Diagnosis and treatment of peripheral vascular diseases

DIAGNOSIS AND TREATMENT

PERIPHERAL

VASCULAR

OF

DISEASES*

MONT R. REID, M.D. CINCINNATI,

I

CANNOT express my heartfeIt

appreciation for the signal honor of addressing you on this occasion. We are gathered here this evening to inaugurate a foundation in honor of a man who is aheady most honored and beloved throughout the worId. Viewed by one who Iives afar and has not hda your precious ’ opportunities of intimate association with Professor RudoIph Matas, I am constrained to the beIief that this occasion brings more honor to you than it can possibIy bring to him. His pIace in the annaIs of medica history is secure beyond any power of yours to change. Your Iives wiI1 be enriched by the pIeasant memories of this historica gathering; the Iives of future speakers, as has mine, wiI1 be inexpressibIy enriched by the priviIege of deIivering an address for this Foundation, and the reason is and wiI1 aIways be that it bears the great name of RudoIph Matas. With his presence he honors us this evening, and through his consent he honors this Foundation with his name. I am fuIIy aware of the historica significance of this occasion; of the rGIe that this foundation’s cherished prize wiI1 pIay in the progress of the art and science of surgery. It is inconceivabIe that any man shouId deserve to receive it during Professor Matas’ Iifetime, or for many years thereafter. The expIanation must be due to that great generosity which, among other traits, has so endeared him to everyone who has been priviIeged to know him. I am, therefore, here this evening with a profound feeIing of humiIity as we11 as appreciation for I reaIize fuII we11 that

0.

there are men among those whom he has trained or among his admirers throughout the worId who are far more worthy to receive this prize for conspicuous contributions to the fieId of vascuIar surgery. I couId not, in good faith, proceed with my address without expressing again to Professor Matas my gratitude for the innumerabIe stimulating suggestions as we11 as the fatherIy interest he has aIways dispIayed in my accompIishments in this fieId of surgery, for out of a11 that deveIoped the bond of intense devotion which binds me to him. The origin of that devotion may aIso be traced to the great friendship and admiration which existed between my former Chief and Professor Matas. Through Professor HaIsted I became interested in vascuIar surgery, and through him I aIso became a pupi of Professor Matas. As the years rolIed by I deveIoped an aImost fIIia1 Iove for Professor HaIsted and shared equaIIy with him his admiration and respect for Professor Matas. After Professor HaIsted’s death I met Professor Matas for the first time and Iistened with i&suppressed emotion to his address entitled, “An Appreciation” which he deIivered in BaItimore in memory of WiIIiam Stewart HaIsted. There I &tnessed a demonstration of those human attributes which win a pupiI’s devotion. AIready recognized the worId over as foremost among contributors to the progress of medicine, first to evaIuate and adopt true progress and first to discard the obsolete, Professor Matas, for the first time, reveaIed to me his phiIosophy of

* hslatas Vascular Surgery Lecture, Jan. 23, 1934. Matas Medal created by VioIet Hart Fund of Tulane University of Louisiana presented to Mont R. Reid, New Orleans, Jan. 23,’ 1934. From the Department of Surgery of the CoIIege of Medicine of the University of Cincinnati and the Cincinnati General llospital. II

I2

American

Journal

of Surgery

Reid-Vascular

life-his ideas with respect to the importance of human Iife, conscience, human sympathy, gentIeness, IoyaIty, honesty, magnanimity and a sense of duty in the practice of medicine and surgery. Throughout the hurricane of progress in his own Iifetime it was obvious that these precious heritages from a11 past medicine had not been driven from his creed by the coId science of modern medicine. True devotion to a man is not born of admiration for his work or for his scientific attainments. It springs from such human attributes as Professor Matas reveaIed on that first occasion of our meeting. In the ten years since that memorable address I have not missed an opportunity to benefit from his great contributions to the science of medicine nor from his sympathy, counse1 and advice. The occasions have been a11 too infrequent; nevertheless, in that time no other man has had a greater influence upon me and my work. On this occasion, therefore, I ask for the right to participate in this ceIebration as one of his pupiIs yieIding to none other in the intensity of my feehngs of admiration, Iove, Ioyalty, and gratitude. In the great honor that you are conferring upon me for whatever merit I may deserve I wouId remind you that the greater share of that honor rightfully belongs to our great teacher. He has bIazed a trai1 of progress in vascular surgery unequahed by any other man in the history of medicine. He is still way out in front, hording the torch and beckoning us to come on. And this foundation, like him, wiII always be a beacon Iight urging men to strive for a prize that wiI1 be coveted for generations to come. Inasmuch as we are inaugurating this evening a foundation to honor surgeons who have made conspicuous contributions to the subject of vascuIar surgery, it may be assumed that I wiI1 endeavor to discuss some of the probIems deahng with diseases of the bIood vesseIs. I hope, however, you wiII agree that it is not the time to discuss problems of operations upon the vascuIar system when in the presence of our great

Diseases master for he possesses a far superior knowIedge of them and a far greater abihty to perform them. Fortunately, the fieId of vascuIar surgery has been extended to incIude many conditions which do not necessariIy invoIve operating upon the bIood vesseIs. From these conditions I have chosen my subject for this evening and, in so doing, I trust that I shaI1 have lived up to the spirit of the motive which prompted the establishment of this foundation. Organic diseases of the arteries are indirectIy responsibIe for more deaths than a11 other diseases combined. Most heart troubIe resuhs from disease of the smaI1 arteries that suppIy nourishment to the muscIes of the heart. The cerebra1 accident of apopIexy is the resuIt of damaged blood vesseIs. The disorders in function of many other vita1 organs, such as the Iiver, kidneys, eyes, and pancreas, are frequentIy the rest& of abnormal bIood vessels. Not infrequentIy the diseased arteries impair the nutrition or function of extremities to such an extent that amputation is It is safe to say that diseased necessary. arteries pIay an important rBIe in the practice of every branch of medicine, especiaIIy in interna medicine. In recent years there has deveIoped an amazing interest in the study and treatment of this greatest of a11causes of death. The surgeon’s interest is now directed to probIems which a few years ago were not considered part of his domain. With some encouragement he has endeavored to improve the bIood suppIy of the heart, the brain, the kidneys He has especiaIIy beand the pancreas. come dissatisfied with the pIacid r6Ie of merely amputating extremities for diseases of the peripheral arteries, and has been taking an active part in the study and treatment of those primary causes which lead to gangrene or other conditions that may require amputation. The compIete story of the vascuIar surgeon’s interest in any one probIem of the diseased arteries in various parts of the body wouId consume more space than

N~rr Snurs

VOL. XXIV,

No. I

Reid---VascuIar

is at my- disposa1. Consequently, I have chosen to bring to you, as my address, first a \rerv brief story of the early history of the peripheral vascuIar diseases, and then to discuss the treatment of the disturbances caused by the obliterative peripheral vascuIar diseases. HISTORICAL

Modern science has proved, beyond doubt, that some forms of peripheral vascular disease are as oId as the recorded history of the human race. The investigations of G. EIIiott Smith and S. G. Shattock in 1908 reveaIed extensive arterioscIerosis in the body of Menephtah, the most wideIy known of the ancient roya Egyptians. Again in 191 I Marc Armand Ruffer of the Cairo MedicaI SchooI made an exhaustive study of Egyptian mummies and amply confirmed the previous observations of Smith and Shattock. It may be that AristotIe’s description of the changes in the sinews of old animals and of “bone in the heart” refers to an arterioscIerotic condition of the bIood vessels. However, there is no record of its observation by scientists in the AIexandrian SchooI which was estabhshed by men trained in the AristoteIian teaching. There is no definite evidence that it was described by Herophilos, reputed to be the first dissector of human bodies, or by Erasistratos. The works of CeIsus and GaIen seem to be based IargeIy on the Iost works of the AIexandrian SchooI but in them there is no mention of human arteria1 diseases. The first definite avaiIabIe notations on periphera1 vascuIar disease appear to beLong to the sixteenth and seventeenth centuries. Antonio Benivieni (I 507) speaks of tubercIes and poIyps of the heart and of “bIack bIood mixed with biIe in the vesseIs.” VesaIius was famiIiar with aneurysms. FaIIopius (1575) noted that a11 of the arteries on one side of a body he dissected had degenerated into bone. No mention is made of it in that great compendium on medicine, the “Medicina,”

Diseases

American Journal of Surgery

‘3

published by Jean Fernel in 1554. Later in this century there were a number of descriptions of bone-Iike arteries. In the great works of Schenck von Grafenberg ( 1~84-97) and TheophiIe Bonet ( 1679) the condition is referred to as “ ossified By 1600 most educated. phyarteries.” sicians were aware of the condition of “ ossification ” of the arteries. Throughout this century the subject was of considerabIe academic interest to such men as Par&, WiIIiam Harvev, Sylvius, Bartholin, Willis, MaIpighi, William Cowper, \Vepfer and others. Yet, gangrene, known and described since earIiest history, was in no way attributed to this condition of the T,-esseIs. It was thought to be due to other causes, especially a Iack of innate heat. In the eighteenth centur). the-re was great speculation by Raymond Vieussens, Johann Friedrich CreII, Albrecht van HaIIer, Giovanni Battista Morgagni, Antonio Scarpa and others with regard to the nature of this hardening of the arteries. Yet no one detected the reIation of it to thrombosis and gangrene. It may be that Morgagni ( I 76 I) suspected the reIationship between “ossification” of the coronary arteries and angina pectoris. John FothergiI1 (I 776) reported the definite association of precordial pain with the hardening of the coronary arteries. Edward Jermer resimiIar views to the ported privateIS London MedicaI Society, but refrained from pubIishing them out of soIicit.ude for John Hunter who was a victim of the malady of angina pectoris. In the nineteenth century great progress was made in the knowIedge both of the nature and the effects of the diseases of the arteries. Xavier Bichat (1801) taught that hardening of the arteries was responsibIe for many symptoms ordinariIy credited to a faiIing heart. Laennec (1819) made his monumenta study of aneurysms and stressed the syphiIitic etiology of most of them. Matthew BaiIIie noted the association of cerebra1 haemorrhage with a diseased state of the cerebra1 arteries. Joseph Hodgson (1813) dispeIIed the pre-

14

‘American Journal of Surgery

Reid-VascuIar

vious idea that hardened arteries were due to bone-formation. Likewise, he attributed to arteria1 disease dissecting aneurysm, gangrene of the extremities, apoplexy, angina pectoris, and softening of the heart waI1 foIIowed by its rupture. Robert CarsweII (1837) published beautiful pIates iIIustrating gangrene of the toes due to ossification of the arteria1 waI1 and deposition of fibrin in the Iumen. AIso, Hodgson, CarsweII and others were we11 aware of the importance of a coIIatera1 circuIation. In this respect the understanding of the EngIish SchooI of Surgeons was in advance of the French SchooI which had not yet grasped the important reIation of arterioscIerosis to dry gangrene of the extremities. However, Jean CruveiIhier very soon pubIished his beautifuIIy engraved two voIume atIas (1829-42) and through it justIy deserves the credit for teaching the worId that arteria1 disease frequentIy caused gangrene of the extremities. He advocated the term “gangrene by obIiteration of the arteries” as a substitute for the Iong-used but misIeading terms “seniIe” gangrene. He aIso and “spontaneous” recognized the changes that may occur in the ai-terioIes (“ arteria1 capiIIaries “) when the Iarge arteries appear normaI. He bemoaned the fact that there was no sure sign which wouId permit the recognition of obIiterated arteries during Iife. In this earIy part of the nineteenth century Lobstein (I 829-33) introduced for the first time the term “arterioscIerosis.” For some years it appears that this term was used to denote a11 forms of arteria1 disease. It is no Ionger possibIe within the Iimits of this address even to sketch the amazing progress that has been made in our knowIedge of arteria1 diseases. For the purposes of my paper it wiI1 suffice to say that great men such as Rokitansky, Virchow, RindAeisch, George Johnson, GuII and Sutton, FriedIBnder and K. Kijster; and advances in technique such as the use of the microkymograph and the microscope, tome, sphygmomanometer soon made it evident

Diseases that “arterioscIerosis” was a very compIex disease capable of manifesting itseIf in many ways or eIse that this term incIuded a variety of different diseases which might become recognized and cIassified under different names, and since the middIe of the past century the trend of thought and work has been in the Iatter direction. Hence, I shaI1 confine myseIf to just a brief historica review of the origin of the different primary periphera1 vascuIar diseases which have been divorced from the incIusive term “ arterioscIerosis ” and given independent names of their own for the purposes of more intensive study and treatment. In most instances these cIassifications are based on cIinica1 and histopathoIogic studies for, except in a few instances, there is aImost nothing known concerning any definite etioIogy of the various periphera1 vascuIar diseases which are now recognized. VASOMOTORPERIPHERAL VASCULARDISEASE That the vasomotor nerves might profoundIy inff uence the function of the periphera1 arteries was recognized about a quarter century after Lobstein introduced the term “arterioscIerosis+” In 1862 Maurice Raynaud pubIished his paper, “De I’asphyxie IocaIe et de Ia gangrhne symmetrique des extremitits.” In the cases he had studied there were no obvious pathoIogic changes in the arteries. He ascribed the cause to vasomotor spasm brought about by excessive action of the vasomotor nerves. Since his time it has been feIt that periphera1 vascuIar disturbances due to vasomotor inff uences shouId be cIassified separateIy rather than as a manifestation of arterioscIerosis. The cIinica1 syndrome which he described is now generaIIy termed “Raynaud’s disease.” As time passed investigators began to recognize other cIinica1 pictures which differed from the cases described by Raynaud, but which seemed to be the resuIt of an abnormaIity in function of the vasomotor nerves. Thus in 1878 Weir MitcheII described the condition which he caIIed “erythromeIaIgia.”

NEW SERIES

VOL.

XXIV,

No.

I

Reid-Vascular

In 1892 SchuItze gave the name “acroparesthesia” to a condition which previously had been described by NothnageI.

Diseases A very important resuIt of all this study of the roie of the vasomotor nerves in periphera1 vascular disease is the reahza-

FIG.

2.

Boulitte’s

modification

of Pachon

osciilometer.

tion that they aIso may play a Iarge part in conjunction with the organic vascular diseases. This part may be a continuous

FIB,. [. Dry gangrene arteries.

of foot and thrombosed (After Cruveilhier.)

sclerotic

To another chnical group of cases which, however, may show marked variations, Cassirer in 1912 gave the caption “chronic acre-asphyxia.” In such conditions as scIeroderma, scIerodactylia, muItipIe neurotic gangrene and IocaI shock, the vasomotor nerves are thought by some investigators to be at fauIt, either primariIy or refIexIy. There are atypica1 vasomotor neuroses and borderline conditions which do not faII definiteIy into any of the various cIassifications. For purposes of a cIea.rer understanding of the nature of the periphera1 vascuIar disturbances, and of a more rationa therapy, the present tendency is to try to group the vasomotor conditions under one of two main subdivisions: the vasospastic and the vasodiIatory disturbances.

FIG. 3. Tycos diatherm for making determinations surface temperature. (After Scott.)

of

one but it is especiahy important to reahze that it may be a temporary part which is often a determining factor in the causation of gangrene. The intense vasospasm incident to the rather sudden occIusion of the peripheral arteries by emboIism or thrombosis or foIlowing exposure to cold and infection probabIy

16

American JournaI of Surgery

Reid-VascuIar

pIays a Iarger rGIe in the threatening gangrene than does the inadequacy of the colIatera1 arterial circulation. When the main peripheral arteries gradualry become completely obIiterated as a result of organic vascuIar diseases, the dangers incident to sudden vasospasm grow reIativeIy unimportant. Thus in modern vascuIar surgery it has become important not onIy to be abIe to recognize the pure vasomotor peripheral vascuIar disturbances, but aIso to evaIuate the permanent and temporary rGIes which the vasomotor nerves may exert in the course of primary organic vascuIar diseases. This problem is made more difficuh by an aImost tota ignorance of the etioIogic factors that are responsibIe for the abnorma1 function of the vasomotor nerves.

Diseases

condition was usuaIIy ascribed to arterioscIerosis in this country, and known as “presenile gangrene.” There is another condition which differs from thromboangiitis obliterans in that the veins are not invoIved and that the process within the artery seems to be essentiaIIy one of thrombosis. For this condition we have used the term “endarteritis obIiterans.” It wouId seem that the process is essentiaIIy an inflammatory one and, as some think, it may be the resuIt of some definite infection. The necessity of recognizing the obIiterative Iesions due to trauma, thrombosis and emboIism has become apparent to aI1. There is considerabIe evidence that certain diseases and infections may pIay an important rBIe in the incidence of arterioscIerosis. This is particuIarIy true of ORGANIC PERIPHERAL VASCULAR DISEASES diabetes aIthough a convincing reIationwith After Raynaud started a segregation of ship has been shown in connection typhoid fever, rheumatism, arthritis, gaIIthe vasomotor periphera1 vascuIar diseases, stones, and other chronic diseases. Due to it remained for von Winiwarter to point the way toward a further cIass&cation of the urgent necessity of treating the diabetes who have arterioscIerotic pethe organic diseases which were stiI1 in patients ripheral vascuIar disease, it has wiseIy grouped under the heading of arterioscIerobecome the custom to speak of diabetic sis. In 1879 he reported a “ PecuIiar Form gangrene or diabetic arterioscIerosis rather of Endarteritis and EndophIebitis with than arterioscIerotic gangrene in a patient Gangrene of the Foot.” He designated the who has diabetes. condition arteritis obIiterans. Erb conIt has been known for a Iong time that tributed greatIy to our knowIedge of the syphiIis often affects the thoracic aorta, cIinica1 aspects of this disease. FinaIIy, in the larger arteries and the cerebral vesseIs. 1908, Buerger gave further evidence that Professor Matas’ studies and methods of the process was a definite pathologic conditreating syphilitic aneurysms are accepted tion yielding a distinct clinical entity. Due praise throughout the to the invoIvement of the veins as we11 with unequaIIed world. That syphiIis may be the cause of a as the arteries he proposed the term diffuse process giving rise to gangrene and “ thromboangiitis obIiterans,” a name of periphera1 vascuIar other symptoms which is now commonIy used in this disease has been suggested from time to country aIthough the condition is fretime ever since 1839 when John Davy The quentIy caIIed “ Buerger’s disease.” reported 2 cases which may have been etioIogy of this condition is stiI1 unknown. caused by it. In 1906 DrueIIe reported a By many it is regarded as infectious; by and CIark, series of 14 cases. DarIing others, as toxic in nature, whiIe there are LetuIIe and Warthin have made interesting some who beIieve that it may resuIt from observations on the condition. Recently a variety of causes. It is entirely probable Louis G. Herrmann reviewed the subject that the conditions which are now pIaced and reported 3 new cases which ilhrstrated in this group wiI1 in time be further subrespectiveIy the angiospastic, endarteritic divided. Prior to Buerger’s work the

NEW

\I..IUES

Vo,..

S.XIV,

No.

I

Reid-VascuIar

and thromboarteritic types of syphilitic peripheral vascuIar disease. AIthough regarded as infrequent in occurrence the present evidence seems to justify the inclusion of syphihtic arteritis m . an> classification of periphera1 vascuIar diseases. Tuberculosis of the arteries is rare. The? ma)- become involved through a direct extension from a nearby Iesion or, more rarely, through infected emboIi from a distance. It is rareIy seen in the periphera1 arteries, but occurs much more frequentI)in the vesseIs of the brain and those of the thoracic and abdomina1 viscera. One case of gangrene of an extremity due to tuberwas culosis of the periphera1 arteries reported by B;iumIer. Acute arteritis of the extremities during the course of typhoid fever, influenza, choIera and scarIet fever was first accurately described by WieseI, and is not an infrequent occurrence. “There have been about 3z cases of Periarteritis Nodosa reported in the Iiterature ” (Buerger). KussmauI and Maier first described the condition in 1866. There may be a true pyogenic infection of the arteries. This may be IocaI or generaI. The commonest form is due to infected emboIi, not infrequentIy resuIting in the formation of mycotic aneurysms. The conditions stiI1 cIassified as arteriosclerosis are the cause of the vast majority of chronic obIiterative arterial diseases. In generaI, the changes regarded as degenerative and usuaIIy associated with advancing age are Iumped together and caIIed “ arterioscIerosis.” Among these changes it is admitted that there are great variations, and some investigators make subdivisions such as the noduIar, seniIe, arterioIar and Mdnckeberg’s types. In the present state of our knowIedge, these types appear to represent variations or stages of the same fundamenta1 pathoIogic process. Yet in the study and treatment of periphera1 vascuIar diseases it seems to be of definite prognostic and therapeutic vaIue to try to recognize varieties of arterioscIerosis, especiaIIy the Miinckeberg’s and

Diseases

American

Journ;~l

i-

r,fS~~rcrry

seniIe types. Undoubtedly, as time goes on and after specific etioIogic factors have been discovered, these variations of arteri-

DID_ sm,,zx

=.MJd

b,-%&h.-.&

_“I

FIG. 4. Method of recording caIorimetric and oscillometric studies of upper extremities, used in the VascuIar Disease Clinic of the Cincinnati Genera1 Hospital.

oscIerosis wiI1 become more readily recognizabIe and be spIit from the parent trunk under names of their own. CLASSIFICATION

OF

PERIPHERAL

VASCULAR

DISEASES

There is much variation in the cIassification of periphera1 vascuIar diseases. BeIow is given the one used in the VascuIar Disease CIinic of the Cincinnati Genera1 HospitaI. PERIPHERAL A.

Primarg

VASCULAR

Vasomotor

DISEASE.

Disturbances.

a. Vasoconstrictor Disturbances (I) Raynaud’s disease (2) Acrocyanosis (Acroasphyxia chronica; Acroparesthesia; ScIerodactyIia) 6. VasodiIatory Disturbances. (I) ErythromeIaIgia (2) Acute painfu1 osteoporosis (?)

18 B.

American Journal of Surgery

Primary Organic

Diseases

Reid-VascuIar of the Arteries*

a. Traumatic (chemica1 and thermal) (I) EmboIism and simple thrombosis (2) Arteriovenous aneurysm (3) PhenoI and al1 caustics (4) Frost bite b. Inflammatorv (toxic) ThrombiaI;giitii obIiterans ii; Specific arteritis (syphilis, tubercuIosis, periarteritis nodosa pyogenic) arteritis (exanthemata, (3) Non-specific typhus, typhoid, pneumonia) arteritis (chronic tox(4) Non-specific emia; ergotism) obliterans (cause unde(5) Endarteritis termined) c. Degenerative changes (I) ArterioscIerosis (senile, diabetic and M8nckeberg)

For a Iong time the great emphasis was Iaid on the importance of the different types of gangrene, and somewhat different forms of surgica1 treatment were advocated for the various forms of gangrene. For instance, it was usuahy advised to permit spontaneous amputation in case of dry gangrene and to amputate high up and earIy in case of moist gangrene. Then came a period, within this century, when there was great interest in methods of estimating the vaIue of the coIIatera1 circuIation and of determining the optimum IeveI for amputation. To it beIong the great tests of Matas, Moskowicz and others. Within the past ten years there has been a tremendous reviva1 of interest in the methods of studying peripheral vascuIar diseases. Students and surgeons are no Ionger satisfied with efforts to cIassify the gangrenes and to determine the optimum IeveI of amputation; they want to know the actua1 degree of circuIatory embarrassment. They want to evaIuate the &es of the vasomotor nerves, mechanical obstruction, infection and the genera1 condition of the patient. A simpIe enumeration of some of the procedures and * Vasospasm may 0ccasionaIIy play a constant part in the picture of the obliterative diseases; it frequently pIays a temporary but very important part during the sudden criticaI periods of a11 vascular diseases.

Diseases devices used in the modern study of peripheral vascuIar diseases is ampIe evidence of the great progress within the Iast decade-the study of the extremities before and after vasomotor reIaxation; the use of the modern oscihometer, thermocoupIe and pIethysmograph; microcapiIIary studies; the effect of position on the coIor changes of the skin; the use of a constant temperature room for studies; roentgenologic studies of the arteries; a study of the caIcium content and of the viscosity of the bIood; the condition of the heart; bloodsugar determinations; routine Wassermann reaction; basa1 metabojism; bIood pressure; puIse rate; subnorma temperature; reaction of skin of extremities to heat and coId; and various other procedures and observations. Most of the instruments and procedures mentioned have been vastly improved or actuaIIy devised within Iess than ten years. OUT-PATIENT CINCINNATI

VascuIar

DISPENSARY

GENERAL

Disease

HOSPITAL

CIinic

Special Information to Be Obtained from All Patients with Peripheral Vascular Disturbances Family Histoy of ArterioscIerosis; Diabetes meIIitus; Angina pectoris; Heart disease or SyphiIis? Past History of Syphilis; Chronic tonsiIIitis or other foci of infection, Injury; Frostbite of toes or fingers; ChiIbIains; Frozen feet or exposure to extreme coId? Phlebitis? Where has the patient resided most of his Iife? Has sugar ever been found in the urine? Have there been any suggestive symptoms of Diabetes meIIitus, as thirst, increased urinary output, nocturia? Any Hypertension, Paroxysmal tachycardia? Story of Present Illness in chronoIogica1 order. Onset of Intermittent cIaudication after how long a waIk? Date and character of any injury to the foot or extremity or back, if any? Operation for in-growing toenaiI? CaIIouses pared? Exactly when and how did the uIceration or gangrene start? Character and degree of the pain in the extremities? Is the pain constant? At night

NEW

SENES VOL. XXIV,

No. r

Diseases

Reid-Vascular

only? After heavy meal? Is the pain brought about by change of posture or use of the extremity?

L...lM.6

b,

A””

_h.e

“8,

5. Method of recording caIorimetric and oscillometric studies of Iower extremities, used in the VascuIar Disease Clinic of the Cincinnati Genera1 HospitaI.

FIG.

Occupation. Description of the posture of the patient whiIe at work. How much disabiIity does the patient have at present? When did it begin ? Is there any history of repeated or Iong standing exposure to ChemicaI fumes; Gases; Radium paint for clock diaIs; Phenol or any of its derivatives? Persolzal Habits. At what age did the patient begin the use of tobacco and in what form? Average daiIy amount used at onset? How often has patient stopped smoking? For how Iong a period of time? What brand of cigars, cigarettes or tobacco is being used at the present? What toIerance or intoIerante for tobacco? Approximately how much tobacco is being consumed each day by this patient? Does the patient take cold baths or showers? If so, how often? Does the patient use any drugs or medicine reguIarIy? Ergotism? Does the patient drink aIcohoIic beverages reguIarIy? What kind? How much is consumed daiIy or weekIy? 6. Physical Examination. Determine the character of the waIIs of the Iarge arteries of the extremities. Fibrous, diffuse, senescent,

Americzrn Journal of Surguy

‘9

corrugated type with or \vithout ca..cification? Dorsalis pedis; posterior tibials? Xlake blood-pressure readings in both arms but

FIG. 6. Sheepskin boot and Iegging designed by a patient with thromboangiitis obIiterans to keep his foot and Ieg warm when riding or hunting. (After Reid. Ann. Surg.)

not in the Iegs. Carry out al1 of the Special Studies reIative to the vascuIar system of the patient. Refer to the Special Sheet of the VascuIar Disease Clinic for details concerning the SpeciaI Studies. Record any clinical or roentgenoIogica1 evidence of cervical rib or ribs. Determine the volume of the pulsation of a11 of the major periphera1 arteries by paIpation (grade the puIsation one pIus to four PIUS). Record exactIy the extent and nature of the infection, Iymphangitis, ulceration or gangrene that may be present. OUT-PATIENT CINCINNATI

Vascular Special

I.

2.

DISPENSARY

GENERAL

Disease

HOSPITAL

Clinic

Studies to Be Done on Patient.\ with Peripheral Vascular Disturbance

General physica examination with specia1 reference to the heart and the entire vascuIar system. EstabIish the IeveI of optimum circuIation of the extremities with the patient in (a) the Recumbent Position and (b) in the Sitting Position.

20

4.

5.

6.

7.

8.

9. IO.

II.

12.

13.

American Journal of Surgery

Reid-Vascular

Diseases

14. AI1 amputated extremities shouId be careNote the length of time necessary for fuIIy dissected and thoroughIy studied. bIanching to occur when the extremity is The arterial system should be injected with elevated and for cyanosis to occur when HiII’s soIution and a roentgenogram taken. the extremity is pIaced in the dependent A copy of the roentgenogram shouId be TransiIIumination of a foot or position. hIed with the HospitaI Record of the hand to determine coIor, caIciIication, etc. patient. Skin temperature readings by means of the on a11patients who 15. Take eIectrocardiograms thermocoupIe. Record a11 of the readings have any evidence of cardiac disturbances. on the SpeciaI Sheet provided by the Vascular CIinic. Use a new sheet for each This critica way of studying periphera1 series of temperature readings and be sure vascuIar diseases has tremendousIy broadto record the date and the time of day the ened the vision of our probIem. Not onIy readings were made. These shouId be done are we cIassifying our cases better, more before and after vasomotor reIaxation and accurateIy estimating the degree of vascuin the constant temperature room. Iar deficiency, and determining the rBIe The OsciIIometric Index as recorded from a11 four extremities at IeveIs indicated on of vasospasm but there have been other the SpeciaI Charts, using the Pachon interesting results. Earlier diagnoses are OsciIIometer and the specia1 cuffs designed being made; students, nurses, internes and for that apparatus. If the examinations are staff members are deveIoping the habit of made soon after the temperature readings feeIing the peda1 p&es; the bIood suppIy record both sets of data on the same sheet. of the arteries is being considered when These studies shouId aIso be done before pIanning and executing operative proand after vasomotor reIaxation. cedures. But most significant of a11 is the A determination of the amount of sugar in gradua1 reaIization that there are thousands the urine and especiaIIy the BIood Sugar of peopIe working and Iiving their Iives IeveI shouId be made on a11 patients with unmindfu1 of their narrow margin of Diabetes MeIIitus. AI1 Diabetic patients with uIcerations of safety due to absent paIpabIe puIsations the toes and a11 patients with major inin the arteries of their feet, that there are flammatory processes of the extremities many others being treated for faIIen arches, must be considered as surgical emergencies. metatarsaIgia, cramps, rheumatism, etc., BIood cuIture shouId be made on a11 when the pain is due to a bIood suppIy patients with extensive infection of an insuffIcient to meet the demands of the extremity or the extremities. tissues for oxygen and that the vast Obtain a cuIture of a11 open wounds. majority of our patients come from those Obtain a roentgenogram of the vessels of unsuspecting individuaIs who for reasons the extremities. of coId, sIight injury or infection have Record on the SpeciaI Sheet of the Vascular developed a necrotizing process with which CIinic any decreased density or porosity changes in the density of the bones as the decreased bIood suppIy cannot cope shown in the roentgenograms. Note careand that heIp is demanded to restore a fuIIy the Iocation and the character of the IivabIe baIance between the demands of changes in density of the bones. the tissue for bIood and the bIood suppIy or Obtain photographs of a11important pathoeIse gangrene wiI1 deveIop. We have ampIy logica Iesions of the extremities. VascuIar confirmed the observations of others, that disturbances should be photographed in osciIIometric and thermometric studies may coIor. indicate a better circuIation in a foot Tissue removed at operation shouId be showing a beginning gangrene than in the pIaced in 10% formaIdehyde soIution opposite foot which has caused no disimmediateIy. A compIete gross and microcomfort. In such cases neither foot has the scopic study shouId be made by the vitaIity to withstand an insuIt to its pathologist. Preserve a11 stained sections of the tissue. tissues, which happens to come to the foot

NE,\\, SEHII:S

VOL.

XXIV,

No.

I

Reid-VascuIar

exhibiting evidences of the better circulation. Frequent observations confirm the belief of many that the most critica period in the course of periphera1 vascuIar diseases is when the main arteries become finaIIy occluded. If the occlusion be a very gradual one the patient may not experience any discomfort; if it be rather sudden, actual or threatening gangrene may foIIow. In such cases an eIement of spasm is added to the rather abrupt demand which is thrown upon the coIIatera1 circuIation. Cannot manx of these patients be tided through the critica phases of their disease unti1 a IivabIe baIance is estabIished between the bIood suppIy and the demands of the tissues for it? Are we not on the threshoId of enormous progress in preventive and curative measures which wiI1 make amputations for peripheral vascuIar disease a reIativeIy infrequent occurrence? THERAPY

Advances in the treatment of peripheral vascuIar diseases have been aImost as startIing as has been the progress in the means of diagnosis and proper cIassification of them. The indications for operating upon the sympathetic nervous system for vasospastic arteria1 conditions are rapidIy becoming more definite. Soon after the epoch-making stud& of RoyIe and Hunter in 1924 there occurred a wiId orgy of sympathetic surgery which for a time threatened this vaIuabIe therapeutic procedure. Discouragement folIowed its appIication to conditions in which vasospasm was pIaying Iittle or no rGIe and aIong with this enthusiasm for a new procedure there was a temporary abandonment of many simpIe forms of treatment which had previousIy been heIpfu1. The reaction was a wave discrediting sympathetic nervous system surgery. The indications for its use had to be Iearned and this required diagnostic procedures which did not exist when enthusiasm first ran wiId. Due to the studies of Leriche, Brown, AIIen, Morton

Diseases and Scott, White, Lewis, CoIIer, Herrmann, and many others, we are now abIe to evaIuate the part that vasospasm plays in

FIG. 7. Shoe lined with wool suggested and used by a patient to keep his feet warm during winter months. (After Reid. Ann. Surg.)

periphera1 vascuIar disease. Notable among these studies was the observation of Brown who showed that the eIement of vasospasm couId be eIiminated when high fever was produced by the intravenous injection of typhoid vaccine. He published a method of arriving at gradients to express the rdles of vasospasm and organic obstruction in periphera1 vascuIar diseases. Then in 1930 Morton and Scott showed that the vasospasm couId be compIeteIy o\:ercome b> the use of spina anesthesia. The same year White produced a simiIar efYect by bIocking with novocaine the regiona symLewis and Pickering pathetic gangIia. (1930) and Iater CoIIer (1932) reported that, for practica1 purposes, vasomotor reIaxation couId be obtained by wrapping a patient in hot wooIen bIankets unti1 the body temperature rose one or two degrees. With our abiIity to measure the degree of vasospasm, the indications for removing it are becoming rapidIy more definite, the resuIts are improving and operations on the sympathetic nerves are being restored to favor. In Raynaud’s disease and other pureIy vasospastic conditions exceIIent resuIts are being uniformIy reported. foIIowing the remova of the cervicothoracic and Iumbar sympathetic gangIia. When vaso-

22

American

Journal

of Surgery

Reid-Vascular

spasm pIays a significant part in the obIiterative vascuIar conditions, sympathetic ganghonectomy appears to be def-

Diseases recentIy approved by Leriche and Stricker appears to be pointing the way toward another definite indication for sympathetic

FIG. 8. Effect of position with respect to heart, upon circuIation of foot in case of periphera1 vascular disease. Too great eIevation above heart is far more detrimenta to circulation than is simiIar degree of dependency. A. Foot is pale and cadaveric; veins are coIIapsed and produce grooves in skin. B. Foot is congested; veins are distended and produce eIevations of skin. c. Position of optimum circuIation. Veins are neither distended nor coIIapsed. This IeveI, with respect to heart, varies with degree of circuIatory embarrassment and must be determined for each case by graduaIIy eIevating foot from position B toward A, and noting at what IeveI effect represented in c occurs. It is aIways somewhat beIow IeveI of heart. This cIinica1 observatiori:,has been confirmed by caIorimetric observations as shown in Figure g. (After Reid. Ann. h-g.)

initeIy indicated. The procedure of Leriche in which he excises segments of vesseIs suddenIy occIuded by a thrombus or emboIus in order to relieve the resuIting severe vasospasm is a significant contribution. Based on the experimenta work of Leriche and Stricker, which was beautifully confirmed upon a human being by Gage of your city, it wouId seem that excision of the sympathetic nerves preIiminary to the Iigation of Iarge arteries may prove to be vaIuabIe in estabIishing a coIIatera1 circuIation and preventing gangrene. The excision of chronicaIIy occIuded arteries as advocated by Dean Lewis and

nervous system surgery. These are the most conspicuous exampIes of the deveIopment of the surgery of the sympathetic nervous system as based on the modern methods of estimating the degree of vasospasm in periphera1 vascuIar diseases. The prospects for its further use when definitely indicated and for a discontinuance of its use when contraindicated seem most encouraging in our efforts to dea1 with periphera1 vascuIar diseases. I wiI1 now endeavor to trace a IittIe more fuIIy the deveIopment of our present attitude toward the treatment of the obIiterative periphera1 vascular diseases

NEW SERIES VOL. XXIV,

No. I

Reid-Vascular

unassociated with a marked degree of vasospasm. Soon after the definite recognition of thromboangiitis obliterans surgeons began to realize that the treatment of it differed from that of arterioscIerotic peripheral vascuIar disease in that amputations might frequentIy be made beIow the knee. The vaIuabIe Matas and Moskowicz tests were IargeIy responsibIe for this concIusion. In 1916 Meyer and Painter began to advocate strongIy more conservative treatment than amputation for Buerger’s disease. Surgeons began to reaIize that some cases may hea and estabIish a coIIatera1 circuIation which might be compatible with the ordinary demands of Iife. This conservative attitude was being sIowIy adopted when it was given added support by the important observations of MeIeney and MiIIer who demonstrated by the injection of the arteries of amputated extremities that thromboangiitis obIiterans was accompanied by a great tendency to the deveIopment of an adequate coIIatera1 circulation. Their studies were soon ampIy confirmed by others. The obvious probIem was whether the deveIopment of the coIIatera1 circuIation couId keep pace with the demands for bIood caused by the occIuding process in the main arteries. This presented two concrete probIems to the surgical profession: What couId be done to heIp the deveIopment of a coIIatera1 circuIation; and what couId be done to hasten heaIing and to Iessen the dangers of amputation during the active and progressive stages of the disease? To these ends an amazing number of therapeutic procedures have been instituted. It may be we11 to note here some of them: The avoidance of injury and infection; the absoIute necessity of keeping the feet warm; the immediate and most meticuIous care of the sIightest wound or infection; keeping the skin of the feet in the most perfect condition by means of baths, oiIs and greases; the avoidance of positions or exercises that may tend to traumatize the main arteria1

Diseases

American Journal of Surgery

23

pathways; a very large fluid intake; a judicial use of thyroid extract when the puIse is sIow and the bIood pressure Iow; the eradication of a11 foci of infection; abstinence from the use of tobacco; the Buerger or Allen vascuIar exercises; Bier’s and in the stages of suction hyperemia; actua1 or threatening gangrene more radica1 measures such as: rest; eIevation; superheated air; hypodermoclysis with large quantities of Ringer’s soIution daiIy; intraduodena1 administration of Iarge amounts of hypertonic saIt solution; intravenous administration of sodium citrate solution; constrictive hyperemia; intravenous administration of sodium iodide and caIcium chIoride; the use of typhoid vaccine and other forms of foreign protein therapy; the use of vasodiIating thermopyrexia; drugs; the Iigation of the femoral vein; anastomosis; arteriovenous periarteria1 sympathectomy and sympathetic ganglionectomy; Iigation or excision of the femora1 artery; paraIysis of the periphera1 sensory nerves. Except for the performance of arteriovenous anastomosis a11 of these procedures are stiI1 used but with varying emphasis in different cIinics throughout the worId. Many of these procedures are simpIy different ways of attempt.ing to arrive at the same physioIogic resuIt. The principa1 therapeutic measures used in the VascuIar Disease CIinic of the Cincinnati Genera1 HospitaI are Iisted in this paper. OUT-PATIENT CINCINNATI

DISPENSAKl-

GENERAL

HOSPITAL.

Vascular Disease Clinic General Directions for Home Care

qf the

Feet

Wash feet each night with neutra1 (face) soap and warm water. Dry feet with a clean soft rag withoul rubbing the skin. AppIy rubbing aIcoho1 (70%) and aIIow the feet to dry thoroughIy, then appIy a IiberaI amount of Vaseline or toiIet JanoIin and gentIy massage the skin of the feet. Always keep your feet warm. Use woolen socks or wool-lined shoes in the winter and

24

American

Journal

of Surgery

Reid-VascuIar

white cotton socks in warm weather. Use a cIean pair of socks each day. Use Ioose fitting bed-socks instead of hotwater bottIes, electric heaters or any other form of mechanica heating devices. 6. Wear properIy fitting shoes and be particuIarIy carefu1 that they are not too tight. Use shoes made of soft Ieather and without box-toes. 7. Cut your toe-naiIs onIy in very good Iight and onIy after your feet have been cleansed thoroughIy. Cut the toe-nails straight across. 8. Do not cut your corns or caIIouses. 9. Do not wear circuIar garters. IO. Do not sit with your Iegs crossed. Do not use strong antiseptic drugs on your II. feet. ParticuIarIy never use Tincture of iodine, Lysol, Cresol or CarboIic acid. 12. Go to your Doctor at the first signs of a blister, infection of the toes, in-growing toe-nai1 or troubIe with bunions, corns or caIIouses. Drink at Ieast four quarts of water each ‘3. day. 14. Eat pIenty of green vegetabIes and fruit in an otherwise weII-baIanced, IiberaI diet, unless you have been ordered to foIIow some special diet. 15. Do not use tobacco in any form. 16. Have some member of your family examine your feet at Ieast once each week. 17. Carry out the exercises prescribed by your Doctor exactly as you were taught to do them in the cIinic. Do them reguIarIy and faithfully. 18. Come to the cIinic for Pavaex treatments as follows : _I M.D. Name ____ Date OUT-PATIENT CINCINNATI

DISPENSARY

GENERAL

HOSPITAL

VascuIar Disease CIinic Routine in Hospital for Patients with Peripberal Vascular Disturbances Name Disp. No. Hosp. No. Date Ward I. Bed should be fitted with a BaIkan frame with hand grips to aid patients in carrying out exercises and permit patients to move around in bed easiIy.

Diseases

APRIL, rgrj4

Affected extremity or extremities shouId be pIaced on a piIIow in the position which affords optimum circuIation to the part. Heels shouId extend over the edge of the piIIow to prevent excessive pressure from the mattress. Position of optimum circuIation as determined in the VascuIar CIinic, A. Right foot, (a) Recumbent position. . . . . . . . . . (6) Sitting position. . . . . . . . . , . B. Left foot, (a) Recumbent position.. ... . (6) Sitting position. . 3, Large, doubIy insulated cradJe over the Iegs and feet. CradIe shouId be Jitted with eIectric bulbs to suppIy extra warmth when needed. We11 balanced, IiberaI diet. Drink at Ieast four quarts of water each day. Patients should abstain from the use of tobacco in any form. Daily cIeansing of the feet. CarefuI application of neutra1 (face) soap and warm water foIIowed by aIcoho1 (70%). Dry feet without friction. AppIy vaseIine or bIand oiIs to roughened or irritated areas. SpeciaI care shouId be given to the toe-naiIs and thick caIIouses. 8. UIcerated areas on the extremities shouId be treated as foIIows: 2.

9. Use onIy non-habit forming drugs for the relief of pain in the extremities. IO. PosturaI treatments as advised by Buerger and modified by AIIen shouId be carried out as foIIows: II. Pavaex treatments as foIIows: 12. AI1 diabetic patients are SimuItaneousIy under the care of the MedicaI and the SurgicaI Services. AI1 important clinica studies on the 13. patients with periphera1 vascuIar disturbances shouId be made in the VascuIar CIinic of the Dipsensary. M.D.

Of all the therapeutic measures there is one, stiII in genera1 use, which is definiteIy harmfu1 and has been productive of many unnecessary amputations. The Iong period in which

eIevation

of an

extremity

has

Ntw

SRHIBS

\or.

.\SlV,

NIJ.

I

Reid--Vascular

been persisted in as an essentia1 part of the therapy has undoubtedly been responsible for an untoId number of amputations. This dogged insistence upon elevation is a glaring exampIe of unbeIievabIe bIindness to a universa1 instinct of patients, for it has always been known that these sufl’erers from periphera1 vascuIar disease, tvhen they were unobserved, not onIy refused to keep the extremity eIevated but often spent their time aIternately hanging it over the side of the bed and putting it back in bed. Based on observations and reason, I have previousIy stressed the great dangers of resting the extremity in an elevated position. RecentIy the dangers of eIevation have been further confirmed by caIorimetric studies. (See Fig. 9.j The net resuIt of a11 this interest in the treatment of thromboangiitis obIiterans is the genera1 beIief that this disease runs a chronic course of varying Iengths of time, and then tends to stop progressing and to become heaIed; and that if amputation can be avoided during this time an adequate coIIatera1 circuIation may deveIop and restore the extremities to good usefuIness. During this critica time there may be months when an amputation appears inevitabIe. Yet, if it can be avoided, the patients usuaIIy make a satisfactory recovery. A recognition of the seriousness of the probIem and the Length of time required, both on the part of the patient and the doctor, is vita1 in securing good resuIts. The probIem is often regarded too IightIy and the patient is aIIowed to assume unwarranted risks of exposure, injury and infection during the active period of the disease. The time is rapidIy approaching when this disease wiI1 be regarded with a seriousness akin to that of tubercuIosis and when sufferers from it wiI1 not be given treatment incidenta to the ordinary routine of their Iives and work unti1 threatened gangrene throws them into a hospita1 and makes them give their entire time to the business of avoiding amputation. With this serious attitude toward thromboangiitis

Diseases

American

Journ:rl

of Surgery

“5

obIiterans and with the full utilization of measures at our disthe therapeutic posa1, satisfactory recoveries are frequentIy

lne /Iv to RrFIG. 9. Effect of position of extremity upon caIorimetric studies. Graphs represent average skin temperature of all toes when foot, as illustrated, is placed in different positions with respect to IeveI of heart. These studies were made at room temperature in order more nearIy to approximate normal conditions. In a11 three types of periphera1 vesseIs temperature faIIs with elevation of foot. In case with norma blood vessels there is a sharp transitory rise of temperature for about thirty minutes when foot is depressed and then there is a gradua1 return to normal; in cases with obliterative vascular disease there is no rise but a gradua1 fall of the surface temperature. Compare this effect of active vascuIar exercises with Figure 14 which shows effect of passive vascuIar exercises upon surface temperature. It may be that color changes of skin in cases of obliterative vascular diseases during active vascular exercises are result of stasis and do not denote any increase in function of peripheral vessels. In the case of thromboangiitis obIiterans Ietters are used to denote patient’s subjective sensations: A = no pain; B = pain beginning in fourth toe; c = pain spreading and becoming worse; D = pain severe; E = excruciating pain in foot; F = pain ceased.

obtained. There has not yet deveIoped the same conservative attitude toward the treatment of arterioscIerotic periphera1 vascuIar disease. This is probabIy due to the fact that

mcmr FIG.

10.4. Norma1 osciIIogram.

PRE.%uRE

FIG.

l/v

0.

P.,

/N

“,uH~~Rr~

male,

M,U,MPrQ~~

pl

fiERC”Rf

aged sixty-five years. Pernicious anemia.

w

BIood

pressure

12oj60.

Clinical,

diagnosis:

P?‘cR
IOR. Generalized

vascuIar scIerosis. R. S., maie, white, aged forty-nine years. Blood pressure IZO/IOO. ClinicaI diagnosis: Arteriosclerotic heart disease and vascuIar sclerosis. FIG. IO. A-D.'OscilIometric studies of patients suffering from various conditions. (After Friedlander.)

!M

New SERIES VOL. XXIV,

No.

Reid-Vascular

I

injection studies of the arteries of amputated extremities have shown that in this condition there is not the same tendency to

PRNXJRE

FIG. IOC. EssentiaI

hypertension.

PREJsu+r

,fY

mlLl.N?L-mE-6

Diseases

American Journd of Surgery

adopted just as conservative an attitude and just as vigorous a treatment of the arteriosclerotic type as of any other type of

M.fRcORY

OF

E. T., femaIe, white, aged fifty years. BIood pressure z50/160. EssentiaI hypertension and nephroscIerosis.

/n

“,‘L,r?ET~~3

(Y

27

CIinicaI diagnosis:

nrRc”~y

FIG IoD. Media1 arterioscIerosis. L. L., femaIe, white, aged sixty-eight years. BIood pressure diagnosis: ArterioscIerosis. Marked in arteries of Iower Iegs.

deveIop the coIIatera1 vesseIs as in thromboangiitis obIiterans. Thus, whiIe the conservative and curative treatment of Buerger’s disease has come rapidIy to be adopted, the radica1 procedure of amputation has IargeIy remained the procedure of choice in arterioscIerosis. For various reasons which I shaI1 discuss, we have recentIy

190/rz0.

Clinica

periphera1 vascuIar disease. In the Iiterature one can find statements by Buerger and others that patients with arterioscIerosis may deveIop an apparent compIete occIusion of the Iarge vesseIs of the Iegs without deveIoping intermittent cIaudication or other symptoms of vascuIar insufficiency. In 1928 AIIen made the

28

American Journal of Surgery

Reid-VascuIar

significant observation that one of his patients showed by thermometric and osciIIometric studies that the foot with

FIG. I I. ControI board of Pavaex unit. By means of various switches duration of treatments, reguIation of degrees of negative and positive pressures and rate of their alternation can be automaticaIIy controlled.

beginning gangrene exhibited evidences of a better circuIation than the opposite Ieg in which he had never had any symptoms whatever. This observation has been repeatedIy confirmed by us. Furthermore, a study of a11 our patients admitted to the hospita1 for conditions other than periphera1 vascular diseases reveaIs that many of them have no pulses in their feet and yet are unconscious of any symptoms referabIe to an impoverished blood suppIy.* Previous to the reaIization of the widespread, unrecognized periphera1 vascuIar diseases, our experience and our judgment were aImost whoIIy founded upon problems arising in connection with those critica periods when as a resuIt of coId, injury, infection or the sudden occIusion of a diseased artery, the Ioss of an extremity was threatened. The inabiIity of the tissues to cope with these extraordinary demands for more bIood usuaIIy Ied to a progression of the insuIt and eventuaIIy to an amputation. A most pessimistic attitude toward * For over a year Doctor Alfred Friedlander has made osciIIometric studies on patients suffering from a variety of cardiac conditions. A preIiminary report of his work appeared in The American Heart Journal for December, 1933. By his permission I am reproducing a few of his charts.

Diseases arterioscIerotic periphera1 vascuIar disease was adopted for we were unaware that there were thousands of people unconscious of a severe embarrassment to their periphera circulation. In 1932 I reported before the Southern MedicaI Association a case which has had great bearing upon the deveIopment of our present ideas concerning the treatment of arterioscIerotic vascuIar disease, and I shaI1 quote here that case report: In the past two years I have watched a patient through four distinct attacks of threatened gangrene. The first occurred when his right dorsalis pedis artery ceased to p&ate; the second was six months later and coincident with the disappearance of puIsation in the right posterior tibia1 artery; the third occurred when puIsation disappeared in the left dorsaIis pedis artery and the fourth recentIy when the Ieft posterior tibia1 artery became occluded. Each attack of threatened gangrene necessitated hospita1 treatment. There was intense pain, mottIing and cyanosis of the foot, extravasation of some bIood into the tissues and considerabIe Ioss of sensation. The shghtest draft of cold air over the invoIved foot caused arterial spasm and intensified the pain. With most carefu1 nursing and attention to heat, the position of the foot with respect to the heart, the ffuid intake, the bIood pressure, cardiac rate and the other things I have mentioned, gangrene did not occur and amputation was not necessary. AIthough a11 four pedal arteries are now occIuded, it seems to me that, with good care, he shouId Iive out the rest of his Iife without any serious troubIe in his feet or the Ioss of a Ieg. The dangers of spasm incident to the rather sudden occlusion of a large vessel are now past. Several years ago I should not have hesitated to advise amputation in any one of his four attacks of threatened gangrene. He is an oId man and his vascuIar troubIe is due to arteriosclerosis. That patient died from a coronary occIusion about a month ago. However, from the time of my report unti1 his death he was abIe to attend to his work, and with onIy very sIight discomfort in his Iegs. Some two years ago we summarized certain facts with respect to arterioscIerotic

NCM SMUBS

VOL.

XXIV,

No.

I

Reid-Vascular

peripheral vascuiar disease: (I) CoId, injury and infection often produce demands with which the reduced circuIation unaided cannot cope; (2) a graduaI occIusion of the peripheral vesseIs may be symptomless whiIe a rapid or sudden occIusion accompanied by great vasospasm may lead to actua1 or threatened gangrene; (3) an affected extremity may by tests show a better circuIation than the symptomless or opposite extremity. With these facts in mind, we then adopted the view that every possibIe effort should be made to tide arterioscIerotic cases through these critica periods of pain, threatened gangrene, reaI gangrene and infection in the beIief that they wiI1 in time estabIish a circuIatory baIance that may be just as adequate as when a sIow gradua1 occIusion of the vesseIs takes pIace. In the hope that we couId effectiveIy combat this temporary demand of an extremity for more bIood than the vascuIar bed for a time can suppIy, we began appIying for these cases the same measures which had for severa years been used for thromboangiitis obIiterans. Soon we were getting some encouraging resuIts in cases in which we shouId previously have advised amputation. StiII there were many cases which, because of their sudden and excessive demand of an extremity for bIood, went on to gangrene and amputation because our therapeutic procedures couId not bring about a suffIcientIy rapid improvement in circuIation. For severa years prior to 1932 I had toyed with the idea that it wouId be desirabIe to have an efficient apparatus which wouId aIternateIy and rapidIy suck bIood into an extremity and force it back toward the heart. I had often spoken of it as a “ PeripheraI Heart Apparatus ” and visuaIized the possibiIity of making its action synchronous with that of the heart. In JuIy 1932, Doctor Louis G. Herrmann came to our clinic from Professor Leriche’s clinic in Strasbourg and our first meeting re\-eaIed that he was very much interested in the same probIem. He reorganized our

Diseases VascuIar Disease CIinic and set about immediateIy to buiId a machine for the treatment of periphera1 vascuIar diseases

FIG. IZ. Patient receiving Pavaex treatment ~passive vascular exercises). Vote that extremity is elevated. (After Herrmann and Reid. J. Med.)

by means of alternating negative and positive environmenta pressures to the extremities. Within a few weeks he was practicaIIy using, by means of a Inandpump, a boot-Iike apparatus which Professor Dennis Jackson had built for our clinic in May, 1928. By the early part of 1933 he had perfected the automatic, motor-driven apparatus which we now use. The idea of the use of negative environmenta1 pressure in the treatment of \.arious vascuIar conditions is, of course, not new with us. In recent articIes in which our present apparatus is accurateIy described we have reviewed the works of Bier, WiIIy Meyer and Schmieden, Klapp, and others, bearing upon the suction treatment of various conditions of the extremities. Sinkowitz and GottIieb in 1917 reported exceIIent resuIts by Bier’s suction hvperemia in 4 cases of thromboangiitis ob‘Iiterans. Braeucker in 1931 treated Ig cases of true Raynaud’s disease by the Bier method of hyperemia. He advocated the continued use of partiaI vacuum for periods of from thirty minutes to two hours, and this was repeated twice each daj-. It is unnecessary and wouId be uninteresting to repeat here a description of our present machine which is on the market under the name of the “ Pavaex Treatment Unit.” The word “Pavaex” was seIected as a

30

American Journal of Surgery

Reid-Vascular

contraction for “passive vascuIar exercises” and is used to designate this form of therapy in contrast to the active vascuIar

Diseases

APRIL. 1934

hours. RecentIy a severe case of frost-bite was treated almost continuousIy a11 night. Since August 15, 1932, 6g patients with

FIG. 13. CoIIateraI arteries about knee and hip joints. When giving Pavaex treatments it is necessary for boot to extend above knee so that treatments wil1 increase circulation through genicuIar arteries.

exercises of Buerger or AIIen. It wiII suffke to say that the machine runs automaticaIIy, can be set to run any Iength of time desired, and is capabIe of producing any strength of alternating negative and positive environmenta pressures as frequentIy as thirty times to the minute. SIight variations in the amount of negative and positive pressures are necessary for different cases. OrdinariIy the seIector switches are set for 80 mm. of mercury negative pressure and 20 mm. of mercury positive pressure. The average rate of aIternation that we have found most beneficia1 is approximateIy one compIete cycIe in thirty seconds. However, with improvement in the circuIation the time of the cycIes may be advantageously changed to fifteen seconds. The average duration of one treatment is twenty minutes, but in severe cases of threatened gangrene, it may be necessary to give the treatment aImost constantIy for many

organic obIiterative arteria1 disease of one or more extremities have received regular and intensive treatment by this method. Forty-seven of these patients had a high degree of periphera1 (senile) arterioscIerosis without evidence of gangrene. Eight patients had trophic Iesions of one or more toes together with moderateIy severe diabetes meIIitus. Six patients had extensive organic arteria1 disease of the thromboangiitis obIiterans type and a11 six had one or more gangrenous digits of the hands or feet. Four patients had syphiIitic obIiterative arteritis of the endarteritic or of the thromboarteritic type. Four of the patients had an atypica1 arteria1 disease of the obhterative type. The cIinical diagnosis in a11 cases was confirmed by compIete vascuIar and vasomotor reIaxation studies under controIIed conditions of temperature and humidity. Cases of pure vasomotor disturbances have not been incIuded in this series of cases.

NEW SI.RIBS

VOL.

XXIV,

No.

1

Reid-VascuIar

Since August 1932, we have given a tota of 5574 treatments by the Pavaex apparatus. Over 5000 of these treatments have been given to these 6g patients with organic obIiterative arteriaI disease. Sixtytwo of these patients have required treatment to both lower extremities. By extensive caIorimetric studies we have demonstrated that there is a marked rise in the surface temperature of an extremity during the treatment and that the temperature does not return to its former Iow Ievel for many hours. When the treatments are given at very frequent intervaIs, the rise of surface temperature and increase of coIIatera1 circuIation can be maintained indefiniteIy. Thus in the acute crises of periphera1 vascuIar diseases when the time eIement is of such great importance in connection with the deveIopment of gangrene, we have witnessed the most miracuIous improvement, and I am going to recite a few illustrative case reports : CASE I. White man, aged sixty-seven, was admitted to the HoImes HospitaI (330268) on July 3, 1933, compIaining of severe pain in the right foot. For severa months he had been having intermittent cIaudication in this leg when walking or attempting to work. Rather suddenIy his right foot became extremeIy painful, cold, white, mottIed, and presented a picture of a threatened gangrene. No pulse could be feIt in either foot. The patient had extensive generaIized arterioscIerosis. Our impression was that he had recentIy had a sudden and rather extensive thrombosis of the scIerotic vessels of his right leg, and that this process together with a’ marked vasospastic condition was responsibre for the condition of his foot. For fifteen days he was given four to five Pavaex treatments each day. These treatments Iasted twenty minutes and the negative environmenta pressure used was 70 mm. mercury. With each treatment the foot wouId become red, the superficial veins would distend with the negative pressure and coIIapse with the positive. FoIIowing the first treatment the pain was greatIy relieved, and after three days it was compIeteIy gone. After five days the toes retained a normal pink coIor between the treatments and the patient began to get up

Diseases

American Journal of Surgery

3’

and around without pain. Since leaving the hospita1 the patient has continued to receive treatment at irreguIar intervaIs but never more

ill

,O”

’

’

,09

’

me

’

,o*

’

ial

’

IO<’

!, , , , , /aI*

d&“&e,

Y*r,lir

FIG. 14. Graph showing changes in skin temperature during and after Pavaex treatment of a patient with advanced arteriosclerotic periphera1 vascuIar disease. These readings were made under controlIed conditions of temperature and humidity. Such changes in surface temperatures of skin are not noted during active vascular exercises for obliterative peripheral vascular diseases. (See Fig. 9.) (After Herrmann and Reid. J Med.)

than once a week. In November he went hunting and waIked for severa miles without experiencing any real discomfort. The int.ermittent cIaudication which had been present for severa months before the treatments has compIeteIy disappeared. The patient is now abIe to carry on his work with very Iittle or no discomfort. CASE II. A white man, aged thirty-eight years, entered the Cincinnati General Hospital on December 29, 1933 at 4:30 P.M. He was in a dazed condition, refused to speak but responded inteIIigentIy by nodding his head in answer to questions. His face and hands were coId and of a reddish bIue color. His feet were coId and of a dark bIue color with marked changes due to very recent and prolonged exposure to extreme coId. There was an odor of acetone to his breath. Temperature 97.2’F.; pulse 92 per minute and respirations 24 per minute. His reIatives stated that he had been committed to an institution for the insane on two different occasions during the past few years. He was reported to be a schizophrenic. Four-

32

American Journal of Surgery

Reid-Vascular

teen days ago he disappeared from home and since that time it is believed that he has been Iiving in a barn with practicaIIy no food and that on the day of entry he arose earIy and waIked about in his stocking feet unti1 Iate in the afternoon. The temperature of that morning was 12’~. The physica examination showed the most important changes in the lower extremities, aIthough the face and hands of the patient were extremeIy coId and bIue due to the proIonged exposure to coId. Both Iower extremities were coId from the *knees down, this increasing distaIIy. Both feet and ankIes were icy coId, swoIIen, indurated and of a mottIed dark purplish color. The coIor extended down over the ankIes and feet from a zone about 3 cm. above the externa1 maIIeoIus. The coIor at the upper Iimit bIended irreguIarIy into the norma color of the skin. The major part of the swelIing was distal to the ankIes, the size of the feet being increased about one-sixth greater than normal size. The right foot showed more changes than the Ieft. AI1 the toes of the right foot were bIue-bIack with this coIor extending in irreguIar pattern on to the foot for a centimeter or more. The tips of the second and fourth toes and a11 of the IittIe toe of the Ieft foot showed this change. The change was aIso present on the posterior aspect of the heels, more pronounced on the right foot, the whoIe posterior aspect of this hee1 being invoIved. The blue-bIack zones had no distinct Iine of demarcation but blended into the lighter coIor zones. The blue-bIack zones were more indurated than the other zones and did not bIanch on pressure. The dorsaIis pedis and posterior tibia1 puIses couId not be feIt in either foot. Sensation was not tested accurateIy, but grossIy was found to be absent over the dista1 two-thirds of the feet. Urine was norma except for the presence of acetone. Treatment: Directly after examination the patient’s feet were massaged gently with oil and wrapped in blankets. This increased the mottIed bIue color and a few minutes afterwards the patient compIained of pain. He was given 500 C.C. of 5 per cent gIucose in physioIogic saIt soIution intravenousIy and warm drinks by mouth. At 5 P.M. the first “Pavaex” treatment was given, twenty minutes to each foot with the positive pressure of 40 mm., and the negative

Diseases

APRIL, 19x4

pressure of 80 mm. DirectIy following this, the changes in the feet consisted of a IocaI rise in temperature and a generaIized fading of the Iighter coIored zones of the foot and especiaIIy of the ankIe: ArteriaI bIood was definiteIy drawn into the foot by the treatment. At 6:30 P.M. the coIor had gone back to the deep cyanosis, but not to the extent as when first seen. At this time the patient was compIaining of pain. At 10:30 P.M. the second treatment was started. DirectIy before this the blue coIor of the feet had faded remarkabIy. The middIe toe of the right foot was a Iight mottIed bIue. The mottIed blue coIor of the feet had faded. After this treatment the coIor was more nearIy normal. A second intravenous treatment was given the same as the first, and the patient’s genera1 condition was becoming much better. At 12:30 P.M. the third treatment was given the same as the first two except that the negative pressure was reduced to 60 mm. After this treatment the above changes were more marked and over the right great toe the blueblack zones had decreased and over the proxima1 haIf there was blanching on pressure. On December 30, 1933, the patient’s genera1 condition was much improved. The appearance of the feet had not greatIy improved over that of the night before. One smaI1 bIister had formed over the first metatarsa1 phaIangea1 joint of the Ieft foot. The patient was given three treatments on this day. The circuIation of the feet improved markedIy but not with the rapidity of the day before. The puIses in a11 of the peda1 vesseIs were present on this day, and the swelling of the feet was reduced. At the end of the Iast treatment the blue-bIack zones were becoming more demarcated. However, this was more definite on the folIowing day. These zones were present on the whoIe of the second and fifth toes, on one-half of the first and fourth toes of the right foot, on the tips of the third and fourth toes and the whoIe of the fifth toe on the left foot. Blister formations were starting on the right great toe and over many of the other smaIIer toes especiaIIy on the Ieft foot. On December 3 I, 1933, the patient was given one Pavaex treatment. His genera1 condition was good. The bIisters which had deveIoped during the night had increased slightly in size. Since then, the bIisters have somewhat increased in size and the naiI on the right great toe The blisters were taooed ~. has ~~. become ~. ~~ Ioose. _ II

NE.\& \ISI
No.

I

Reid-Vascular

to relie1.e pressure, but were not further disturbed. .4t present the patient is in good genera1 condition, and the gangrene is limited to the distal parts of three toes of the right foot. Based on Previous experience with frostit seemed certain to all bite gangrene,

those who saw this patient that he would lose a major portion of both feet. CASE III. A white man, aged fifty-seven, known diabetic for five years, came to the Cincinnati General HospitaI July 12, 1933, I\-ith a smaI1 area of gangrene on the dorsum of the left foot at the base of the fourth and fifth toes. The roentgenograms sho\ved osteomyelitis of the fifth metatarsal bone. His Mood pressure was r40:/85. No pulse couId be felt in his feet and our vascular studies showed a high degree of arteriosclerosis. On July 20, the IittIe toe and practically a11 the fifth metatarsa1

bone were removed. After a period of Dakinization the \youncI was grafted with pinch grafts on August 19, and he was discharged with the \\ound completely heaIed on September 7. ‘I‘wo weeks after leaving the hospita1 he returned with a draining sinus at the base of the fourth toe of the same foot and an area of gangrene 2 cm. in diameter. There were no signs of healing after severa weeks of intensive local treatment. He was then given seven Pavaex treatments, with 80 mm. mercury negative and 20 mm. positive pressure for periods of twenty minutes each. These treatments were begun on November IO, and completed on November 22. His circuIation was much improved, and on November 23 Doctor Louis Herrmann did a modified Lisfranc amputation of the left foot. A month Iater a few pinch grafts were applied to the wound and ten days later the patient event home with his kvound completely healed. He is still getting treatments with the Pavaex apparatus. His circuIation is greatly improved. It seemed to us that the Pavaex treatments made it possible to do a Lisfranc amputation upon this patient whose major peripheral vesseIs of his leg were completely occluded. It is extremeIy difficult at the present time to express in mathematical terms the benefits which have been derived from this form of therapy. The multiphcity of signs and symptoms (discoloration of the toes,

Diseases

subjective and objective sensation of coId aching or burning pains in extremities, the feet, easy- fatigue of the muscles of the extremities, rest pain in the feet or intermittent claudication) which arc directly or indirectly the result of organic disease accounts in of the peripheral arteries, part for this difliculty. A careful analvsis of the results obtained in the 69 patients reported in this work gave us the following data. In all the patients who had recei\.ed intensive treatment for two \veeks or longer there was a definite increase in the surface temperature of the extremity when observed under controlled conditions of temperature (20’~) and humidity- (
34

American Journd

of Surgery

Reid-Vascular

increase in the circuIation in the extremities remains for about forty-eight hours after each treatment. It is highIy important that patients with organic disease of the periphera1 arteries continue to practice those measures for the genera1 care of the feet which have been repeatedIy emphasized by AIIen and by Reid. The passive vascuIar exercises are an extremely vaIuabIe adjunct to the whoIe treatment which invoIves paying attention to many detaiIs and the use of many therapeutic measures. In our hands the Pavaex treatment has been much the most effective singIe stimuIant to the deveIopment of a coIIatera1 circuIation. In those critica periods of periphera1 vascuIar disease in which there is a rapid or sudden threat of gangrene, it has certainIy been responsibIe for the saving of many Iimbs which wouId otherwise have had to be amputated. Its action is much more rapid and, in addition, it does not cause the increased consumption of oxygen and increased metaboIic activities incident to the use of the active vascuIar exercises.* Its usefuIness is not. Iimited to the treatment of periphera1 vascuIar diseases. FoIIowing the Iigation of a Iarge artery or its occIusion by emboIi or thrombosis, the Iife of an extremity may be saved by treating it with intermittent negative and positive environmental pressures. It has been used to increase the circuIation in cases of chronic infection and, as originaIIy by Bier, for arthritis and other conditions. This paper, Iike a11 others deaIing with the same subject, is based primariIy upon the study and treatment of patients who are aIready suffering from periphera1 vascuIar disease. Connected with this probIem there is a vast and, as yet, an almost untouched fieId of preventive medicine. Nine times out of ten, the routine examination of the heart, kidneys and other organs is but an effort to estimate * In acute conditions or advisabIe to attempt exercises.

it is not usuaIIy possible to empIoy active vascuIar

Diseases the efficiency of the bIood vesseIs of these vita1 organs and to Iearn if it may be necessary to take measures to foresta troubIe that is Iurking in the future. The time is aIready upon us when an estimate of the bIood suppIy to the extremities shouId be an integra1 part of the routine physica examination of a11 patients. In our hospita1 it is encouraging to see that the doctors and nurses are graduaIIy Iearning to fee1 the peda1 puIses as we11 as the radia1. With the osciIIometer and simpIe observations as to the effect of position upon the coIor of the feet, we can get a stiI1 more accurate idea of the vascuIar eff%ziency of the extremities. The means for estimating periphera1 vascuIar efficiency are aImost as accurate as are the means of estimating the ef5ciency of the bIood vesseIs of the heart and kidney. They are waiting to be put into general use by our profession. Once it becomes the practice to study the peripheral vesseIs and to advise peopIe when there is a thin margin of safety in the bIood suppIy of their Iegs, there are many things that can be done to avoid those critica periods of pain, infection, gangrene and amputation. Then, too, there wiI1 be a noticeabIe diminution in the number of patients treated for cramps, metatarsaIgia, faIIen arches, and rheumatism. NOTE: Much of this work was made possibIe by a research fund given by Rebecca A. Scarborough in memory of George Hoadly, Jr. REFERENCES ALLEN, A. W., and SMITHWICK, R. H. J. A. M. A., 91:

I 161-1168,

1928.

BIER, A. Deutscb. med. Wchnschr., 25: 505-06, 1899. Hyperaemie aIs HeiImitteI. Leipzig, VogeI, 1903. BRAEUCKER, W. Chirurg., 3: 756760, 1931. Arch. f. klin. C&r., 167: 807-824, 1931. BROOKS, B. J. A. M. A., 82: IoI6-1019, 1924. BROOKS, B., and JOSTES, F. A. Arch. Surg., g: 485-503, 1924.

BROWN, G. E.: J. A. M. A., 87: 379-383, 1926. BUERGER. L. The CircuIatorv Disturbances of the Extremities. Saunders, PhfIa., 1924. COLLER, F. A., and MADDOCK W. G. Ann. Surg., 96: 719-732, 1932. CASSIRER, R. Die Vasomotorischtrophischen Neurosen; eine Monographie. Ed. 2, Berlin, 1912.

NEW

:;I..HII:S

VOL. XXIV,

No. L

Reid-Vascular

E. V. Arte’riosclerosis. N. Y. Macmillan 1933. (Among other excellent articles, see Dr. E. R. Long’s excellent historica sketch, pp. 19-52.) DAVY, J. Researches PhysioIogical and Anatomical. London, 1839, p. 426. DARUNC, S. T., and CLARK, H. C. J. Med. Research,

COWDRY,

32: I-26,1915.

DRUELLE, hl. La gangri-ne des membres par art&rite syphilitique. Paris, I 906. FRIEDLANDER, A. Am. Heart J., 9: 212-218, 1933. FONTAINE, R., and HEKRMAUU, L. G. Ann. Surg., 97: 26, 1933. GAGE. I. hl. Reported atthe Meetingof the South. Surg. Assoc., Hot Springs, Va., Dec., 1933 (unpublished). HE.RRMANN, L. G. Am. J. .!?yphilis, 17: 305, 1933. HERRMANN, L. G., and REID, M. R. J. Med., 14: 524529, 1933. HERRMANN, L. G., and REID, M. R. Arch. Surg. (in press). HUNTER, J. I. Surg. &nec. Obst., 39: 721-743, 1924. KUSSMAUL, A., and MAIER, R. Deutscb. Arch. f. klin. Med., I: 484-518, 1866. KLIZPP, R. Miincben. Med. Wcbnscbr., 52: 79&797,1905. LANDIS, E. M., and GIBBON, J. H. JR. J. Clin. Invest., 12: 925-961, 1933. LERICHE, R. Alvr. J. SURG., n.s. 14: 55-67,

1931.

LERICHE, R., and STRICKER, P. L’arteriectomie dans Ies art&rites obIit&antes. Paris, Masson, 1933. LETULI.E, hl., HEITZ, J., and MAGNIEL, M. Arch. Mel. du Coeur, 18: 497-51 I, 1925. LEWIS, T., and PICKERING, G. W. Heart, 16: p. 33, 1931. MATAS, R. In: Keen’s System of Surgery. PhiIa., Saunders, I 92 I, 5: chap. Ixx; 7: chap. xxiv. J. A. M. A., 63: 1441-1447. 1914. Halsted, Surgical Papers. Bait., Johns Hopkins Press, 1924, VoI. I: pp. xv-XIiii.

Diseases >b?LEVEY,

F. L., and GRILLER, G. G. .4nn. Surp., 81:

976-993,

1925.

MEYER, W. Ann. Surg., 63: 280-296,

1910. ILIEYER, W., and SCHMIEDEN, V. Bier’s lIs_peremic Treatment. PhiIa., Saunders, 1908. MITCIIELL, S. W. Nervous Disease. Phila., Lea, 1881, p. 180 et seq. M&KKEBERG, J. G. Am. Heart J., 171: 141-167, 1903. hIORTOU, J. J., and Scars, W. J. 11. J. Clin. Znoes~., 9: 23p262, 1930-31. h,~osKOwlcz, L. Mitt. d. Grenzgeb. d. Med. u. Cbir., LI 7: 2 IG (cited by Buerger). PAINTER, C. F. St. Paul M. J., 18: 41-46, 1916. PAC~ION,V. Compt. rend. Sot. biol., 66: 776, 1909. AIso Norris-Bazett-Mch~lillan. Blood Pressure, Its CIinical Applications. Ed. 4, PhiIa., Lea & Febiger, 1927, pp. 9ip102. RAYNAUD, M. De I’asphyxie locale et dc Ia gangrene symmetrique des extremites. Paris, 1862. ROYLE, N. D. Surg. Gynec. Obst., 39: y-720, 1924. REID, M. R. Ann. Surg., 96: 733-743, 1932. South. M. J., 26: 1o7-115, 1933. Reported at the Meeting of the South. Surg. Assoc., Hot Springs, Va., Dec., 1933 (unpublished). REID, hl. R., and I~I:RRM.~NN,L. G. J. Med., 74: zoo204, 1933. SCHULTZE, F. Deutsche. Ztscbr. f. Nervenb., 3: 300-318, 1892. SCOTT, \V. .I ht. J. A. h. A., 94: 1987, 1930 SINKOWITZ, S. G., and GOTTLIEB, I. J. J. A. M. A., 48: 961-963, 1917. VOX WINIWARTER, F. Langb. Arch. I. klin. Chir., 23: 202-226, 1879. WARTHIN, A. S. 1v. l’ork M. J., I I 5: 69-73, 1922. WHITE, .J. C. J. A. M. A., 94: 1382-1388, 1930.