raynaud’s phenomena due to secondary vesseI spasm were first excluded. The diagnosis of Raynaud’s disease was onIy arrived at by excIusion. In the typica forms, the stage of scIerodactyIia with deep uIcerations was not subjected to operation, as our results in this group have been unsatisfactory. Operation for Raynaud’s * From the Department
of Surgery University
ILLINOIS
disease seemed most successfu1 in the patient in whom organic obstruction of the digita arteries was absent or shght and in whom invoIvement of the skin, joints, and tendons had not yet taken pIace. Between these two groups there is a third, in which there is some organic damage, but diIatation of the vesseIs by reffex heat or vasodiIators was stiI1 possibIe but incompIete. This group shows such improvement that operations are justihed. Operations on patients suffering from Buerger’s disease have not been advocated in: (I) an acute infIammatory stage; (2) in a Iate stage with a cIosed coIIatera1 bed (frozen vascuIar tree); (3) patients past the age of 40; (4) if economic status permits a Iong rest in an even warm &mate or if the cardiovascuIar apparatus is diffuseIy invoIved. It is most difficuIt to argue for or against a sympathectomy in patients around 40 years of age who have had an acute arteritis in the earIy twenties, whose disease has been quiescent for many years and now present themseIves with a second ffare-up, usuaIIy in another previousIy uninvoIved extremity. Such patients show IittIe capacity for vasodiIatation and show some scIerotic changes. They may have myocardiaI damage. In such cases, intensive conservative treatment together with paravertebra1 aIcoho1 injection has arrested the disease in fifteen patients. This method shouId certainIy be tried before sympathectomy in such borderIine cases.*
STUDIED
HIS report is based on a follow-up study of 105 sympathectomies done on fifty patients suffering from various types of periphera1 circuIatory disturbances. INDICATIONS
of IIIinois
t ParavertebraI injections of aIcoho1 as advocated by Reichert’ have been done on twenty-five patients suffering from obIiterating arterioscIerosis and are discussed eIsewhere.2
of IIIinois and the Circulatory 78
Group of St. Luke’s Hospital, Chicago.
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de Takats-Sympathectomy
We have urged sympathectomy, however, in individuals between 20 and 40, who are having their First attack and who have a good capacity for vasodiIatation. The resuIt of the sympathectomy mainIy depends on the stage of the disease, which may differ in each of the four extremities. In case the upper extremity is invoIved, which is more frequent than suspected, sympathectomy is done as soon as nutritiona1 changes? such as atrophy, UIceration or gangrene are manifest. FoIlowing operation, the same conservative regime is instituted as preoperativeIy and is folIowed for many years.3 This consists of compIete abstinence from tobacco, increased ffuid and saIt intake, a series of typhoid vaccine injections twice a year and intermittent venous hyperemia treatments to stretch the venocapihary bed. This Iast method is more effective in the sympathectomized patient, where the resistance to stretch has been diminished.4 In pohomyelitic children, if they are younger than 8 years, if the paralysis is Iimited to one extremity and is moderate are in degree, and if their extremities coId, pIurn-coIored and painful, if noduIar patches of cyanosis, edema and chiIblains are present, a sympathectomy wiI1 provide increased vascuIarity. An acceIeration of growth, as reported by Harris5 has not been observed in our cases. In the fourth group, I have gathered a group of vasomotor and nutritiona distubances, diagnosed as Sudeck’s atrophy, traumatic osteoporosis, stump-neuroma, and causaIgia and have caIIed them reflex dystrophies.6 Not onIy does the edema, cyanosis, and sensitivity to heat disappear, but bone may recaIcify, as shown by Fontaine and Herrmann. A group of “uncIassiIied” cases had to be established in this material. Some of the most dramatic successes have been obtained in this group without, however, estabIishing the possibiIity of a dehnite preoperative diagnosis.
American JournaI of Surgery
ANALYSIS
79
OF RESULTS
It is quite diffrcuh to evaluate any method used in the treatment of peripheral vascular disease. SiIberP has recentIy pointed out that unIess certain factors are eIiminated, the vaIue of any treatment must remain dubious. These factors are (I) the tendency to spontaneous improvement; (2) the effect of cessation of smoking; (3) the norma variations in vasoconstriction due to environmenta changes in temperature and the patient’s psychic state. To this one may add the effect of (I) rest in bed, (2) miId heat, (3) pIenty of &ids, (4) reguIation of the patient’s diet, and (5) the surgica1 care of uIceration and necrosis. ObviousIy a compIete eIimination of al1 these factors in analyzing one form of therapy is aImost impossibIe. In trying to find out the place of sympathectomy in the treatment of periphera1 vascuIar disease, further diffrcuIties present themseIves. A good resuIt in Raynaud’s disease means freedom from painfu1 vasospastic attacks and softening of the scIerotic digits; but in patients suffering from Buerger’s disease an arrest of the disease and the avoidance of amputation must be regarded as a good resuIt even if a functionaI restoration to normaIcy is an anatomic impossibility. That proper seIection of cases, technicaIIy compIete operavoidance of regeneration and ations, adequate postoperative follow-up are important factors in obtaining good resuIts has been pointed out eIsewhere.g In spite of the muItipIicity of variabIes, an attempt has been made to evaIuate the resuIts of sympathectomy. It has been done by utilizing severa methods. First, objective evidence has been sought that periphera circuIation has been modified by the operation. Second, in patients suffering from symmetrica Iesions of approximately identical severity, one extremity was Ieft for contro1 over a period of several years. Third, the total materia1 of 105 sympathectomies performed on fifty patients suffering from various types of periphera1 vascular
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disease has been folIowed for at Ieast two years and the resuhs tabuIated according to criteria to be discussed. g 8 b
L ._C
90
“SW a S 0 70 s ’ 60 6 ._ 1 3 50 x C
z-40 3 0
ths Operation
podtop.
poStiP.
FIG. I. 02 saturation of venous blood taken from the femora1 vein before, two weeks and severa months after sympathectomy. Note the marked rise in the first three instances, a moderate rise in the fourth and a definite drop in the fifth case. This Iast patient developed a popliteal thrombosis folIowing operation which, however, did not resuIt in gangrene. THE
MODIFICATIONS FOLLOWING
OF
CIRCULATION
SYMPATHECTOMY
The bIood vesseIs of the sympathectomized Iimb react to direct appIication of heat and coId and aIso to ischemia in the norma manner.g But, being deprived of their vasomotor innervation, these vesseIs are freed of a number of extrinsic and intrinsic stimuIi, which arrive to the vesseIs over the efferent sympathetic pathways. Thus cooIing or pinching the body,lO pain, fright or anger” do not produce vasoconstriction in the sympathectomized extremity, nor wiI1 heating the bodylZ or the production of fever with typhoid vaccine13 produce vasodiIatation.. The question arises, how important are these factors in reguIating circuIation? When studies in bIood flow are made with a modified HewIett-van Zwaluvenburg method, it becomes apparent that great fluctuations in bIood flow are produced by the stimuIi enumerated above. Sympathectomy aboIishes these fluctuations. In a recent study of
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some of my patients, GeIIhorn and Stecklg found that the inhaIation of COZ, which normaIIy produces a marked centra1 vasoconstriction of periphera1 vesseIs, is aboIished in the compIeteIy sympathectomized extremity and may even give rise to a paradoxica1 vasodiIatation as the IocaI vasodiIating action of CO2 may now become manifest. This method may serve as an index for the compIeteness of sympathetic denervation. Another effect of a permanent vasomotor paIsy can be detected by the study of bIood gases, notabIy the oxygen saturation of the venous bIood (Fig. I) draining the sympathectomized extremity. Detailed figures have been presented eIsewhere.g A simpIe graph iIIustrates some data obtained on four patients by Dr. F. K. Hick, a11 of whom had arteria1 and venous (femoraI) punctures before, shortly after and several months after the operation. The degree of the rise depends on avaiIabIe coIIateraIs and corresponds cIoseIy with the cIinica1 improvement. In one case shown here, the oxygen saturation dropped from 66 per cent to 47 per cent. An expIanation of this was found in an acute popIitea1 thrombosis foIIowing the operation, which, however, did not resuIt in gangrene. THE
CLINICAL
COURSE
UNILATERAL
OF THE
DISEASE
IN
SYMPATHECTOMIES
Sympathectomy according to our present knowIedge does not remove diseased structures. WhiIe some authors have reported inff ammatory or degenerative changes in the gangIia removed from Raynaud’s disease or Buerger’s disease, other studies, notabIy those of Craig and Kernohan,14 reveaIed no pathoIogic changes. Our materia1 has been studied with neurohistoIogic methods by Dr. Hassin, who has never reported any abnorma1 histoIogic findings. The vasomotor paIsy which is obtained by sympathectomy has a favorabIe effect on the circuIation of an affected Iimb even though it does not strike at the cause of the disease. There are eight patients in this series, who either purposeIy or uninten-
NEW SERIES VOL. XLVII,
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tionaIIy have one denervated extremity, whiIe the other one has been Ieft aIone or sympathedtomy has been incomplete. The
American
Journal
of Surgery
81
Six of these patients suffer from Raynaud’s disease. The operated side is compIeteIy dry, warm and the texture of the
FIG. 2. Effect of reffex cold on the sympathectomized and control extremity. Right lower extremity sympatheetomized severat months previousIy. Note marked vasoconstriction in the control extremity in contrast with paradox increase in pulsation on right side, This increase is due to the systemic rise in blood pressure which folIowed the immersion of both hands in ice water.
Ftilures
of syxpathectomz
Percentaqe of failure.5 FIG. 3. Failures of sympathectomy affected by preoperative diagnosis. Note that Raynaud’s disease shows a failure of 15 per cent which is partty due to incomptete operations and partIy to the fact that most of these were cervicodorsal sympathectomies which give notoriousIy poor resuIts. The unclassified group shows the Iargest percentage of faiIures because most of them are probably not of vasospastic origin. (See aIso TabIe IV.) Failurc2s
of
m ~y_p
20
influenced
athectomy
30 PQrcentaQe
40
FIG. 4. TabIe
III in graphic
30
of
operated side has usuaIIy been more invoIved by the disease process than its feIIow.
failures
by--deqree
HJ
form.
skin is Iooser. Color changes may stiII occur, chiefly at the tips of the digits, but are not painfu1. The burning on reIease of
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de Takats-Sympathectomy
The controI side the spasm is absent. sweats profuseIy, spasms occur on emotiona1 stimuIi or environmenta changes;
JANUARY, 1940
standstiI1. In another patient, who had lost both feet before coming under observation, one upper extremity has been sympathec-
FIG. 5. Oscillometric curves of a 21 year old patient suffering from Buerger’s disease. Note the marked opening of the vascular bed fifteen minutes after the intravenous injection of sodium nitrite on the right side. The left side hardIy responded to the vasodiIator. This patient’s right foot is in an earher stage of disease than the Ieft; better resuIts may be expected from sympathectomy on this side. FailUms
0
f&&~
d&ant
5
ws
of
s)lm_pathectomy
10 Percenta+
15
20
of failureS
FIG. 6. IIIustrating the percentage of faiIures (TabIe IV) in graphic form.
the scIerodactyIia sIowIy progresses; smaI1 uIcers hea sIowIy or not at aI1. The same picture is true of the incompIeteIy sympathectomized extremity. Patients who are we11 seIected invariabIy request operation on the contro1 side at an earIy date. Two patients suffering from Buerger’s disease have had uniIatera1 Iumbar sympathectomies. In both instances the side which was far more affected and had shown uIceration was operated upon. In one patient who has now been foIIowed for three years and has been getting a11 the benefits of conservative treatment, the sympathectomized limb is now warmer, the uIcer is heaIed and his waIking abiIity couId be improved by intermittent venous hyperemia. The other extremity is at a
tomized; in that hand there were muItipIe ulcers and continuous pain, both of which were favorabIy inff uenced. The contro1 side, in spite of a11 conservative treatment is These patients are sIowIy progressing. especiaIIy mentioned because the argument that conservative measures used in conjunction with sympathectomy might have been the cause of improvement cannot hold here. As pointed out before, sympathectomy inhibits the ffuctuations of vasomotor tonus; these fluctuations are intensive enough to elicit a mechanism which sympathectomy aboIishes in Raynaud’s disease. In Buerger’s disease (Fig. 2), however, there is onIy infrequent evidence of acute vasospastic phenomena; there seems to be
NEW SERIES VOL. XLVII,
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a more chronic continuous sympathetic stimuIation originating reff exIy from segmenta thrombi. Such a reff ex vasoconstriction can be interrupted by local excision of thrombosed vesseIs, by a spina anesthetic or by a sympathectomy.6 The Iast, of course, is the most feasibIe and permanent. ANALYSIS
OF
THE
WHOLE
TABLE OF SYMPATHECTOMY TORY
The stage of the disease in which the operation is undertaken (Table III) and TABLE FAILURES
III
OF SYMPATHECTOMY OF
STRUCTURAL
(rag
INFLUENCED
Operations
2::;
-I No structural disease Vesse1.s dilate fully Moderate structura1 changes Incomplete capacity for vasodiIation Advanced structura1 changes* Minima1 capacity for vasodiIatation
CIRCULA-
DISTURBANCES
I
Total.
.._
. . . .I
IO
26 56
3
3
10
10
6
10
50
105
4 4
IO
7
86
DEGREE
1928%1936)
No. of
II FOR PERIPHERAL
21
BY
INVOLVEMENT
Criteria
Stage
1928-1936
Ravnaud’s disease. Buerger’s disease Poliomyelitis with vessel spasm. .. Reflex dystrophy (causatgia, osteoporosis) . .. Unclassified.. .
83
FaiIures, Per Cent
MATERIAL
OnIy patients operated on before the end of 1936 have been incIuded. (TabIe II.) RESULTS
American Journal of Surgery
22
5
76
12
7
72
I
I
* Note that in Group 3 the percentage of faiIures is 72. ObviousIy operations in this group are justified only in an attempt to save the Ieg from amputation. Note aIso that most patients beIong to the second group.
5 *
+,a I
I-
the spontaneous course of the disease at the time and foIIowing the operation are important factors in the end resuIts. (Fig. 4.)
2
I
* Improvement indicates definite am&oration of symptoms but not complete relief. Failure indicates that the disease had either progressed or remained at its preoperative state. The only death occurred five days after lumbar sympathectomy, due to coronary thrombosis.
Of the many variabIes, I have picked three factors for anaIysis, and the resuIts have been tabuIated accordingly. The preoperative diagnosis modifies the obtained results in that there is the Iargest percentage of faiIures in the uncIassified group, stiI1 a considerabIe percentage in Raynaud’s disease and very encouraging resuIts in Buerger’s disease. (Fig. 3.) This rather startling resuIt is expIained first of a11 by the fact that most operations in the uncIassified group and in Raynaud’s disease were on the upper extremity which is notoriousIy more diffIcuIt to denervate, and secondIy by the very rigid criteria which are used to determine the operabiIity of Buerger’s disease. AIso the unclassified group wiII graduaIIy be eliminated by a definite etiologic diagnosis and wiI1 form a part of the non-operative group in the future.
TABLE TYPE
OF
OPERATION
IV AFFECTING I
Operation
No. of
RESULTS I
Failures*
Operations
l-l Lumbar sympathectomy . . CervicodorsaI sympathectomy PregangIionic dorsal sympathectomy.. .... . Extended cervicodorsa1 sympathectomy ....... .. TotaI....................
2 (5 per cent)
40
I
25
5
(20
per cent)
24
3 (12
per cent)
I6
I
105
(6 per cent)
I I (10
I
per cent)
* FaiIure of sympathectomy: no change from preoperative status or progress of deterioration. Note that lumbar sympathectomy and the extended cervicodorsal sympathectomy have the Iowest percentage of failures.
Patterson Ross’5 has cIassified Raynaud’s disease into three groups and I beIieve that this couId be done for al1 periphera1 circulatory disturbances. According to the predominance of the vasospastic against the structura1 eIement, the success of sympathectomy in the different groups is striking. In the first stage there is no or
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de Takats-Sympathectomy
very little detectabIe change in the arteries or in the soft tissues of the digits. (Fig. 5.) The vessels diIate fulIy when heat is
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group are onIy justified in an attempt to save the Ieg from amputation. UnIess a surgeon is thoroughIy famihar with the
i::: :/ j
‘..;,
3
; ::,..-
i:J
4
FIG. 8. Extended cervicodorsa1 sympathectomy performed through the anterior, supracIavicuIar approach. The chain was cut above the stellate and beIow the third dorsal ganglion.
E
B A C FIG. 7. Diagram of cervicodorsa1 sympathetic chain. I, stellate ganglion. ~a, intermediate ganglion, 2, 3, and 4, second, third and fourth dorsal gangIia. A, cervicodorsa1 sympathectomy. B, pregangIionic sympathectomy. c, extended cervicodorsal sympathectomy. This Iast operation has given us resuIts in sixteen cases which are comparabIe to those obtained by the Iumbar sympathectomy.
applied reffexIy, when the sympathetic fibers are blocked with novocaine or when sodium nitrite is injected intravenousIy. In the second stage there is uIceration of the tips of digits or painfuI stehate scars. The vessels show capacity for vasodilatation but it comes on slowIy and is incompIete. In the third stage patients have advanced structura1 disease of the arteries. The vessels onIy have a minimal or no capacity to diIate. The soft tissues are atrophic or sclerotic and the tips of the digits are t&rated or gangrenous. Most patients both in private and dispensary practice beIong to the second and third group. The first group may not see a surgeon nor is it easy to determine that arrest of the disease might not take pIace. In this group conservative measures carried out for a sufficiently Iong time, give one an insight into the spontaneous course of the disease. Obviously operations in the third
course of periphera1 vascuIar disease, its remissions and exacerbations, he wiI1 operate either too often or not often enough. The type of operation performed is the third and Iast factor (TabIe IV) we have analyzed. Lumbar sympathectomy, in the consensus of all workers (Fig. 6), has aIways given superior resuIts to sympathectomies done for the upper extremities. As shown in the graph, Iumbar sympathectomies, most of which were done for Buerger’s disease, poIiomyeIitis or causaIgic syndromes, have been quite successfu1. The cervicodorsa1 sympathectomies have been done in three different ways. (Fig. 7.) The diagram to the Ieft iIIustrates the remova of the steIIate gangIion; the dorsa1 chain is sectioned beIow the second thorThis is Adson’s method acic gangIion. except that a cervica1 approach is used in my chnic. The diagram in the middIe shows the principle of the pregangIionic sympathectomy as advocated by TeIford. The sympathetic chain is cut beIow the third gangIion, and the third and second white rami are cut. This wouId Ieave the postgangIionic fibers intact. It is stated by J. C. White16 that such postganghonic degeneration which occurs after a typica cervicodorsa1 sympathectomy is the cause of recurrent spasms in Raynaud’s disease as the vesseIs are now sensitized to epine-
NEW SERIES VOL. XLVII,
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No. I
phrine. The diagram to the right shows my present method in which the excision is extended upward to in&de the inter-
R
Anterior
American
Journal
of Surgery
8s
wiII rise enormousIy after sympathectomy from 50 to 70,000 ohms to 300,000 ohms or more. (Fig. 9.) For practica1 purposes,
L
Sympathectomy
Sympathectonly
FIG. 9. Determinations of gaIvanic skin resistance on the control and on the sympathectomized side. Note that on the palmar surface of the operated hand the skin resistance rises above 300,000 ohms. Note aIso that on the ulnar surface the readings are equally high, indicating a compIete operation. The skin resistance on the Iower and upper arm did not seem to rise at alI.
mediate ganghon or if this is invisible to strip the vertebra1 artery and caudaIward it incIudes the third thoracic gangIion. (Fig. 8.) My resuIts with this last type have been better than with the pregangIionic method, which does not cut the important first white ramus,17 so that some sweating remains in the hand. Since the recurrence in Raynaud’s diseases foIIowing operation occurs within six months or a year and sensitization phenomena appear six to eight days after operation,‘* the sensitization cannot be considered a sign of recurrence in the postgangIionic sections. The completeness of the operation either on the Iower or on the upper extremity can be demonstrated by Minor’s starch-iodine or Grace Roth’s cobaItous chIoride test. A very accurate and numerica expression of the compIeteness of sympathectomy can be obtained by determining the resistance of the skin to the gaIvanic current. This
however, the paIpating finger can readiIy detect a strip of moisture on the sympathectomized limb. On the upper extremity this moist strip is usuaIIy of uInar distribution, on the Iower it foIIows the femora1 or saphenous nerve. This has Ied us to take specia1 care in removing a11 of the second and preferably the third thoracic gangIion on the upper extremity and the second or even first lumbar gangIion for the Iower extremity. This technica discussion is important because of my conviction that faiIures, at Ieast in this materia1 frequently occur in insuffrciently sympathectomized Iimbs. A compIeteIy dry hand has not ever become moist-the Iongest observation being eight years. But a shght area of perspiration Ieft on a sympathectomized Iimb wiI1 grow as if regeneration could occur from an overlooked fiber. In evahrating resuIts this point requires consideration.
86
AmericanJournal ofSurgery
de Takats-Sympathectomy 7. FONTAINE, R.,
SUMMARY
AND
CONCLUSIONS
As a resuIt of this study it is feIt that sympathectomy has a definite pIace in the treatment of periphera1 circuIatory disturbances. The resuIts are influenced by the type and extent of the disease, by the naturaI course of the disease, by the extent of the operation and some other factors which eIude statistical analysis and have to be determined in the individua1 case. Sympathectomy shouId be undertaken by men who are fuIIy famiIiar with periphera1 vascuIar syndromes, their natural course and their response to other forms of therapy. Undertaken under such conditions sympathectomy shows an increasing percentage of successfu1 results. REFERENCES 1. REICHERT, F. L. Intermittent
cIaudication without gangrene, controlled by sympathetic nerve block. Ann. Surg., 97: 503, 1933. 2. DE TAKATS, G., BECK, W. C., REYNOLDS, J., and ROTH, E. The neurocircuIatory cIinic; a summary of its activities. In press. 3. DE TAKATS, G. PeripheraI vascular disease; its signiticance for genera1 practitioners and speciaIists. J. A. M. A., 104: 1463, 1935. 4. DE TAKATS, G., HICK, F. K., and COULTER, J. S. Intermittent venous hyperemia in the treatment of peripheral vascular disease. J. A. M. A., 108: 1951, 1937. 5. HARRIS, R. I., and MACDONALD, J. L. The effect of lumbar sympathectomy on growth of Iegs paraIyzed by anterior poIiomyeIitis. J. Bone 0 Joint Surg., 18: 35, 1936. 6. DE TAKATS, G. Reflex dystrophy of the extremities. Arch. Surg., 34: 939, 1937.
JANUARY, ,940
and HERRMANN, L. G. Posttraumatic painfuI osteoporosis. Ann. Surg., 97: 26, 1933. 8. SILBERT, S. EvaIuation of resuIts in treatment of periphera1 circuIatory diseases. Am. Heart J., 15: 265, 1938. g. DE TAKATS, G. The effect of sympathectomy on peripheral vascular disease. Surgery, 2: 46, 1937. Sympathectomy for peripheral vascuIar disease. Arch. Int. Med., 60: ggo-roo1, 1937. IO. CAPPS, R. B. A method for measuring tone and reflex constriction of the capiIIaries, venuIes and veins of the human hand with the resuIts in norma and diseased states. J. Clin. Investigation, 15: 229, 1936. II. STORUP, G., BOLTON, B., and CARMICHAEL, E. A. Vasomotor responses in hemipIegic patients. Brain, 58: 456, x935. 12. LEWIS, T., and PICKERING,G. W. Vasodilatation in the Iimbs in response to the warming of the body with evidence for sympathetic vasodilator nerves in man. Heart, 16: 33, 1931. 13. JOHNSON, C. A., SCUPHAM, G. W., and GILBERT, N. C. Studies in peripheral vascular phenomena. II.Observations on periphera1 circulatory changes foIIowing unilatera1 cervica1 ganglionectomy and ramisectomy. Surg., Gynec. & Oh., 55: 737, 1932. 14. CRAIG, W. M., and KERNOHAN, J. W. The surgica1 removal and histoIogic study of sympathetic gangha in Raynaud’s disease, thromboangiitis obtiterans, chronic infectious arthritis and scIeroderma Surg., Gynec. &+Obst., 56: 767, 1933. 15. Ross, J. P. The recognition of structura1 changes in the arteries in Raynaud’s disease. St. Barth. Hosp. Rep., 68: 121, 1935. 16. SMITHWICK, R. H., FREEMAN, N. E., and WHITE, J. C. The effect of epinephrin on the sympathectomized extremity: an additionat cause of faiIure on operations for Raynaud’s disease. Arch. Surg., 29: 759, 1934. 17. KUNTZ, A., ALEXANDER, WM. F., and FURCOLO, C. L. CompIete sympathetic denervation of the upper extremity. Ann. Surg., 107: 25, 1938. 18. SIMMONS, H. T., and SHEEHAN, D. Inquiry into “reIapse” following sympathectomy. Lancet, 2: 788 (Oct. 2) 1937. lg. GeIhorn and Steck. Am. Heart .I., 18: 206, 1939.
DE TAKATS,
M.D.
Associate Professor of Surgery, University CHICAGO, MATERIAL
T
TABLE OF
I
SYMPATHECTOMY VASCULAR
FOR
PERIPHERAL
DISEASE
lgz8--1g36 SeIection of Cases /Lack of marked structura1 changes Raynaud’s phenomena. Absence of scIerodactvIia (Stages I and 2 ” Absence of acute infiammatory stage Buerger’s disease.. . . . Below 40 years of age with definite colIateraI reserve Poor response to consert vative treatment Moderate paraIysis limited to one extremity; evidence PoIiomyeIitis. . . ! of vasospastic phenomena Age preferabIy between 6 1 and IO years Reflex dystrophy (cau- Severe cases producing disabiIity, resistant to physiosalgia, traumatic vesse1 spasm, Sudeck’s therapy, exhibiting abnoratrophy). 1 ma1 vasomotor phenomena Rapid onset of digita thrombosis with impending UncIassified.. . . . . . . , . 1 gangrene MostIy upper extremities \ invoIved Diagnosis
In the group diagnosed as Raynaud’s disease (TabIe I), a number of patients exhibiting Raynaud’s phenomena due to secondary vesseI spasm were first excluded. The diagnosis of Raynaud’s disease was onIy arrived at by excIusion. In the typica forms, the stage of scIerodactyIia with deep uIcerations was not subjected to operation, as our results in this group have been unsatisfactory. Operation for Raynaud’s * From the Department
of Surgery University
ILLINOIS
disease seemed most successfu1 in the patient in whom organic obstruction of the digita arteries was absent or shght and in whom invoIvement of the skin, joints, and tendons had not yet taken pIace. Between these two groups there is a third, in which there is some organic damage, but diIatation of the vesseIs by reffex heat or vasodiIators was stiI1 possibIe but incompIete. This group shows such improvement that operations are justihed. Operations on patients suffering from Buerger’s disease have not been advocated in: (I) an acute infIammatory stage; (2) in a Iate stage with a cIosed coIIatera1 bed (frozen vascuIar tree); (3) patients past the age of 40; (4) if economic status permits a Iong rest in an even warm &mate or if the cardiovascuIar apparatus is diffuseIy invoIved. It is most difficuIt to argue for or against a sympathectomy in patients around 40 years of age who have had an acute arteritis in the earIy twenties, whose disease has been quiescent for many years and now present themseIves with a second ffare-up, usuaIIy in another previousIy uninvoIved extremity. Such patients show IittIe capacity for vasodiIatation and show some scIerotic changes. They may have myocardiaI damage. In such cases, intensive conservative treatment together with paravertebra1 aIcoho1 injection has arrested the disease in fifteen patients. This method shouId certainIy be tried before sympathectomy in such borderIine cases.*
STUDIED
HIS report is based on a follow-up study of 105 sympathectomies done on fifty patients suffering from various types of periphera1 circuIatory disturbances. INDICATIONS
of IIIinois
t ParavertebraI injections of aIcoho1 as advocated by Reichert’ have been done on twenty-five patients suffering from obIiterating arterioscIerosis and are discussed eIsewhere.2
of IIIinois and the Circulatory 78
Group of St. Luke’s Hospital, Chicago.
NEW SERVESVOL. XLVII,
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de Takats-Sympathectomy
We have urged sympathectomy, however, in individuals between 20 and 40, who are having their First attack and who have a good capacity for vasodiIatation. The resuIt of the sympathectomy mainIy depends on the stage of the disease, which may differ in each of the four extremities. In case the upper extremity is invoIved, which is more frequent than suspected, sympathectomy is done as soon as nutritiona1 changes? such as atrophy, UIceration or gangrene are manifest. FoIlowing operation, the same conservative regime is instituted as preoperativeIy and is folIowed for many years.3 This consists of compIete abstinence from tobacco, increased ffuid and saIt intake, a series of typhoid vaccine injections twice a year and intermittent venous hyperemia treatments to stretch the venocapihary bed. This Iast method is more effective in the sympathectomized patient, where the resistance to stretch has been diminished.4 In pohomyelitic children, if they are younger than 8 years, if the paralysis is Iimited to one extremity and is moderate are in degree, and if their extremities coId, pIurn-coIored and painful, if noduIar patches of cyanosis, edema and chiIblains are present, a sympathectomy wiI1 provide increased vascuIarity. An acceIeration of growth, as reported by Harris5 has not been observed in our cases. In the fourth group, I have gathered a group of vasomotor and nutritiona distubances, diagnosed as Sudeck’s atrophy, traumatic osteoporosis, stump-neuroma, and causaIgia and have caIIed them reflex dystrophies.6 Not onIy does the edema, cyanosis, and sensitivity to heat disappear, but bone may recaIcify, as shown by Fontaine and Herrmann. A group of “uncIassiIied” cases had to be established in this material. Some of the most dramatic successes have been obtained in this group without, however, estabIishing the possibiIity of a dehnite preoperative diagnosis.
American JournaI of Surgery
ANALYSIS
79
OF RESULTS
It is quite diffrcuh to evaluate any method used in the treatment of peripheral vascular disease. SiIberP has recentIy pointed out that unIess certain factors are eIiminated, the vaIue of any treatment must remain dubious. These factors are (I) the tendency to spontaneous improvement; (2) the effect of cessation of smoking; (3) the norma variations in vasoconstriction due to environmenta changes in temperature and the patient’s psychic state. To this one may add the effect of (I) rest in bed, (2) miId heat, (3) pIenty of &ids, (4) reguIation of the patient’s diet, and (5) the surgica1 care of uIceration and necrosis. ObviousIy a compIete eIimination of al1 these factors in analyzing one form of therapy is aImost impossibIe. In trying to find out the place of sympathectomy in the treatment of periphera1 vascuIar disease, further diffrcuIties present themseIves. A good resuIt in Raynaud’s disease means freedom from painfu1 vasospastic attacks and softening of the scIerotic digits; but in patients suffering from Buerger’s disease an arrest of the disease and the avoidance of amputation must be regarded as a good resuIt even if a functionaI restoration to normaIcy is an anatomic impossibility. That proper seIection of cases, technicaIIy compIete operavoidance of regeneration and ations, adequate postoperative follow-up are important factors in obtaining good resuIts has been pointed out eIsewhere.g In spite of the muItipIicity of variabIes, an attempt has been made to evaIuate the resuIts of sympathectomy. It has been done by utilizing severa methods. First, objective evidence has been sought that periphera circuIation has been modified by the operation. Second, in patients suffering from symmetrica Iesions of approximately identical severity, one extremity was Ieft for contro1 over a period of several years. Third, the total materia1 of 105 sympathectomies performed on fifty patients suffering from various types of periphera1 vascular
80
American Journalof Surgery
de Takats-Sympathectomy
disease has been folIowed for at Ieast two years and the resuhs tabuIated according to criteria to be discussed. g 8 b
L ._C
90
“SW a S 0 70 s ’ 60 6 ._ 1 3 50 x C
z-40 3 0
ths Operation
podtop.
poStiP.
FIG. I. 02 saturation of venous blood taken from the femora1 vein before, two weeks and severa months after sympathectomy. Note the marked rise in the first three instances, a moderate rise in the fourth and a definite drop in the fifth case. This Iast patient developed a popliteal thrombosis folIowing operation which, however, did not resuIt in gangrene. THE
MODIFICATIONS FOLLOWING
OF
CIRCULATION
SYMPATHECTOMY
The bIood vesseIs of the sympathectomized Iimb react to direct appIication of heat and coId and aIso to ischemia in the norma manner.g But, being deprived of their vasomotor innervation, these vesseIs are freed of a number of extrinsic and intrinsic stimuIi, which arrive to the vesseIs over the efferent sympathetic pathways. Thus cooIing or pinching the body,lO pain, fright or anger” do not produce vasoconstriction in the sympathectomized extremity, nor wiI1 heating the bodylZ or the production of fever with typhoid vaccine13 produce vasodiIatation.. The question arises, how important are these factors in reguIating circuIation? When studies in bIood flow are made with a modified HewIett-van Zwaluvenburg method, it becomes apparent that great fluctuations in bIood flow are produced by the stimuIi enumerated above. Sympathectomy aboIishes these fluctuations. In a recent study of
Jmumu, rgqo
some of my patients, GeIIhorn and Stecklg found that the inhaIation of COZ, which normaIIy produces a marked centra1 vasoconstriction of periphera1 vesseIs, is aboIished in the compIeteIy sympathectomized extremity and may even give rise to a paradoxica1 vasodiIatation as the IocaI vasodiIating action of CO2 may now become manifest. This method may serve as an index for the compIeteness of sympathetic denervation. Another effect of a permanent vasomotor paIsy can be detected by the study of bIood gases, notabIy the oxygen saturation of the venous bIood (Fig. I) draining the sympathectomized extremity. Detailed figures have been presented eIsewhere.g A simpIe graph iIIustrates some data obtained on four patients by Dr. F. K. Hick, a11 of whom had arteria1 and venous (femoraI) punctures before, shortly after and several months after the operation. The degree of the rise depends on avaiIabIe coIIateraIs and corresponds cIoseIy with the cIinica1 improvement. In one case shown here, the oxygen saturation dropped from 66 per cent to 47 per cent. An expIanation of this was found in an acute popIitea1 thrombosis foIIowing the operation, which, however, did not resuIt in gangrene. THE
CLINICAL
COURSE
UNILATERAL
OF THE
DISEASE
IN
SYMPATHECTOMIES
Sympathectomy according to our present knowIedge does not remove diseased structures. WhiIe some authors have reported inff ammatory or degenerative changes in the gangIia removed from Raynaud’s disease or Buerger’s disease, other studies, notabIy those of Craig and Kernohan,14 reveaIed no pathoIogic changes. Our materia1 has been studied with neurohistoIogic methods by Dr. Hassin, who has never reported any abnorma1 histoIogic findings. The vasomotor paIsy which is obtained by sympathectomy has a favorabIe effect on the circuIation of an affected Iimb even though it does not strike at the cause of the disease. There are eight patients in this series, who either purposeIy or uninten-
NEW SERIES VOL. XLVII,
de Takats-Sympathectomy
No. I
tionaIIy have one denervated extremity, whiIe the other one has been Ieft aIone or sympathedtomy has been incomplete. The
American
Journal
of Surgery
81
Six of these patients suffer from Raynaud’s disease. The operated side is compIeteIy dry, warm and the texture of the
FIG. 2. Effect of reffex cold on the sympathectomized and control extremity. Right lower extremity sympatheetomized severat months previousIy. Note marked vasoconstriction in the control extremity in contrast with paradox increase in pulsation on right side, This increase is due to the systemic rise in blood pressure which folIowed the immersion of both hands in ice water.
Ftilures
of syxpathectomz
Percentaqe of failure.5 FIG. 3. Failures of sympathectomy affected by preoperative diagnosis. Note that Raynaud’s disease shows a failure of 15 per cent which is partty due to incomptete operations and partIy to the fact that most of these were cervicodorsal sympathectomies which give notoriousIy poor resuIts. The unclassified group shows the Iargest percentage of faiIures because most of them are probably not of vasospastic origin. (See aIso TabIe IV.) Failurc2s
of
m ~y_p
20
influenced
athectomy
30 PQrcentaQe
40
FIG. 4. TabIe
III in graphic
30
of
operated side has usuaIIy been more invoIved by the disease process than its feIIow.
failures
by--deqree
HJ
form.
skin is Iooser. Color changes may stiII occur, chiefly at the tips of the digits, but are not painfu1. The burning on reIease of
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American Journal of Surgery
de Takats-Sympathectomy
The controI side the spasm is absent. sweats profuseIy, spasms occur on emotiona1 stimuIi or environmenta changes;
JANUARY, 1940
standstiI1. In another patient, who had lost both feet before coming under observation, one upper extremity has been sympathec-
FIG. 5. Oscillometric curves of a 21 year old patient suffering from Buerger’s disease. Note the marked opening of the vascular bed fifteen minutes after the intravenous injection of sodium nitrite on the right side. The left side hardIy responded to the vasodiIator. This patient’s right foot is in an earher stage of disease than the Ieft; better resuIts may be expected from sympathectomy on this side. FailUms
0
f&&~
d&ant
5
ws
of
s)lm_pathectomy
10 Percenta+
15
20
of failureS
FIG. 6. IIIustrating the percentage of faiIures (TabIe IV) in graphic form.
the scIerodactyIia sIowIy progresses; smaI1 uIcers hea sIowIy or not at aI1. The same picture is true of the incompIeteIy sympathectomized extremity. Patients who are we11 seIected invariabIy request operation on the contro1 side at an earIy date. Two patients suffering from Buerger’s disease have had uniIatera1 Iumbar sympathectomies. In both instances the side which was far more affected and had shown uIceration was operated upon. In one patient who has now been foIIowed for three years and has been getting a11 the benefits of conservative treatment, the sympathectomized limb is now warmer, the uIcer is heaIed and his waIking abiIity couId be improved by intermittent venous hyperemia. The other extremity is at a
tomized; in that hand there were muItipIe ulcers and continuous pain, both of which were favorabIy inff uenced. The contro1 side, in spite of a11 conservative treatment is These patients are sIowIy progressing. especiaIIy mentioned because the argument that conservative measures used in conjunction with sympathectomy might have been the cause of improvement cannot hold here. As pointed out before, sympathectomy inhibits the ffuctuations of vasomotor tonus; these fluctuations are intensive enough to elicit a mechanism which sympathectomy aboIishes in Raynaud’s disease. In Buerger’s disease (Fig. 2), however, there is onIy infrequent evidence of acute vasospastic phenomena; there seems to be
NEW SERIES VOL. XLVII,
de Takats-Sympathectomy
No. 1
a more chronic continuous sympathetic stimuIation originating reff exIy from segmenta thrombi. Such a reff ex vasoconstriction can be interrupted by local excision of thrombosed vesseIs, by a spina anesthetic or by a sympathectomy.6 The Iast, of course, is the most feasibIe and permanent. ANALYSIS
OF
THE
WHOLE
TABLE OF SYMPATHECTOMY TORY
The stage of the disease in which the operation is undertaken (Table III) and TABLE FAILURES
III
OF SYMPATHECTOMY OF
STRUCTURAL
(rag
INFLUENCED
Operations
2::;
-I No structural disease Vesse1.s dilate fully Moderate structura1 changes Incomplete capacity for vasodiIation Advanced structura1 changes* Minima1 capacity for vasodiIatation
CIRCULA-
DISTURBANCES
I
Total.
.._
. . . .I
IO
26 56
3
3
10
10
6
10
50
105
4 4
IO
7
86
DEGREE
1928%1936)
No. of
II FOR PERIPHERAL
21
BY
INVOLVEMENT
Criteria
Stage
1928-1936
Ravnaud’s disease. Buerger’s disease Poliomyelitis with vessel spasm. .. Reflex dystrophy (causatgia, osteoporosis) . .. Unclassified.. .
83
FaiIures, Per Cent
MATERIAL
OnIy patients operated on before the end of 1936 have been incIuded. (TabIe II.) RESULTS
American Journal of Surgery
22
5
76
12
7
72
I
I
* Note that in Group 3 the percentage of faiIures is 72. ObviousIy operations in this group are justified only in an attempt to save the Ieg from amputation. Note aIso that most patients beIong to the second group.
5 *
+,a I
I-
the spontaneous course of the disease at the time and foIIowing the operation are important factors in the end resuIts. (Fig. 4.)
2
I
* Improvement indicates definite am&oration of symptoms but not complete relief. Failure indicates that the disease had either progressed or remained at its preoperative state. The only death occurred five days after lumbar sympathectomy, due to coronary thrombosis.
Of the many variabIes, I have picked three factors for anaIysis, and the resuIts have been tabuIated accordingly. The preoperative diagnosis modifies the obtained results in that there is the Iargest percentage of faiIures in the uncIassified group, stiI1 a considerabIe percentage in Raynaud’s disease and very encouraging resuIts in Buerger’s disease. (Fig. 3.) This rather startling resuIt is expIained first of a11 by the fact that most operations in the uncIassified group and in Raynaud’s disease were on the upper extremity which is notoriousIy more diffIcuIt to denervate, and secondIy by the very rigid criteria which are used to determine the operabiIity of Buerger’s disease. AIso the unclassified group wiII graduaIIy be eliminated by a definite etiologic diagnosis and wiI1 form a part of the non-operative group in the future.
TABLE TYPE
OF
OPERATION
IV AFFECTING I
Operation
No. of
RESULTS I
Failures*
Operations
l-l Lumbar sympathectomy . . CervicodorsaI sympathectomy PregangIionic dorsal sympathectomy.. .... . Extended cervicodorsa1 sympathectomy ....... .. TotaI....................
2 (5 per cent)
40
I
25
5
(20
per cent)
24
3 (12
per cent)
I6
I
105
(6 per cent)
I I (10
I
per cent)
* FaiIure of sympathectomy: no change from preoperative status or progress of deterioration. Note that lumbar sympathectomy and the extended cervicodorsal sympathectomy have the Iowest percentage of failures.
Patterson Ross’5 has cIassified Raynaud’s disease into three groups and I beIieve that this couId be done for al1 periphera1 circulatory disturbances. According to the predominance of the vasospastic against the structura1 eIement, the success of sympathectomy in the different groups is striking. In the first stage there is no or
84
American JournaI of Surgery
de Takats-Sympathectomy
very little detectabIe change in the arteries or in the soft tissues of the digits. (Fig. 5.) The vessels diIate fulIy when heat is
Jmumu,
,040
group are onIy justified in an attempt to save the Ieg from amputation. UnIess a surgeon is thoroughIy famihar with the
i::: :/ j
‘..;,
3
; ::,..-
i:J
4
FIG. 8. Extended cervicodorsa1 sympathectomy performed through the anterior, supracIavicuIar approach. The chain was cut above the stellate and beIow the third dorsal ganglion.
E
B A C FIG. 7. Diagram of cervicodorsa1 sympathetic chain. I, stellate ganglion. ~a, intermediate ganglion, 2, 3, and 4, second, third and fourth dorsal gangIia. A, cervicodorsa1 sympathectomy. B, pregangIionic sympathectomy. c, extended cervicodorsal sympathectomy. This Iast operation has given us resuIts in sixteen cases which are comparabIe to those obtained by the Iumbar sympathectomy.
applied reffexIy, when the sympathetic fibers are blocked with novocaine or when sodium nitrite is injected intravenousIy. In the second stage there is uIceration of the tips of digits or painfuI stehate scars. The vessels show capacity for vasodilatation but it comes on slowIy and is incompIete. In the third stage patients have advanced structura1 disease of the arteries. The vessels onIy have a minimal or no capacity to diIate. The soft tissues are atrophic or sclerotic and the tips of the digits are t&rated or gangrenous. Most patients both in private and dispensary practice beIong to the second and third group. The first group may not see a surgeon nor is it easy to determine that arrest of the disease might not take pIace. In this group conservative measures carried out for a sufficiently Iong time, give one an insight into the spontaneous course of the disease. Obviously operations in the third
course of periphera1 vascuIar disease, its remissions and exacerbations, he wiI1 operate either too often or not often enough. The type of operation performed is the third and Iast factor (TabIe IV) we have analyzed. Lumbar sympathectomy, in the consensus of all workers (Fig. 6), has aIways given superior resuIts to sympathectomies done for the upper extremities. As shown in the graph, Iumbar sympathectomies, most of which were done for Buerger’s disease, poIiomyeIitis or causaIgic syndromes, have been quite successfu1. The cervicodorsa1 sympathectomies have been done in three different ways. (Fig. 7.) The diagram to the Ieft iIIustrates the remova of the steIIate gangIion; the dorsa1 chain is sectioned beIow the second thorThis is Adson’s method acic gangIion. except that a cervica1 approach is used in my chnic. The diagram in the middIe shows the principle of the pregangIionic sympathectomy as advocated by TeIford. The sympathetic chain is cut beIow the third gangIion, and the third and second white rami are cut. This wouId Ieave the postgangIionic fibers intact. It is stated by J. C. White16 that such postganghonic degeneration which occurs after a typica cervicodorsa1 sympathectomy is the cause of recurrent spasms in Raynaud’s disease as the vesseIs are now sensitized to epine-
NEW SERIES VOL. XLVII,
de Takats-Sympathectomy
No. I
phrine. The diagram to the right shows my present method in which the excision is extended upward to in&de the inter-
R
Anterior
American
Journal
of Surgery
8s
wiII rise enormousIy after sympathectomy from 50 to 70,000 ohms to 300,000 ohms or more. (Fig. 9.) For practica1 purposes,
L
Sympathectomy
Sympathectonly
FIG. 9. Determinations of gaIvanic skin resistance on the control and on the sympathectomized side. Note that on the palmar surface of the operated hand the skin resistance rises above 300,000 ohms. Note aIso that on the ulnar surface the readings are equally high, indicating a compIete operation. The skin resistance on the Iower and upper arm did not seem to rise at alI.
mediate ganghon or if this is invisible to strip the vertebra1 artery and caudaIward it incIudes the third thoracic gangIion. (Fig. 8.) My resuIts with this last type have been better than with the pregangIionic method, which does not cut the important first white ramus,17 so that some sweating remains in the hand. Since the recurrence in Raynaud’s diseases foIIowing operation occurs within six months or a year and sensitization phenomena appear six to eight days after operation,‘* the sensitization cannot be considered a sign of recurrence in the postgangIionic sections. The completeness of the operation either on the Iower or on the upper extremity can be demonstrated by Minor’s starch-iodine or Grace Roth’s cobaItous chIoride test. A very accurate and numerica expression of the compIeteness of sympathectomy can be obtained by determining the resistance of the skin to the gaIvanic current. This
however, the paIpating finger can readiIy detect a strip of moisture on the sympathectomized limb. On the upper extremity this moist strip is usuaIIy of uInar distribution, on the Iower it foIIows the femora1 or saphenous nerve. This has Ied us to take specia1 care in removing a11 of the second and preferably the third thoracic gangIion on the upper extremity and the second or even first lumbar gangIion for the Iower extremity. This technica discussion is important because of my conviction that faiIures, at Ieast in this materia1 frequently occur in insuffrciently sympathectomized Iimbs. A compIeteIy dry hand has not ever become moist-the Iongest observation being eight years. But a shght area of perspiration Ieft on a sympathectomized Iimb wiI1 grow as if regeneration could occur from an overlooked fiber. In evahrating resuIts this point requires consideration.
86
AmericanJournal ofSurgery
de Takats-Sympathectomy 7. FONTAINE, R.,
SUMMARY
AND
CONCLUSIONS
As a resuIt of this study it is feIt that sympathectomy has a definite pIace in the treatment of periphera1 circuIatory disturbances. The resuIts are influenced by the type and extent of the disease, by the naturaI course of the disease, by the extent of the operation and some other factors which eIude statistical analysis and have to be determined in the individua1 case. Sympathectomy shouId be undertaken by men who are fuIIy famiIiar with periphera1 vascuIar syndromes, their natural course and their response to other forms of therapy. Undertaken under such conditions sympathectomy shows an increasing percentage of successfu1 results. REFERENCES 1. REICHERT, F. L. Intermittent
cIaudication without gangrene, controlled by sympathetic nerve block. Ann. Surg., 97: 503, 1933. 2. DE TAKATS, G., BECK, W. C., REYNOLDS, J., and ROTH, E. The neurocircuIatory cIinic; a summary of its activities. In press. 3. DE TAKATS, G. PeripheraI vascular disease; its signiticance for genera1 practitioners and speciaIists. J. A. M. A., 104: 1463, 1935. 4. DE TAKATS, G., HICK, F. K., and COULTER, J. S. Intermittent venous hyperemia in the treatment of peripheral vascular disease. J. A. M. A., 108: 1951, 1937. 5. HARRIS, R. I., and MACDONALD, J. L. The effect of lumbar sympathectomy on growth of Iegs paraIyzed by anterior poIiomyeIitis. J. Bone 0 Joint Surg., 18: 35, 1936. 6. DE TAKATS, G. Reflex dystrophy of the extremities. Arch. Surg., 34: 939, 1937.
JANUARY, ,940
and HERRMANN, L. G. Posttraumatic painfuI osteoporosis. Ann. Surg., 97: 26, 1933. 8. SILBERT, S. EvaIuation of resuIts in treatment of periphera1 circuIatory diseases. Am. Heart J., 15: 265, 1938. g. DE TAKATS, G. The effect of sympathectomy on peripheral vascular disease. Surgery, 2: 46, 1937. Sympathectomy for peripheral vascuIar disease. Arch. Int. Med., 60: ggo-roo1, 1937. IO. CAPPS, R. B. A method for measuring tone and reflex constriction of the capiIIaries, venuIes and veins of the human hand with the resuIts in norma and diseased states. J. Clin. Investigation, 15: 229, 1936. II. STORUP, G., BOLTON, B., and CARMICHAEL, E. A. Vasomotor responses in hemipIegic patients. Brain, 58: 456, x935. 12. LEWIS, T., and PICKERING,G. W. Vasodilatation in the Iimbs in response to the warming of the body with evidence for sympathetic vasodilator nerves in man. Heart, 16: 33, 1931. 13. JOHNSON, C. A., SCUPHAM, G. W., and GILBERT, N. C. Studies in peripheral vascular phenomena. II.Observations on periphera1 circulatory changes foIIowing unilatera1 cervica1 ganglionectomy and ramisectomy. Surg., Gynec. & Oh., 55: 737, 1932. 14. CRAIG, W. M., and KERNOHAN, J. W. The surgica1 removal and histoIogic study of sympathetic gangha in Raynaud’s disease, thromboangiitis obtiterans, chronic infectious arthritis and scIeroderma Surg., Gynec. &+Obst., 56: 767, 1933. 15. Ross, J. P. The recognition of structura1 changes in the arteries in Raynaud’s disease. St. Barth. Hosp. Rep., 68: 121, 1935. 16. SMITHWICK, R. H., FREEMAN, N. E., and WHITE, J. C. The effect of epinephrin on the sympathectomized extremity: an additionat cause of faiIure on operations for Raynaud’s disease. Arch. Surg., 29: 759, 1934. 17. KUNTZ, A., ALEXANDER, WM. F., and FURCOLO, C. L. CompIete sympathetic denervation of the upper extremity. Ann. Surg., 107: 25, 1938. 18. SIMMONS, H. T., and SHEEHAN, D. Inquiry into “reIapse” following sympathectomy. Lancet, 2: 788 (Oct. 2) 1937. lg. GeIhorn and Steck. Am. Heart .I., 18: 206, 1939.