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The thermal reflex vasodilatation test in peripheral vascular disease
THE
THERMAL REFLEX VASODILATATION PERIPHERAL VASCULAR DISEASE GAMIJEI,
SALAND, M.D., ITERMAN -YEW
KLEIN,
CHARLES
IN
AKD
M.D.
ZURROW, YORK,
M.D.,
TEST
N.
T.
TTENTION has already been called to the value of a vasodilating test in the study of the peripheral vascular diseases. As early as 1883, Mitchell’ showed that paralysis of a peripheral nerve trunk by cold is associated with hyperthermia in the anesthetic zone. In 1926, Brown’ obtained vasodilatation by means of the intravenous administration of typhoid vaccine. In May, 1930, White,” and Brill and Lawrence,4 at the same time, but working independently, showed that spinal anesthesia caused an increase in the surface temperature of the feet. Scott and Morton,5 in June, 1930, found that general anesthesia gave the same complete obliteration of vasoconstriction. Again, in October, 1931, Scott and Morton” injected the posterior tibia1 nerve to differentiate arterial spasm from organic obstruction. Sir Thomas Lewiq7 in 1929, used heat to induce peripheral refles vasodilatation. In 1932, Gibbon and Landis8 observed that immersing the hands and forearms in warm water produced vasodilatation in the lower extremities of six normal persons, and that the temperature of the toes began to rise in fifteen minutes and rose to over 31.5O C. in all cases. In November, 1933, Landis and Gibbon” studied patients with peripheral vascular disease, and found that the immersion test compared favorably with other methods of vasodilatation. The reason for using a vasodilatation test is obvious to all workers in the field of vascular diseases. It is a known fact that arterial spasm can simulate every symptom and physical sign of organic obstruction, such as cold feet, painful extremities, claudication, absent pulsations, rubor, and pallor. It is also known that instrumental aids, such as oscillometric tracings and intra-arterial thorotrast injections, reveal only the presence or absence of obstruction, but when obstruction is demonstrated, these tests do not differentiate spasm from organic block.
A
In our work we followed the method of Gibbon and Landis for t,he following reasons: (1) it eliminated the danger of trauma to the vessels, (2) injection carried with it the risk of infection, and (3) many patients objected to an injection. From the department Received for publication
of peripheral Oct. 29,
rascular 1938.
581
diseases,
Bronx
Hospital,
New
York.
582
THE
BNEKII
‘AK
IlEART
JOUKSAL
We are reporting results on seventy-three patients who had sympt,oms of peripheral vascular disease. Each patient had a complete history and physical examination, urine examination, blood counts, and blood Wassermann and Kahn tests. When necessary, a chemical examination of the blood was made and electrocardiograms taken. The local examination was supplemented by recorded oscillometric tracings at the knee and ankle, roentgenograms of the peripheral vessels and, finally, by t,hc thermal test. Just prior to doing the thermal test the case was classified as either one of organic, functional, or no peripheral vascular disease. However, in this report we divided our cases into t,wo main groups, namely, Group I, cases in which the temperature of the big toe rose to 30.5O C. or over, and, Group II, cases in which the temperat,ure of the big toe failed to rise to 30.5’ C. Technique of the Test.--We followed the technique of Gibbon and 1,andis.s We tried to keep the room temperature as constant as possible, and avoided all drafts. The subject, whose rectal temperature xv-as not over 100” F., was seated on a chair with the lower extremities in the horizontal position, exposed from above the knees. The readings mere taken with the Taylor Dermatherm on the dorsum of the big toe at the base of the nail. Both extremities Tvere examined. Readings were taken until the temperature of the big toe was the lowest possible at the room temperature prevailing. We tried to have the initial temperature of the big toe 26” C., or lower; this frequently necessitated an exposure of one-half hour or longer. Both forearms and hands were then immersed in water at 45” C., and readings from the big toes were taken with the dcrmatherm every three minutes for a period of one-half hour. At the time of immersion the patient’s body was covered with wool blankets. Rectal temperatures were taken at the end of each test. Normally, a significant rise in toe temperature should occur in fifteen minutes, and at the end of thirty minutes should reach the absolute value of 30.5” C., or over. For the sake of simplicity in following our results we have reported the findings in only one extremity, and me have selected the extremity showing the lower reading.
Ration& of the l%ewnul Il’est.-Immersion of the forearms in water at 45O C. tends to raise the temperature of t.he blood in those limbs. When the warmer venous blood reaches the medulla it affects the vasomotor center, inducing a reduction of vasomotor tone in an attempt to maintain constant body temperature. Group 1 (A).-Cases in which the temperature did not rise to 30.5’ C. (initial temperature of the big toe ‘26.0’ C., or lower). In this group there were forty-four cases, including thirty-three of arteriosclerosis obliterans with or without ulceration, infection, or gangrene, five casesof thromboangiitis obliterans, one of scleroderma, one of thrombophlebitis with arteritis, one of vasospasm, and three in which no vascular disease was diagnosed. Forty subjects in this series failed to show an elevation of the temperature of the big toe to 30.5’ C. In other words, the thermal test gave corroborative evidence of organic obstruction in forty out of forty-four cases, or 91 per cent. However, four patients who were re-
SALAND
ET
AL.
:
THERMAL
RBEF-LEX
VASODILATATION
583
TEST
garded as having no organic obstruction also failed to show a rise to the absolute value of 30 .tie C . Group I (B).-Cases in which the temperature did not rise to 30.5’ C. (initial temperature of the big toe above 26.0° C.) . This group comprised eleven cases of arteriosclerosis obliterans, with or without ulceration, infection or gangrene. In no instance, in spite of the fact that the initial temperature of the big toe was over 26.0° C., was there a rise to 30.5’ C. In other words, there was 100 per cent corroboration of the presence of organic vascular disease in this series. The percentage corroboration of the test for the entire Group I was 93 per cent. Group II (A).-Cases in which the temperature rose to 30.5O C., or over (initial temperature of the big toe 26.0° C., or lower). In this group there were seven cases, in all of which the diagnosis of no peripheral vascular involvement had been made. In all of these cases the temperature of the big toe rose as it would in a normal individual, a 100 per cent corroboration by the thermal test of the fact that in these cases there was no organic obstruction. Group II (B).-Cases in which the temperature rose to 30.5O C., or over (initial temperature of the big toe above 26.0’ C.). In this group there were eleven cases, including two of arteriosclerosis obliterans, one of Raynaud’s disease, and eight in which no peripheral vascular disease was diagnosed. The patient with Raynaud’s disease had no involvement of the lower extremities, and for the purpose of this article may be grouped with the nine normal subjects. All eleven subjects showed a rise in the temperature of the big toe to 30.5’ C. In this group, therefore, the thermal test corroborated the clinical findings in 82 per cent of the cases. TABLE SVMMARY
I
OF THERMAL
RESPONSE
SURFACE DIAGNOSIS
TEMPERATURE BIG TOE
TOTAL NO. ROSE To 30.5”
Organic occlusive arterial disease No peripheral vascular disease
c.
2 16
OF
FAILED To RISE TO 30.5”
c.
51 4
PER CENT CORROBORATION OF DIAGNOSIS BY THERMAL TEST 96 80
DISCUSSION
We have studied seventy-three patients who were sent to our clinic for diagnostic and therapeutic purposes. We did a vasodilatation test in each case in addition to using other known methods of proving the presence or absence of organic obstruction. We have shown that in cases in which there was no evidence of vascular disease the thermal test was normal in 80 per cent, and that in those in which a diagnosis of organic obstruction had been made the thermal test showed that the surface
584
THE,
AXEKICAN
HEmAKT
JOURNAL
temperature of the big toe failed to rise to 80.5” c’. in 96 per cent of the cases. In two cases in which a clinical diagnosis of arteriosclerosis obliterans was made, the response to the thermal test was normal. One must assume in such cases that either there is an element of spasm, and that this spasm is relaxed by vasodilatation, or that, there exists a sufficient collateral blood supply to allow enough blood to reach the extremity and warm it. If the latter should bc true, then it is rational to assume that, this test can be used to ~CBSIIW the effect of any kind of therapy used in peripheral vascular disease. CONCLUSION
The thermal reflex vasodilatation test is a safe and simple method to differentiate organic from nonorganic obstruction of the peripheral arterial system, and also to determine whether or not the blood supply to a limb is sufficient. REFERENCES
1. Mitchell,
S. W. : Cases of Lesions of Peripheral Nerve-Trunks, With CommenAm. J. M. SC. 85: 17, 1883. Brown, G. E.: The Treatment of Peripheral Vascular Disturbance of the Extremities, J. A. M. A. 87: 379, 1926. White, J. C.: Diagnostic Blocking of Sympathetic Nerves to Extremities with Procaine, J. A. M. A. 94: 1382, 1930. Brill, S., and Lamrence, L. B.: Changes in Temperature of the Lower Extremities Following the Induction of Spinal Anesthesia, Prof. SOC. Exper. Biol. & Med. 27: 728, 1930. Obliteration of Vasoconstrictor Gradient Scott, W. J. M., and Morton, J. J.: in the Extremities Under Nitrous Oxide-Oxygen, Ether and Tribom-Ethyl Alcohol Anesthesias, Proc. Sot. Exper. Biol. & Med. 27: 945, 1930. Scott, W. J. M:, and Morton, J. J.: Differentiation of Peripheral Arterial Spasm and Occlusion in Ambulatory Patients, J. A. M. A. 97: 1212, 1931. Relating to Peripheral Mechanism Involved in Spasmodic Lewis, T. : Experiments Arrest of Circulation in the Fingers, a Variety of Raynaud’s Disease, Heart 15: 7, 1929. Gibbon, J. H., Jr., and Landis, E. M.: Vasodilatation in the Lower Extremities in Response to Immersing the Forearms in Warm Water, J. Clin. Investigation 11: 1019, 1932. Landis, E. M., and Gibbon, J. H., Jr.: A Simple Method of Producing Vasodilatation in the Lower Extremities, Arch. Int. Med. 52: 785, 1933.
taries,
2. 3. 4. 5. 6. 7. 8. 9.
THERMAL REFLEX VASODILATATION PERIPHERAL VASCULAR DISEASE GAMIJEI,
SALAND, M.D., ITERMAN -YEW
KLEIN,
CHARLES
IN
AKD
M.D.
ZURROW, YORK,
M.D.,
TEST
N.
T.
TTENTION has already been called to the value of a vasodilating test in the study of the peripheral vascular diseases. As early as 1883, Mitchell’ showed that paralysis of a peripheral nerve trunk by cold is associated with hyperthermia in the anesthetic zone. In 1926, Brown’ obtained vasodilatation by means of the intravenous administration of typhoid vaccine. In May, 1930, White,” and Brill and Lawrence,4 at the same time, but working independently, showed that spinal anesthesia caused an increase in the surface temperature of the feet. Scott and Morton,5 in June, 1930, found that general anesthesia gave the same complete obliteration of vasoconstriction. Again, in October, 1931, Scott and Morton” injected the posterior tibia1 nerve to differentiate arterial spasm from organic obstruction. Sir Thomas Lewiq7 in 1929, used heat to induce peripheral refles vasodilatation. In 1932, Gibbon and Landis8 observed that immersing the hands and forearms in warm water produced vasodilatation in the lower extremities of six normal persons, and that the temperature of the toes began to rise in fifteen minutes and rose to over 31.5O C. in all cases. In November, 1933, Landis and Gibbon” studied patients with peripheral vascular disease, and found that the immersion test compared favorably with other methods of vasodilatation. The reason for using a vasodilatation test is obvious to all workers in the field of vascular diseases. It is a known fact that arterial spasm can simulate every symptom and physical sign of organic obstruction, such as cold feet, painful extremities, claudication, absent pulsations, rubor, and pallor. It is also known that instrumental aids, such as oscillometric tracings and intra-arterial thorotrast injections, reveal only the presence or absence of obstruction, but when obstruction is demonstrated, these tests do not differentiate spasm from organic block.
A
In our work we followed the method of Gibbon and Landis for t,he following reasons: (1) it eliminated the danger of trauma to the vessels, (2) injection carried with it the risk of infection, and (3) many patients objected to an injection. From the department Received for publication
of peripheral Oct. 29,
rascular 1938.
581
diseases,
Bronx
Hospital,
New
York.
582
THE
BNEKII
‘AK
IlEART
JOUKSAL
We are reporting results on seventy-three patients who had sympt,oms of peripheral vascular disease. Each patient had a complete history and physical examination, urine examination, blood counts, and blood Wassermann and Kahn tests. When necessary, a chemical examination of the blood was made and electrocardiograms taken. The local examination was supplemented by recorded oscillometric tracings at the knee and ankle, roentgenograms of the peripheral vessels and, finally, by t,hc thermal test. Just prior to doing the thermal test the case was classified as either one of organic, functional, or no peripheral vascular disease. However, in this report we divided our cases into t,wo main groups, namely, Group I, cases in which the temperature of the big toe rose to 30.5O C. or over, and, Group II, cases in which the temperat,ure of the big toe failed to rise to 30.5’ C. Technique of the Test.--We followed the technique of Gibbon and 1,andis.s We tried to keep the room temperature as constant as possible, and avoided all drafts. The subject, whose rectal temperature xv-as not over 100” F., was seated on a chair with the lower extremities in the horizontal position, exposed from above the knees. The readings mere taken with the Taylor Dermatherm on the dorsum of the big toe at the base of the nail. Both extremities Tvere examined. Readings were taken until the temperature of the big toe was the lowest possible at the room temperature prevailing. We tried to have the initial temperature of the big toe 26” C., or lower; this frequently necessitated an exposure of one-half hour or longer. Both forearms and hands were then immersed in water at 45” C., and readings from the big toes were taken with the dcrmatherm every three minutes for a period of one-half hour. At the time of immersion the patient’s body was covered with wool blankets. Rectal temperatures were taken at the end of each test. Normally, a significant rise in toe temperature should occur in fifteen minutes, and at the end of thirty minutes should reach the absolute value of 30.5” C., or over. For the sake of simplicity in following our results we have reported the findings in only one extremity, and me have selected the extremity showing the lower reading.
Ration& of the l%ewnul Il’est.-Immersion of the forearms in water at 45O C. tends to raise the temperature of t.he blood in those limbs. When the warmer venous blood reaches the medulla it affects the vasomotor center, inducing a reduction of vasomotor tone in an attempt to maintain constant body temperature. Group 1 (A).-Cases in which the temperature did not rise to 30.5’ C. (initial temperature of the big toe ‘26.0’ C., or lower). In this group there were forty-four cases, including thirty-three of arteriosclerosis obliterans with or without ulceration, infection, or gangrene, five casesof thromboangiitis obliterans, one of scleroderma, one of thrombophlebitis with arteritis, one of vasospasm, and three in which no vascular disease was diagnosed. Forty subjects in this series failed to show an elevation of the temperature of the big toe to 30.5’ C. In other words, the thermal test gave corroborative evidence of organic obstruction in forty out of forty-four cases, or 91 per cent. However, four patients who were re-
SALAND
ET
AL.
:
THERMAL
RBEF-LEX
VASODILATATION
583
TEST
garded as having no organic obstruction also failed to show a rise to the absolute value of 30 .tie C . Group I (B).-Cases in which the temperature did not rise to 30.5’ C. (initial temperature of the big toe above 26.0° C.) . This group comprised eleven cases of arteriosclerosis obliterans, with or without ulceration, infection or gangrene. In no instance, in spite of the fact that the initial temperature of the big toe was over 26.0° C., was there a rise to 30.5’ C. In other words, there was 100 per cent corroboration of the presence of organic vascular disease in this series. The percentage corroboration of the test for the entire Group I was 93 per cent. Group II (A).-Cases in which the temperature rose to 30.5O C., or over (initial temperature of the big toe 26.0° C., or lower). In this group there were seven cases, in all of which the diagnosis of no peripheral vascular involvement had been made. In all of these cases the temperature of the big toe rose as it would in a normal individual, a 100 per cent corroboration by the thermal test of the fact that in these cases there was no organic obstruction. Group II (B).-Cases in which the temperature rose to 30.5O C., or over (initial temperature of the big toe above 26.0’ C.). In this group there were eleven cases, including two of arteriosclerosis obliterans, one of Raynaud’s disease, and eight in which no peripheral vascular disease was diagnosed. The patient with Raynaud’s disease had no involvement of the lower extremities, and for the purpose of this article may be grouped with the nine normal subjects. All eleven subjects showed a rise in the temperature of the big toe to 30.5’ C. In this group, therefore, the thermal test corroborated the clinical findings in 82 per cent of the cases. TABLE SVMMARY
I
OF THERMAL
RESPONSE
SURFACE DIAGNOSIS
TEMPERATURE BIG TOE
TOTAL NO. ROSE To 30.5”
Organic occlusive arterial disease No peripheral vascular disease
c.
2 16
OF
FAILED To RISE TO 30.5”
c.
51 4
PER CENT CORROBORATION OF DIAGNOSIS BY THERMAL TEST 96 80
DISCUSSION
We have studied seventy-three patients who were sent to our clinic for diagnostic and therapeutic purposes. We did a vasodilatation test in each case in addition to using other known methods of proving the presence or absence of organic obstruction. We have shown that in cases in which there was no evidence of vascular disease the thermal test was normal in 80 per cent, and that in those in which a diagnosis of organic obstruction had been made the thermal test showed that the surface
584
THE,
AXEKICAN
HEmAKT
JOURNAL
temperature of the big toe failed to rise to 80.5” c’. in 96 per cent of the cases. In two cases in which a clinical diagnosis of arteriosclerosis obliterans was made, the response to the thermal test was normal. One must assume in such cases that either there is an element of spasm, and that this spasm is relaxed by vasodilatation, or that, there exists a sufficient collateral blood supply to allow enough blood to reach the extremity and warm it. If the latter should bc true, then it is rational to assume that, this test can be used to ~CBSIIW the effect of any kind of therapy used in peripheral vascular disease. CONCLUSION
The thermal reflex vasodilatation test is a safe and simple method to differentiate organic from nonorganic obstruction of the peripheral arterial system, and also to determine whether or not the blood supply to a limb is sufficient. REFERENCES
1. Mitchell,
S. W. : Cases of Lesions of Peripheral Nerve-Trunks, With CommenAm. J. M. SC. 85: 17, 1883. Brown, G. E.: The Treatment of Peripheral Vascular Disturbance of the Extremities, J. A. M. A. 87: 379, 1926. White, J. C.: Diagnostic Blocking of Sympathetic Nerves to Extremities with Procaine, J. A. M. A. 94: 1382, 1930. Brill, S., and Lamrence, L. B.: Changes in Temperature of the Lower Extremities Following the Induction of Spinal Anesthesia, Prof. SOC. Exper. Biol. & Med. 27: 728, 1930. Obliteration of Vasoconstrictor Gradient Scott, W. J. M., and Morton, J. J.: in the Extremities Under Nitrous Oxide-Oxygen, Ether and Tribom-Ethyl Alcohol Anesthesias, Proc. Sot. Exper. Biol. & Med. 27: 945, 1930. Scott, W. J. M:, and Morton, J. J.: Differentiation of Peripheral Arterial Spasm and Occlusion in Ambulatory Patients, J. A. M. A. 97: 1212, 1931. Relating to Peripheral Mechanism Involved in Spasmodic Lewis, T. : Experiments Arrest of Circulation in the Fingers, a Variety of Raynaud’s Disease, Heart 15: 7, 1929. Gibbon, J. H., Jr., and Landis, E. M.: Vasodilatation in the Lower Extremities in Response to Immersing the Forearms in Warm Water, J. Clin. Investigation 11: 1019, 1932. Landis, E. M., and Gibbon, J. H., Jr.: A Simple Method of Producing Vasodilatation in the Lower Extremities, Arch. Int. Med. 52: 785, 1933.
taries,
2. 3. 4. 5. 6. 7. 8. 9.