PERIPHERAL ARTERIAL DISEASES Postgrad Med J: first published as 10.1136/pgmj.22.243.22 on 1 January 1946. Downloaded from By SAUL S. SAMUELS, A.M., M.D. New York, N.Y. Arterial Diseases arteries that might be mentioned, but clinical Peripheral evidence of which is difficult to determine. They This new specialty has evolved within the past are encountered so infrequently that it hardly twenty years into a separate and distinct branch of seems important to devote much time to them. medicine and surgery. In its infancy it was rele- Among these may be mentioned syphilitic arteritis, gated to the internist who had some special interest tuberculosis of the peripheral arteries and certain in this work, just as in the early days of urology an non-specific forms of peripheral arteritis, which acquaintance with venereal diseases was sufficient have as yet been incompletely studied. for the designation of specialist in this field. In the field of functional disturbances of the peripheral arterial system, we consider two main General sub-groups. The first, and more important of Considerations these is Raynaud's Disease. This is a disturbance The peripheral arterial diseases may be separated of the control mechanism of the peripheral arteri- into two definite groups. The first and more oles which causes frequent attacks of vasospasm important is that of the changes in the arterial in the extremities and in the various acral parts of walls. These two groups may be again sub- the body, such as the tip of the nose, tongue and divided so that in the organic field we recognise ears. It is frequently associated with a peculiar two major varieties of organic arterial disease in trophic disturbance of the skin, hands, arms, face the extremities. The most common of these, and and chest. This is a distinct variety of sclero- by far the most important from the standpoint of derma. Dermatologists seem to distinguish this frequency of occurrence, is arteriosclerosis. At this form of scleroderma from that which is not en- it be well to differentiate the term countered in Disease and which point might Raynaud's appears Protected by copyright. arteriosclerosis from the disease process known as to be preceded by an inflammatory reaction in the arteriosclerosis obliterans. The practical signifi- dermal tissues. Another frequent accompaniment cance of this distinction lies in the fact that arterio- of Raynaud's Disease is a peculiar variety of rheu- sclerosis, that is to say, definite structural changes matoid arthritis, involving usually the small joints in the walls of the arteries may be present to a of the hands and feet and in some instances the great degree without in any way interfering with larger joints of the body. the arterial onflow. In other words, the mere The other functional derangement of the peri- presence of arteriosclerosis of the peripheral pheral arterial system is known as erythromelalgia arteries as shown by roentgen films does not in or Weir Mitchell's Disease. This interesting but itself indicate arterial insufficiency in that parti- extremely rare disease will be mentioned here cular individual. When, however, the element of merely for the sake of completeness, but from a obstruction is added to arteriosclerosis, induced practical standpoint it is so seldom encountered as either by progressive narrowing of the lumen of to require comparatively little consideration. Its the artery or by encroachment on its blood carrying main features are a paralysis of the vasomotor http://pmj.bmj.com/ capacity by the formation of thrombi on mural mechanism to such an extent that an almost plaques, insufficiency of the arterial flow may then constant vasodilatation is obtained in all four be expected. In such a case the proper termino- extremities. In some instances, however, the dis- logy is arteriosclerosis obliterans. The- frequent turbance may be confined to a single limb. I have association of an arteriosclerotic process with seen such a case resulting from severe trauma to an diabetes mellitus accentuates the importance of upper extremity. According to Brown of the Mayo this disease in the field of peripheral vascular Clinic, the diagnostic features of erythromelalgia diseases. Whether or no the presence of diabetes are severe burning pain in the affected extremities on September 26, 2021 by guest. intensifies the arteriosclerotic process, particularly which symptoms are relieved only by immersion of in the uncontrolled diabetic patient, is still open the affected parts in ice-cold water. He stresses to question. In any event the combination of the the importance of this means of obtaining relief as two adds considerable difficulty to the treatment an essential factor in arriving at a diagnosis. It is of gangrene of the extremities. important to recognise this fact because frequently The other important organic arterial disease is both in practice and in the literature of peripheral thromboangiitis obliterans, commonly known as vascular diseases the error has been made of diag- Buerger's Disease. This will be described in nosing erythromelalgia merely on the basis of red- greater detail in the following pages. Aside from ness and perhaps some swelling with burning pain arteriosclerosis and thromboangiitis obliterans, of one or more extremities. It must not be for- there are other organic diseases of the peripheral gotten that the condition known as rubor, parti- PERIPHERAL ARTERIAL DISEASES. SAUL S. SAMUELS, A.M., M.D. 23 Postgrad Med J: first published as 10.1136/pgmj.22.243.22 on 1 January 1946. Downloaded from .. ..... ....... ...... .... ....... FIG. 2.-Gangrene in thromboangiitis obliterans. Protected by copyright. 2: http://pmj.bmj.com/ on September 26, 2021 by guest. .?..'^......' .:...... FIG. i.-Samuels' Test for plantar ischemia. FIG. 3.-Same case healed without operation. M.D. 24 PERIPHERAL ARTERIAL DISEASES. SAUL S. SAMUELS, A.M., Postgrad Med J: first published as 10.1136/pgmj.22.243.22 on 1 January 1946. Downloaded from FIG. 4.-Diabetic gangrene of heel. Protected by copyright. http://pmj.bmj.com/ on September 26, 2021 by guest. FIG. 5.-Same case healed. PERIPHERAL ARTERIAL DISEASES Januacav,, I946 Postgrad Med J: first published as 10.1136/pgmj.22.243.22 on 1 January 1946. Downloaded from cularly in the lower extremities, is frequently the peripheral arterial system before passing final present in long-standing cases of arteriosclerosis judgment as to the cause of the symptoms. obliterans or in thromboangiitis obliterans and to Just as in coronary artery disease where the the inexperienced observer the appearance of this general clinical picture is frequently called. angina one stage, namely rubor, may induce an erroneous pectoris, so in the field of arterial insufficiency of diagnosis of erythromelalgia. the lower extremities one groups all the symptoms Here I wish to stress the fact that in recent together in the category of intermittent claudica- years there has been a great tendency to over- tion. In its classic form this syndrome consists of emphasise the importance of vasomotor change, a feeling of fatigue or actual cramp in the calf of particularly vasospasm, in the organic arterial the affected leg induced by walking, particularly diseases. Unfortunately, therapy of the organic fast walking or climbing a flight of steps. Thus, diseases has been directed in many instances to the after a variable distance, often depending upon the elimination of vasospasm. The fallacy of this severity of the arterial disease, the patient is forced concept lies in the fact that the vasomotor dis- to stop because of disabling symptoms. After a turbances associated with the organic arterial rest period of a moment or so, the patient is able to diseases are for the most part confined to the very proceed for a comparatively short distance after early stages of these diseases and are comparatively which the disabling symptom reappears. This infrequent in the later stages .where the organic classic form of intermittent claudication does not, element is a predominant feature. In accordance however, always manifest itself in every case. As with this misconception, too many operative pro- mentioned previously, it may resemble a form'of cedures, particularly sympathectomy, have been sciatic pain or it may appear as a tightening of the advocated and been performed unnecessarily in small muscles of the foot, inducing a cramp-like cases where simpler methods of treatment were seizure which does not allow the patient to proceed indicated. in walking, or there may be numbness of the toes or of the entire foot or Paresthesias of leg. Protected by copyright. various kinds can also be brought to light after Symptomatology walking a short distance and may be the only sign At the outset it is important to know that the called to the patient's notice that something un- symptoms of arterial insufficiency in the extremi- usual is occurring in the feet. Any of these symp- ties are extremely variable and may be absent toms may be accompanied by subjective coldness entirely in the presence of advanced occlusive of either the toes or the entire foot of the affected disease, or they may simulate many other common extremity. This is particularly true in those cases conditions. For these reasons, it is important to where there has been a fairly recent interference lay more stress on the objective findings elicited by with arterial flow such as in a thrombosis of a main a careful physical examination, rather than on the vessel. Arriving at a diagnosis merely on symp- patient's statement of symptoms. Failure fo toms alone has, of course, led to many strange recognise this point has resulted in numerous in- therapeutic procedures. A prescription of arch correct diagnoses on the part of excellent practi- supports, of specially constructed shoes, of various tioners and specialists, who apparently rely too intricate strappings of the feet and legs have all http://pmj.bmj.com/ much upon the patient's story.