PERIPHERAL ARTERIAL DISEASESBy SAUL S. SAMUELS, A.M., M.D.

New York, N.Y.

Peripheral Arterial DiseasesThis new specialty has evolved within the past

twenty years into a separate and distinct branch ofmedicine and surgery. In its infancy it was rele-gated to the internist who had some special interestin this work, just as in the early days of urology anacquaintance with venereal diseases was sufficientfor the designation of specialist in this field.

General ConsiderationsThe peripheral arterial diseases may be separated

into two definite groups. The first and moreimportant is that of the changes in the arterialwalls. These two groups may be again sub-divided so that in the organic field we recognisetwo major varieties of organic arterial disease inthe extremities. The most common of these, andby far the most important from the standpoint offrequency of occurrence, is arteriosclerosis. At thispoint it might be well to differentiate the termarteriosclerosis from the disease process known asarteriosclerosis obliterans. The practical signifi-cance of this distinction lies in the fact that arterio-sclerosis, that is to say, definite structural changesin the walls of the arteries may be present to agreat degree without in any way interfering withthe arterial onflow. In other words, the merepresence of arteriosclerosis of the peripheralarteries as shown by roentgen films does not initself indicate arterial insufficiency in that parti-cular individual. When, however, the element ofobstruction is added to arteriosclerosis, inducedeither by progressive narrowing of the lumen ofthe artery or by encroachment on its blood carryingcapacity by the formation of thrombi on muralplaques, insufficiency of the arterial flow may thenbe expected. In such a case the proper termino-logy is arteriosclerosis obliterans. The- frequentassociation of an arteriosclerotic process withdiabetes mellitus accentuates the importance ofthis disease in the field of peripheral vasculardiseases. Whether or no the presence of diabetesintensifies the arteriosclerotic process, particularlyin the uncontrolled diabetic patient, is still opento question. In any event the combination of thetwo adds considerable difficulty to the treatmentof gangrene of the extremities.The other important organic arterial disease is

thromboangiitis obliterans, commonly known asBuerger's Disease. This will be described ingreater detail in the following pages. Aside fromarteriosclerosis and thromboangiitis obliterans,there are other organic diseases of the peripheral

arteries that might be mentioned, but clinicalevidence of which is difficult to determine. Theyare encountered so infrequently that it hardlyseems important to devote much time to them.Among these may be mentioned syphilitic arteritis,tuberculosis of the peripheral arteries and certainnon-specific forms of peripheral arteritis, whichhave as yet been incompletely studied.

In the field of functional disturbances of theperipheral arterial system, we consider two mainsub-groups. The first, and more important ofthese is Raynaud's Disease. This is a disturbanceof the control mechanism of the peripheral arteri-oles which causes frequent attacks of vasospasmin the extremities and in the various acral parts ofthe body, such as the tip of the nose, tongue andears. It is frequently associated with a peculiartrophic disturbance of the skin, hands, arms, faceand chest. This is a distinct variety of sclero-derma. Dermatologists seem to distinguish thisform of scleroderma from that which is not en-countered in Raynaud's Disease and which appearsto be preceded by an inflammatory reaction in thedermal tissues. Another frequent accompanimentof Raynaud's Disease is a peculiar variety of rheu-matoid arthritis, involving usually the small jointsof the hands and feet and in some instances thelarger joints of the body.The other functional derangement of the peri-

pheral arterial system is known as erythromelalgiaor Weir Mitchell's Disease. This interesting butextremely rare disease will be mentioned heremerely for the sake of completeness, but from apractical standpoint it is so seldom encountered asto require comparatively little consideration. Itsmain features are a paralysis of the vasomotormechanism to such an extent that an almostconstant vasodilatation is obtained in all fourextremities. In some instances, however, the dis-turbance may be confined to a single limb. I haveseen such a case resulting from severe trauma to anupper extremity. According to Brown of the MayoClinic, the diagnostic features of erythromelalgiaare severe burning pain in the affected extremitieswhich symptoms are relieved only by immersion ofthe affected parts in ice-cold water. He stressesthe importance of this means of obtaining relief asan essential factor in arriving at a diagnosis. It isimportant to recognise this fact because frequentlyboth in practice and in the literature of peripheralvascular diseases the error has been made of diag-nosing erythromelalgia merely on the basis of red-ness and perhaps some swelling with burning painof one or more extremities. It must not be for-gotten that the condition known as rubor, parti-

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PERIPHERAL ARTERIAL DISEASES. SAUL S. SAMUELS, A.M., M.D. 23

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FIG. i.-Samuels' Test for plantar ischemia.

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FIG. 2.-Gangrene in thromboangiitis obliterans.

2:

FIG. 3.-Same case healed without operation.

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24 PERIPHERAL ARTERIAL DISEASES. SAUL S. SAMUELS, A.M., M.D.

FIG. 4.-Diabetic gangrene of heel.

FIG. 5.-Same case healed.

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PERIPHERAL ARTERIAL DISEASES

cularly in the lower extremities, is frequentlypresent in long-standing cases of arteriosclerosisobliterans or in thromboangiitis obliterans and tothe inexperienced observer the appearance of thisone stage, namely rubor, may induce an erroneousdiagnosis of erythromelalgia.Here I wish to stress the fact that in recent

years there has been a great tendency to over-emphasise the importance of vasomotor change,particularly vasospasm, in the organic arterialdiseases. Unfortunately, therapy of the organicdiseases has been directed in many instances to theelimination of vasospasm. The fallacy of thisconcept lies in the fact that the vasomotor dis-turbances associated with the organic arterialdiseases are for the most part confined to the veryearly stages of these diseases and are comparativelyinfrequent in the later stages .where the organicelement is a predominant feature. In accordancewith this misconception, too many operative pro-cedures, particularly sympathectomy, have beenadvocated and been performed unnecessarily incases where simpler methods of treatment wereindicated.

SymptomatologyAt the outset it is important to know that the

symptoms of arterial insufficiency in the extremi-ties are extremely variable and may be absententirely in the presence of advanced occlusivedisease, or they may simulate many other commonconditions. For these reasons, it is important tolay more stress on the objective findings elicited bya careful physical examination, rather than on thepatient's statement of symptoms. Failure forecognise this point has resulted in numerous in-correct diagnoses on the part of excellent practi-tioners and specialists, who apparently rely toomuch upon the patient's story. A familiar storyis that of the patient with symptoms of painradiating down the back of the thigh originating inthe buttock, which is so often incorrectly ascribedto sciatica. As a matter of fact, this is a fairlycommon symptom of arterial insufficiency of thelower extremities, particularly in the early stagesof arteriosclerosis obliterans. Other misleadingsymptoms are pains in various parts of the feetwhich simulate the symptoms of pes planus.Again, particularly in arteriosclerosis, the symp-toms may resemble almost completely those ofarthritis of the knees and ankles. The commonassociation of osteoarthritis with peripheral arterio-sclerosis obliterans has been observed and reportedby Steinbrocker and myself. It behoves one,therefore, in studying middle aged or elderlypatients with arthritic symptoms in the lower ex-tremities, to carry out a complete examination of

the peripheral arterial system before passing finaljudgment as to the cause of the symptoms.

Just as in coronary artery disease where thegeneral clinical picture is frequently called. anginapectoris, so in the field of arterial insufficiency ofthe lower extremities one groups all the symptomstogether in the category of intermittent claudica-tion. In its classic form this syndrome consists ofa feeling of fatigue or actual cramp in the calf ofthe affected leg induced by walking, particularlyfast walking or climbing a flight of steps. Thus,after a variable distance, often depending upon theseverity of the arterial disease, the patient is forcedto stop because of disabling symptoms. After arest period of a moment or so, the patient is able toproceed for a comparatively short distance afterwhich the disabling symptom reappears. Thisclassic form of intermittent claudication does not,however, always manifest itself in every case. Asmentioned previously, it may resemble a form'ofsciatic pain or it may appear as a tightening of thesmall muscles of the foot, inducing a cramp-likeseizure which does not allow the patient to proceedin walking, or there may be numbness of thetoes or of the entire foot or leg. Paresthesias ofvarious kinds can also be brought to light afterwalking a short distance and may be the only signcalled to the patient's notice that something un-usual is occurring in the feet. Any of these symp-toms may be accompanied by subjective coldnessof either the toes or the entire foot of the affectedextremity. This is particularly true in those caseswhere there has been a fairly recent interferencewith arterial flow such as in a thrombosis of a mainvessel. Arriving at a diagnosis merely on symp-toms alone has, of course, led to many strangetherapeutic procedures. A prescription of archsupports, of specially constructed shoes, of variousintricate strappings of the feet and legs have allbeen encountered. It is well to stress again at thispoint the fact that symptoms may be extremelydisabling in the mildest form of organic disease,while in some cases patients with extreme insuffi-ciency in an extremity may insist that all theirtrouble lies in the opposite leg in which the physi-cian finds the least evidence of arterial disease. Wethus come to the most important part of the studyfor purposes of diagnosis of these cases, namely,*the various diagnostic procedures at our disposal.

Diagnostic ProceduresBefore outlining the best methods of arriving at

a diagnosis of peripheral arterial obstruction, it willbe well to discuss the classical procedure which hasbeen taught as the standard in text-books and bymany teachers. I refer to the procedure of pal-pating the dorsalis pedis pulse. It has been

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POST-GRADUATE MEDICAL JOURNALtaught that the absence of, this pulse by palpationis sufficient indication for the diagnosis of peri-pheral arterial disease. And conversely, that thepresence of this pulse indicates the absence ofarterial disease. Nothing could be further fromthe truth. If one assumes that the dorsalis pedisartery can be felt to pulsate at its usual prominentpoint on the dorsum of the foot, one is not therebytold the condition of the distal distribution of thedorsalis pedis artery and its branches. In otherwords, incipient arterial disease may be present inthe extremity even though the dorsalis pedis arterypulsates. The same can be said of the posteriortibial artery which can be felt in only a smallportion of its extent behind and below the internalmalleolus. If the examining physician detects pul-sation of this portion of the artery, there is givenno information on the status of the posterior tibialartery distal to its point of palpation, nor does onehave any information concerning the condition ofthe plantar arterial system.A more accurate and more sensitive approach to

the question of diagnosis must therefore be used.In the advanced case of organic disease mereinspection of the foot will, in almost every instance,reveal the presence of pallor or ischemia in varyingdegree, depending upon the extent of the arterialobstruction. In other words, a badly involved legwill show extreme pallor of the foot, either of theplantar surface or of the foot as a whole if thepatient is in the reclining position. In some casesthis ischemia may be so severe as to resemble thefoot of a cadaver. In the slightly involved casesischemia is not easily seen except by specialmethods. Elevation of the feet above the level ofthe heart, obtained by having the patient flat withlegs elevated to an angle of at least 45° will in themoderately involved case produce ischemia orblanching of the plantar surface of the affectedextremity. Fortunately in the organic arterialdiseases the condition is usually asymmetric andrelative colour changes are easily discernible. Imust stress the importance of good even lightfalling upon the plantar surfaces of the feet asthey are elevated. In the very early cases eleva-tion alone may be insufficient to bring out ischemia.Therefore a reinforcement of the test is necessary.This consists in a pumping action of the leg, pro-duced by having the patient flex the feet veryrapidly, using the ankle joints as pivots and not thetoes alone, for a few moments. During this timeexcess blood of both extremities will be pumped bythe calf muscles and the action of gravity out ofthe plantar surface of the feet and a distinct andunmistakable plantar ischemia will be elicited inthe involved extremities. This colour change isapparent even in the earliest cases of arterialdisease and in those where the dorsalis pedis and

posterior tibial pulses may still be palpated. It isthus seen how important this simple test for plantarischemia is for arriving at a diagnosis of peripheralarterial obstruction. Ischemia cannot be elicited inthe pure vasospastic diseases such as Raynaud'sDisease. For here the ischemia is pure vasospasmand can be induced only by those causes whichproduce it as a form of disease, namely exposure tocold or emotional disturbance. Thus in the sign ofplantar ischemia we have pathognomonic evidenceof the existence of organic arterial insufficiency inan extremity.

Relative coldness of the affected extremity is tobe expected in the ischemic foot. This is a con-firmatory sign and may be recognised easily bymanual palpation of the feet in corresponding areas.Delicate electrical thermometers and other similarinstruments of precision are unnecessary for ordi-nary examination. They do have a place in re-search or advanced study of peripheral arterialphenomena, but for routine examination simplemanual palpation is sufficient. Thus there are twosimple procedures at one's disposal for arriving ata diagnosis. It is unfortunate that these methodshave been slighted in the past and it is to be hopedthat they will soon supplant the inadequate andmisleading procedure of pulse palpation.As in the study of hypertension, one is not satis-

fied with mere qualitative diagnosis. One prefersmechanical proof of the existence of either hyper-tension or of organic arterial obstruction. Whatthe sphygmomanometer is to blood pressure study,so is the oscillometer to the consideration of peri-pheral arterial disease. Rather than go into ahistorical discussion of this interesting instrument,I will refer merely to two types in general use,namely the visual type, corresponding to theordinary blood pressure apparatus and the record-ing type of oscillometer. Of the two the latter isby far the better, both from the standpoint of accu-racy and of permanence of record. In other words,an accurate impressional tracing of pulsation canbe obtained, while in the visual type one mustfollow the travels of the indicating needle over adial and must contemplate the extent or amplitudeof each pulsation. The oscillometer measures thepulsation of the main arteries under pulsation. Itthus represents the sum total of pulsation of all ofthe main vessels at any particular level. Unfor-tunately it does not measure the collateral circu-lation which is usually made up, for the most part,of a network of tiny vessels which apparently donot pulsate, but form a continuous flow. Clinicalevidence of collateral circulation must be obtainedby other means. For instance, increase in warmthof the extremity, improved colour,and, of course,the healing of gangrenous ulcers are all indicationsof the improved collateral circulation which cannot

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PERIPHERAL ARTERIAL DISEASES. SAUL S. SAMUELS, A.M., M.D. 27

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FIG. 6.-Primary arteriosclerotic gangrene.

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FIG. 7.-Healed arteriosclerotic gangrene.

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FIG. 9.-Bilateral diabetic gangrenehealed.

FIG. io.-Healed diabetic gangrene.

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PERIPHERAL ARTERIAL DISEASES. SAUL S. SAMUELS, A.M., M.D. 29

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FIG. ii.-Same case, plantar view.

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FIG. 12.-Healed arteriosclerotic gangrene.

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' 30 PERIPHERAL ARTERIAL DISEASES. SAUL S. SAMUELS, A.M., M.U.

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FIG. I3.-Healed diabetic gangrene.

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FIG. I4.-Healed diabetic gangrene.

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PERIPHERAL ARTERIAL DISEASES

be measured by the oscillometer. The diagnosticimportance of the oscillometer lies in the fact thatone is able to measure quantitatively the relativeextent of arterial pulsation in the extremity and asthere is usually an asymmetric involvement of thearterial circulation in organic diseases, the relativevalues are of considerable importance. Thus thereare no normal figures for oscillometric readingssince the gradations of the machine are purelyarbitrary. However, as a general rule, one maysay that the normal range of oscillometric readingsat the ankle level is within two to ten divisions ofthe scale. As the cuff is applied proximally on thelimb the normal range naturally increases so thatat the popliteal region one may expect a normalrange of from five to twenty divisions and propor-tionately higher values on the thigh. The sameapplies to readings taken on the upper extremities.They are less in extent at the periphery of theextremity and increase as one approaches the body.It is obvious, therefore, that relative readings onopposite limbs at the same level are more accurateand of greater importance than the actual figuresthemselves.A vital value of the oscillometer lies in its ability

to furnish information concerning prognosis. Ithas been observed over a long period that thosecases wherein the oscillometer needle does notpulsate at the ankle level have a relatively poorprognosis, particularly in regard to conservativetreatment. This is readily understood when it isknown that the oscillometer records pulsation ofthe large vessels only and if there is no pulsation,one must conclude that the large vessels are com-pletely blocked and that one may therefore assumethat the collateral circulation stemming from theseblocked vessels is correspondingly poor, hence thechances for success of conservative therapy aresmall. On the other hand, the presence of a pul-sation as revealed by the oscillometer at the anklelevel, no matter how small, should give one encour-agement in the prosecution of conservative treat-ment in spite of all other apparent difficulties.A word here concerning the use of various pro-

cedures and tests for the determination of vaso-spasm in the affected extremity. It must first ofall be understood that vasospasm is of importanceonly in the very early stages of organic arterialdisease and is usually completely absent in theadvanced stages. Furthermore, it must also berecognised that it plays only a secondary part inthe clinical picture of these diseases and whenpresent, as in the early stages, is easily overcomeby simple therapeutic procedures. Unfortunately,its influence has been over-exaggerated, particu-larly in the treatment of thromboangiitis obliteransand many tests and diagnostic methods have beenadvocated to determine its presence or absence.

Unfortunately many of these procedures involvethe use of nerve blocks of varying degree, of theadministration of general anaesthetics and some-times of the use of spinal anesthesia. Since theinformation obtained from these tests is of com-paratively little value, and as the effect of theseprocedures may be disastrous, it is not recom-mended that they be carried out. A detaileddescription of these various procedures for thedetermination of vasospasm may be obtained fromstandard text-books and will not be described inthis paper.

Roentgen examination of the extremities mayshow calcification of the tibial arteries. This ismerely confirmatory evidence of an arterioscleroticprocess and is in no sense to be interpreted as adiagnostic test of arterial insufficiency. In otherwords, extensive arteriosclerosis with calcificationof the vessel walls may be present and yet theremay be no interference with arterial circulation.When the element of narrowing of the arteriallumen is involved, either by thickening of thearterial wall or by thrombotic occlusion in thevessels, one may suspect arterial insufficiencywhich may be determined by the clinical testsenumerated previously.

EtiologyThe essential difference between thromboan-

giitis obliterans and arteriosclerosis obliterans liesin the fact that the former definitely is an inflam-matory disease of the arteries and veins, whilearteriosclerosis is a structural modification of thearteries probably induced by metabolic disturb-ances. At no time in the course of this disease isthere evidence, either clinically or pathologically,of inflammatory reaction. The use of the wordarigiitis in Buerger's Disease implies at once theinvolvement of both arteries and veins in theinflammatory process in contrast to arteriosclerosiswhere the changes are confined to the arteries alone.The inflammatory nature of Buerger's Diseaseimmediately suggests the possibility of some agentas the exciting cause of the malady. Buerger wasof the opinion that the noxious agent lay in theinflamed vessel and could be easily transmittedfrom vessel to vessel or from person to person.Other investigators believed that an unidentifiedstreptococcus was the cause of the disease. How-ever, a great drawback to the possibility of microbicinvolvement lay in the fact that the disease isessentially one of males and very rarely exists infemales. The tendency to racial selection is alsounexplainable from the standpoint of a germdisease.

I have for a long time been of the opinion thatsome infectious agent is at work in thromboangiitis

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POST-GRADUATE MEDICAL JOURNALobliterans, basing my opinion upon the acuteinflammatory process so often found in botharteries and veins and in the presence of large giantcells characteristic of the disease. This giant cell,corresponding to the foreign body giant cell ofnon-specific infections, prompted me to the con-clusion that we are undoubtedly dealing witheither a protozoon or a member of the fungusgroup. Since various strains of fungi are presentin the normal foot, and in many instances callforth the disease known as "athlete's foot" andsince this latter is so predominant in the popula-tion, while Buerger's Disease is comparatively rare,it occurred to me that we were perhaps dealingwith a specific as yet unidentified strain of fungusas the actual cause of the disease. It is interestingto note that according to dermatologists, fungous ormycotic infections of the feet are more frequent inmales than in females. Thompson has recentlymade an exhaustive study of fungus infections ofthe feet and has noted that there are more cases offungus infection of the feet in thromboangiitisobliterans than in the normal population. Ithoroughly agree with Thompson and other in-vestigators in this field but feel that a specificorganism must be isolated before definite con-clusions can be drawn. Isolation of the suspectedfungus from an area of acute migrating phlebitiswill undoubtedly go far towards confirming thistheory.As for the etiologic studies of arteriosclerosis, one

must read the monograph by Winternitz to appre-ciate his theory which may be correct. Otherexplanations are for the most part theoretical andhave little practical value. The influence of uncon-trolled diabetes mellitus must not be underestimatedin hastening and accentuating an underlyingarteriosclerotic process.Whether or not syphilitic arteritis of the legs

exists as a specific disease is open to question.Final judgment must rest upon actual pathologicexamination of amputated legs or excised vessels.Diagnosis from a clinical basis alone is inaccuratesince the mere presence of a positive Wassermannor Kahn Test may be purely coincidental and doesnot necessarily indicate that a syphilitic process ispresent in the arteries of the extremities. I haveencountered numerous instances of both Buerger'sDisease and arteriosclerosis obliterans with positiveWassermann reactions, but in no case have I beenconvinced that I was dealing primarily withsyphilitic disease.

Treatment of Peripheral Arterial DiseaseIn this presentation I shall attempt to describe

the general principles upon which the details oftreatment are to be based. The conclusions that I

have drawn are the result of over twenty years'experience in both private and hospital practice inthe treatment of ambulatory and bedridden casesof peripheral arterial disease. While some of mymethods and ideas may be contradictory to thosegenerally taught and held in the profession gener-ally, the results obtained undoubtedly speak forthemselves.The first principle of importance is the realisa-

tion by the physician and patient that the vaso-constricting action of smoking is definitely harmfulin all varieties and in all stages of peripheralarterial disease. While this fact has been knownempirically for many years, it is only lately thatcarefully controlled experiments have proven thecorrectness of this theory. Experiments by manyobservers using delicately adjusted electrical ther-mometers attached to the finger tips and toes haveshown that while engaged in the smoking of acigarette the temperature of the subject underinvestigation falls considerably. In some instancesa drop of six degrees centigrade has been observedwhile smoking. This is, of course, due purely andsimply to vasoconstriction. For this reason, there-fore, smoking must be completely prohibited in allforms of peripheral arterial disease. A patientwho refuses to stop smoking completely and imme-diately is wasting both his time and that of thephysician, as no successful therapeutic procedurehas yet been discovered to counteract the harmfuleffect of smoking. It is thus not be be assumedthat smoking is the direct cause of Buerger'sDisease, but is rather an aggravating factor.The vasoconstricting action of exposure to cold

must also be taken into consideration in treatment.Thus in cold weather it is important that theextremities and the body be properly clothed. Theuse of wool undergarments, stockings and gloves isessential in cold weather. In the case of womensome difficulty may be experienced in carrying outthis method of dressing. In men, however, therecan be no excuse for not adopting it completely.This brings up the question of change of climatefor these patients. It has been my experience thatthey do no better in warmer climate than in one towhich they are ordinarily accustomed. As amatter of fact, many patients relate that they walkand feel much better in cold weather than they doin the heat of summer.The application of external heat to the extremi-

ties in peripheral arterial diseases is a dangerousprocedure. I refer particularly to the use of hotwater bottles, electric heating pads, thermostati-cally controlled electric cradles and various otherapparatus. The great objection to these measureslies in the fact that the extremities, particularlythe feet, are usually hyposensitive so that excessiveheat may be applied without the patient realising

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PERIPHERAL ARTERIAL DISEASESthat a severe burn is taking place. Because of thistraditional and dangerous method of treatmentmany legs have been unnecessarily amputatedbecause of a severe burn experienced by the appli-cation of some form of external heat. A safe andeffective method of inducing vasodilatation of thelegs by external heat is the use of a hot or fairlywarm sitz bath. This may be taken daily, prefer-ably just before retiring and for a period of tenminutes or thereabouts. In no case should thetemperature of the water be above Io5° C. and thelevel of the water should be no higher than the hipswith the patient sitting ih the tub.

Buerger advocated the use of a system of con-trolled changes in position of the legs as a meansof stimulating blood flow in the lower extremities.These exercises are carried out by the patient fromone to four times a day depending upon convenienceor under existing circumstances. The patient liesflat on the back on a bed or couch and elevates thelegs to an angle of 45° or more, holding them up-right in this position until blanching occurs. Thisusually takes about two minutes. In the nextposition the patient sits upright and allows the feetto hang over the edge of the bed until they becomesomewhat reddened. This usually takes aboutthree minutes. After this there follows a restperiod of two minutes during which time thepatient is flat on the back again with the feet onthe bed in a horizontal position. This cycle ofthree positions is repeated three or four times,depending upon circumstances. It is a good planto follow the evening exercises immediately withthe hot bath described above. After the bath thefeet should be carefully dried and a fungicidalpowder applied between the toes. A preparationof calcium propionate has proven most effective asa fungicide in these cases.An excellent auxiliary vasodilating agent has

been found in the use of short wave to the legs.This may be given at fifteen minute periods,usually three times a week or oftener as indicated.The current should be regulated, preferably bythe patient, so that there is at no time a feeling ofdiscomfort in the legs but rather one of moderatewarmth. In administering thousands of treat-ments by this form of therapy I have never en-countered any accidental burns or other harmfuleffects as one would expect from the application ofexternal heat.

Alcohol in the form of a beverage has proved tobe one of the most effective vasodilators. It maybe prescribed in doses of 15 to 30 c.c. three times aday with good results. I ari at present investi-gating a new vasodilating compound (2-Benzyl-4, 5-imidazoline HCL). This compound is knownas "Priscol" and is administered both by hypo-dermic and orally in tablet form. Results of its

use in cases characterised by excessive vasospasmare so far encouraging, but a definite report cannotbe made until more experience is had with this newdrug.The introduction of various tissue extracts, such

as extract of pancreas with insulin removed, variousmuscle extracts, kidney extract and other similarpreparations was felt to be the answer to relief ofthe difficulty and disability of intermittent claudi-cation. Prolonged experience with these variouspreparations usually given by hypodermic injec-tion, leads me to the conclusion that their value isdoubtful and that the good results obtained are forthe most part psychic in nature. In order toobtain therapeutic results tremendous doses ofthese materials would have to be employed ratherthan the small amount at present in use. Thepain and discomfort from such large doses would,of course, prohibit their practical use.A word here concerning the use of various

mechanical appliances to facilitate circulation inthe extremities. Among these may be mentionedthe "pavex" machine and various forms of inter-mittent venous compression. It was felt for a timethat the last word had been spoken in the treat-ment of peripheral arterial diseases when thesemachines were introduced. Increasing experiencewith them, however, soon convinced the professionthat the claims of their inventors were somewhatexaggerated and their practical value nil. Unfor-tunately, in some instances, actual danger waspresent in their use because of the trauma to thelarge vessels of the thigh and the subsequentdevelopment of either gangrene or spreading in-fection or phlebothrombosis. The use of any ofthese machines therefore in any stage or in anyvariety of peripheral arterial disease is not recom-mended.

Relief of vasospasm in peripheral arterial diseasesby severing the sympathetic pathways to the ex-tremities has been recommended from manysources. The operation either in the form of aLeriche sympathectomy or in the nature of anextensive operation such as a lumbar or cervicalganglionectomy may produce temprary relief ofvasospasm in the extremity, but is in no sense tobe considered as a cure for any of these diseases.Their effects upon the organic obstruction which isfundamental to these conditions is nil. It is myfeeling that just as effective vasodilatation can besecured in most of the peripheral arterial diseasesby the simpler and safer methods described above.For this reason I do not advocate the indiscriminateapplication of this formidable operative procedurein peripheral arterial disease.A word concerning the use of typhoid vaccine

intravenously to induce high fever as a vasodilatingaid. I have seen three cases of sudden massive

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POST-GRADUATE MEDICAL JOURNALgangrene of a previously healthy extremity resultfrom typhoid vaccine intravenously as a form oftreatment. It is well known that during the chillphase of the reaction there is a change in theclotting time of the blood and that extensivethrombosis and major occlusions may occur. Thebeneficial effects of this form of therapy are soslight in comparison to the risk attached to theiruse that I do not advocate this form of treat-ment.The use of the various choline derivatives and

vasodilators in peripheral vascular diseases hasproved to be ineffective, and their use by ionto-phoresis is attended with considerable danger ofburns.

Experience of twenty years or more with the useof intravenous injections of hypertonic saline hasdemonstrated the value of this form of treatmentin thromboangiitis obliterans. It is not to be con-sidered a specific for the disease nor is too muchreliance to be placed upon it to the exclusion ofother factors previously enumerated in the manage-ment of these cases. The only specific objectiveeffects that have been noted with the use of intra-venous saline are an immediate temporary in-crease in pulse amplitude in the extremities asdemonstrated bythe oscillometer, increased warmthof the feet, renewed toenail growth and the healingof chronic ulcers and of extensive areas of gangreneof the extremities. It is assumed, of course, thatin addition to the use of saline injections thepatient is not smoking and is co-operating in allother respects. The solution is administered threetimes a week, 300 c.c. at a time fairly rapidly bythe gravity method using an eighteen or nineteengauge needle. Five per cent sodium chloride isreserved for the younger vigorous patients, parti-culorly those with thromboangiitis obliterans. Inthe older group or in those showing a tendency tolocal irritation at the site of injection, three percent sodium chloride or two per cent saline is pre-ferable. These injections may be given in theoffice or at the patient's home. They are con-tinued for many months either until improvementin symptoms is obtained or until gangrenous areasand ulcers are healed. Contraindications arehypertension, myocardial or renal disease.The treatment of gangrene necessitates a thor-

ough understanding of the pathogenesis of thiscondition. One must distinguish two forms ofgangrene. One is gangrene in its pure or primaryform, the type that is caused by obstruction in thevessels alone. This is encountered in its classicalform in embolism or in sudden thrombosis of alarge artery. Here the usual picture is suddenonset of coldness, ischemia and extreme pain inthe affected limb followed by progressive bluenessof the extremity ending in complete mummifica-

tion or drying of the affected part. This wasformerly designated "dry gangrene." The aim oftreating this form of gangrene is to wait patientlyfor a line of demarcation to form which will indicatethe ultimate extent of the gangrenous process.After this line has been established an attemptshould be made to separate the dying or deadtissue from the living part. This can sometimesbe accomplished by careful dissection along theline of demarcation or in some instances it may beeffected by attempting to macerate the deadtissues. This is best accomplished by foot soaks ofsoap and water followed by the application ofboric acid ointment. All efforts must be em-ployed to avoid contamination of the gangrenousareas so that secondary infection shall not ensue.This requires careful dressings by the attendingsurgeon utilising all usual methods of antisepsis.In the removal of a gangrenous toe by this method,one must be particularly careful when the varioustendon sheaths, particularly those of the flexortendons of the toes are opened. The administra-tion of penicillin intramuscularly for a few daysbefore and after the removal of the gangrenous toeor toes may prevent the development of subsequentinfection of the open tendon sheaths. Followingthe separation and removal of the gangrenous partsin this type, a granulating ulcer will usually befound which if not secondarily infected will usuallyheal by the continued application of a bland oint-ment, such as boric acid. If infection of the tendonsheaths does supervene, treatment must be carriedout in the manner to be described in the nextparagraph.A more common and a more dangerous form of

gangrene is that seen most often in arteriosclerosiswith diabetes, although it may also occur withoutdiabetes. Here, of course, one is dealing primarilywith insufficient blood supply in the extremitiesusually caused by arteriosclerosis obliterans. Inthese cases there is usually present, in greater orless degree some form of mycotic infection of thefeet. These fungi are usually present in the inter-digital spaces of the toes; or they may also be foundin various excrescences of epithelium such as corns,calluses and other areas of the skin. These para-sites may be present for many years and maycause no particular harm. In some instances,however, particularly in the interdigital spaces,they may cause maceration of the skin between thetoes with resulting itching and burning. Thepatient is prone to tamper with these infectedareas, either by rubbing the fingers between thetoes or by application of a strong irritating anti-septic. If the location is in a corn or callus, thepatient may attempt to remove these areas bymeans of infected razor blades or by picking theseexcrescences with dirty finger nails. In any event

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PERIPHERAL -ARTERIAL DISEASES. SAUL S. SAMUELS, A.M., M.D. 35:::::::::::::::i·::i··: ?':: :::~ '"' ::' ...... .........

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PERIPHERAL ARTERIAL DISEASESthere is usually introduced a secondary pyogenicinfection and from this point on real troubledevelops. As a result of the secondary infectionthere is localised edema and extension of the in-fection into the adjacent tissues. This causessecondary thrombosis of the small arteries leadingto the toes with the result that gangrene surelyfollows. This then is known as secondary or in-fected gangrene in contrast to that type describedin the previous paragraph.

In the diabetic patient spread of the infection ismore rapid and more dangerous and when thecondition is not recognised'and continues to spreadit usually results in a purulent infection of thetendon sheaths of the foot and of the fascial spacesof the foot. On the dorsum of the foot the infec-tion is usually not very extensive nor of very greatconsequence as the anatomical structures in thatlocation are not very complex as compared to theplantar tissues. Having, therefore, the combina-tion of gangrene and infection it is logical toassume that since the gangrene is dependent uponthe development of the infection, treatment shouldbe directed to the underlying cause of the gangreneIn this case it is the infection. In other words, insecondary gangrene such as encountered in dia-betics and others, one's attention should be directednot to the condition of the circulation in theextremities, but rather to the extent and treatmentof the infection. This is a new approach to thetreatment of diabetic gangrene and must bethoroughly understood if amputation of limbs isto be avoided. In the early stages of these infec-tions, before pus has formed, the local applicationof various antiseptics will prove sufficient. Amongthese the most beneficial has been azochloramid intriacetin. Penicillin in high dilution and tyro-thricin either in solution or in the form of a creamhave also proven effective. The sulpha drugs bylocal application and by mouth have not provensatisfactory in secondary or infected gangrene.When the presence of frank pus has been estab-

lished in the foot immediate incision and drainage,plus the direct application of a powerful antiseptic,agent must be employed without delay. If aninfected tendon sheath is found, it must be openedcompletely. This is also true of infected fascialspaces of the foot. These also must be openedextensively and thoroughly and the contents ofinfected or necrotic tissue completely removed.The resulting cavity should then be flushed outwith peroxide of hydrogen followed by a wash ofsome mild antiseptic solution, such as Dakin'ssolution, zephiran or some similar compound.After this, the cavity is packed tightly with gauze,saturated either with azochloramid in triacetin ordilute penicillin or dilute tyrothricin. Of thethree, I have found azochloramid preferable be-

cause of its effect upon a greater number of organ-isms than the other two agents.A local anesthetic must never be used in making

these incisions of the feet as gangrene will certainlyfollow. In most cases no anaesthetic whatever isrequired. A sharp scissors or scalpel will usuallyprove most effective because these feet are for themost part hyposensitive. Where indicated, how-ever, a light general anesthetic may be used.

If toes or other parts are found to be completelygangrenous at the time of the incision the deadpart may be removed safely. Dressings arechanged daily, using the same routine of irrigation,with peroxide of hydrogen followed by a mild anti-septic solution and then firm packing with satu-rated gauze. It will be observed after a shorttime that as the infection is conquered, the gan-grenous process subsides. The use of penicillinsystematically during this phase of the treatmentof infected gangrene is still open to question.Many cases respond favourably to the use of peni-cillin systemically along with adequate localtreatment of the foot, but in some cases undoubt-edly due to the type of organisms present, nothingor very little can be accomplished with the use ofpenicillin by intramuscular injections. Therefore,too much faith should not be placed in this remedyin the treatment of secondary gangrene.As the infection is overcome and the gangrenous

parts become demarcated and are removed,healthy granulations will appear in various partsof the foot. Persistence in this treatment will soonresult in the formation of a granulating woundwhich will eventually epithelialise. Thus evenwith the loss of one or more toes or even of all toesof the foot a good functioning extremity can beexpected.

In the gangrene of thromboangiitis obliterans,one must realise that the disease is usually self-limited and that if all the rules enumerated abovehave been carefully followed, particularly thatrelative to smoking, a good result can be obtained.Here the question of infection is not very impor-tant as the condition is essentially one of primarygangrene and the object of treatment is to keep theparts as clean as possible and to allow spontaneousdemarcation and separation of the gangrenousportions. Daily foot soaks of green soap andwarm water or of a mild chloramine solution areindicated followed by the application of blandointment such as boric acid ointment. If this istoo painful, the use of benzocaine or other anaes-thetic ointments may be tried.

Complete bed rest with the affected limbs in thehorizontal position at all times is essential in thetreatment of gangrene. In many instances thepatient will apparently obtain relief from pain bysitting upright in bed or in a chair day and night

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POST-GRADUATE MEDICAL JOURNALwith the feet hanging. While this affords tempo-rary relief, it also causes an extensive edema ofthe foot and eventually of the entire leg, whichis not conducive to healing and which usuallycauses the gangrene and infection to spread. Thiscondition I have designated "positional edema"and the only method of overcoming it is to insistupon the patient keeping the extremities in bed ina horizontal position at all times, after which theedema will be observed to disappear completely inabout six to twelve hours.

This brings up the importance of complete bedrest in all cases of impending or threatened gan-grene. An early sign of this is increasing pain inthe extremities at night, whereby the patient mustin some cases get off the bed and walk about theroom to secure relief. Immediate hospitalisationwith complete bed rest is imperative at this stage.In addition both legs are wrapped in sheet cottonfrom the toes to the groin to secure retention of thenatural body warmth. This in itself is a powerfulvasodilator and will usually give spectacular relieffrom night pain. Morphine and its derivatives arestrictly to be avoided in the treatment of any andall phases of these diseases, as they soon becomehabit forming and may cause complications moredifficult to treat than the original condition. Thecombination of no smoking, bed rest, aspirin andwhiskey has proven more effective than any knownnarcotic.What are the indications for amputation of a leg

in peripheral arterial disease? As in other branchesof medicine and surgery no hard and fast rule canbe laid down. One must rather rely upon experi-ence and good judgment based upon a thoroughknowledge of the disease. In general, however, itcan be stated that there are two main indicationsfor amputation of the leg.

I. Destruction of so much of the weight bearingportion of the extremity by gangrene that afunctioning leg cannot be expected.

2. Infection in the foot or leg which cannot becontrolled by any of our known modermethods.

Amputation of toes before a line of demarcationhas occurred is a dangerous procedure and shouldnot be done, as it very often leads to further spreadof the gangrene into the foot.The level of amputation is important. At the

outset it must be stated that indications foramputation below the knee are an adequate circu-lation either original or collateral below the kneeand infection confined to the foot. It follows,however, that if such a combination is present, onereally has no indication of amputation at all,rather one must feel that conservative therapy isin order. There are some cases, however, where

the physician may feel that too much of the weightbearing portion of the foot has been destroyed andyet where circulation is apparently adequate belowthe knee, where this type of operation may be done.This is particularly true if the oscillometer indicatessome pulsation at the ankle level.The following technique has proven most effec-

tive for this type of operation. Three levels aremarked off on the skin with the back of a scalpel onthe leg to be amputated. The middle level isplaced about six inches below the tibial tubercleindicating the level at which the tibia will besawed. Another level is marked off about oneinch proximal to this indicating the level of theskin incision. At this point a circular incision ismade through the skin and soft parts down to thebone. No tourniquet is used and all bleedingvessels are carefully clamped as the operation pro-ceeds. Directly over the fibula a longitudinalincision is made starting at the circular skin incisionand extending proximally up to the fibula level pre-viously marked on the skin. By blunt dissectiona piece of fibula is removed using a rib cutter forthe purpose corresponding to the upper and lowerlevel marked out on the skin. After this piece of.fibula has been removed, the soft parts are re-tracted along the tibia until the level of tibialsection is reached. The periostium of the tibia isthen cut and scraped distally and the bone issawed through at that point. The sharp anteriorborder of the tibia is then bevelled off with either asaw or rongeur forceps and the soft parts are closedover the end of the tibia, bringing them well underthe anterior surface of the exposed tibia. The skinedges are approximated carefully and no drains areused.Most amputations of the leg are best performed

above the knee where the procedure is simple, ispractically shockless and has the lowest mortalityrate on record for this type of operation. This isespecially indicated when the oscillometer revealsno pulsation whatsoever at the ankle level of theaffected limb. Without the use of a tourniquet, acircular incision is made through the skin and softparts at the upper border of the patella down tothe bone. Accurate hemostatis is essential. Thesoft parts are then retracted proximally for abouttwo inches with the use of a warm wet towel. Atthis proximal point, the periostium of the femur isincised and scraped distally and the bone is sawedthrough at that level.Here it is important to emphasise the necessity

for simplicity of technique. This applies particu-larly to handling the sciatic nerve, which is merelycut at right angles and allowed to retract spon-taneously. No injection of alcohol or other irri-tating manipulations are advisable. After removalof the leg, the muscles and other soft parts are

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January, I946 PERIPHERAL ARTERIAL DISEASES 39allowed to fall together naturally and they aresewed over the end of the bone. The stump of thepopliteal artery is buried. The soft parts and skinare then sewed together very carefully and nodrains are used.The question of choice of anesthesia is impor-

tant. I have found that a well-administered cyclo-propane anesthesia is the best in all cases, particu-larly in elderly people. It is accompanied with noshock whatsoever and gives no postoperativecomplications or discomfort. After reacting fromthe anesthetic, patients are allowed to sit up inbed and may eat their next regular meal if they sodesire. The day after operation they are routinelytaken out of bed and allowed to sit up in a chair foras long as they please and the same for every daythereafter. On the third or fourth day they maybe allowed to get about on crutches if they desire.On the sixth or seventh day stitches may be re-moved and if primary union is obtained, as itusually is, they are sent home on the eighth or thetenth day completely healed. An artificial legmay be ordered immediately and may be appliedas soon as ready by the limb maker. With amortality rate of approximately five per cent forthis type of operation it is obvious that there is noparticular advantage in the use of refrigeration asa method of anesthesia in these amputations. It

is the simplicity and gentleness of the operativetechnique that is important rather than the type ofanesthesia that is used, although I do feel thatcyclbpropane is highly preferable to refrigeration.

SummaryIn the field of peripheral arterial diseases it is

essential that the doctor know how to diagnose acase in its earliest stages. The method of doingthis has been described. After making a properdiagnosis, the question of management of the caseis then in order. Fundamental principles basedupon long experience in this field have beendescribed, enabling the doctor to treat thesepatients in an intelligent manner. Gangrene is,for the most part, a preventable disease and a gooddeal of the responsibility for this prevention restsupon intelligence and well-founded principles oftreatment rather than upon the employment ofsome new gadget or apparatus or single method oftreatment which has received unwarranted popu-larity. Amputation of limbs, when necessary,must be done in a simple and gentle manner forthe ultimate aim of saving the patient's life and ofgetting the patient back to tn ambulatory condi-tion as soon as possible.

MEDICAL NEWSThere will be a clinical meeting of the Medical Society of the L.C.C. Service on Thursday,February 7th, at 2.45 p.m., at MAUDSLEY HOSPITAL, Denmark Hill, S.E.5, when membersof the staff of Maudsley Hospital will demonstrate cases.

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